The tyranny of developmental milestones

A few days ago, the Better Half and I got an e-mail from the teacher in my son’s montessori toddler program.  (He will be three in the coming months.)  He has been doing quite well in general, though he still has a tendency to grab things he wants and run away with them.  His language skills are fantastic, he’s friendly and empathetic, and he plays well with all the other kids.  But he tends to stick things in his mouth.  This had been waning, but over the past week she had noticed it again more.  She was writing to express her concern, and to recommend that we have him evaluated for a sensory disorder.  (I have been given leave by the Better Half to relate these matters in this forum.)

Suffice it to say that the Better Half and I were not particularly compelled by this recommendation.  First of all, we haven’t really noticed these behaviors at home.  Also, I’d been out of town for several days, and we’d recently had to make some adjustments in his other childcare arrangements.  It’s not at all surprising that some of his more immature behaviors might have resurfaced as he adjusted to these changes.  We sent the teacher a polite response explaining why we were not especially concerned at this time.

But here’s the thing — I happen to be a pediatrician.  Furthermore, I work in a practice where the founding partner specializes in developmental and behavioral pediatrics.  Indeed, a large percentage of our patients comprise children with some kind of developmental disorder.  I am thus probably far more familiar with normal and abnormal development than even your average pediatrician, who in turn is far more familiar with normal development than your average layperson.  I’ve read lots and lots and lots of developmental reports.  And it was no great shakes for me to shoot a quick e-mail to my partner, explain the situation, and for him to write back and concur that there was no basis for concern.

The same initial e-mail sent to a different parent for the exact same concerns would quite likely have resulted in a referral to a development specialist or occupational therapist, who (depending on their tendency to favor intervention) could have recommended expensive and time-consuming therapies.  For a parent who didn’t have the resources I have close at hand, the same message would likely have been a source of great distress.  And I think that’s a problem.

None of this is to single my son’s teacher out for criticism.  I think she’s wonderful.  She handles some of his less adorable behaviors with patience and a montessori-appropriate sang-froid I find enviable.  (It’s much more placid than my usual “you put that back this instant!” approach.)  I don’t really think this is about her.  I think it’s about our cultural approach to developmental milestones and expectations.

The Denver Developmental Screening test was developed in the 1960 to help detect developmental delays early.  By the time I entered medical school, its use (or that of similar screening tools) was standard.  Indeed, Massachusetts (along with several other states) mandates some kind of developmental screening as part of routine well checks.  To what degree this heightened scrutiny has contributed to the rise in autism-spectrum disorder diagnoses is a subject of controversy.  In any case, attention to developmental milestones is a a matter of professional requirement for pediatricians (and, I presume, family practitioners who take care of children).

This imperative to scrutinize children’s development has spilled over into the culture of parenting in this country.  We pediatricians are doubtless partly responsible for this.  We ask about milestones at visits and hand out materials about what children are expected to have achieved by certain ages.  To some degree this is helpful.  If there really is a disorder, it’s better for it to be detected early, when therapies may help obviate some of the delays and difficulties.

But anyone who’s leafed through a book about parenting a small child within the past couple of decades knows that there is now tremendous attention paid to children meeting these milestones “on time.”  They have gone from helpful diagnostic tools to benchmarks of normality, predictors of lifelong potential.  If your kid talks a month or two early, maybe she’s gifted.  If he doesn’t walk until 14 months, maybe a referral for physical therapy should be considered.  And that’s not how they’re meant to work.  Further, there has been at least some criticism that our developmental expectations are heavily influenced by our cultural norms [PDF], and that children raised in different societies reach different skills at very different times.

This same anxiety seems increasingly to inform our approach to behavioral quirks (such as my son’s tendency to stick things in his mouth).  I have many patients who, similar to other children’s aversion to certain foods (which, except in extreme cases, is considered a normal preference), dislike certain tactile stimuli.  Some can’t tolerate feeling a tag on the back of their shirts.  Some strongly dislike the sensation of the seam along the toe of their socks.  My esteemed co-blogger has herself mentioned her visceral aversion to the touch of velvet.  What might once have been accepted with a shrug as a somewhat usual character trait is pathologized into a disorder now, and lands kids in occupational therapy.

As with almost everything in life, there’s a spectrum in this.  For kids who are significantly behind in one developmental domain (verbal skills, social interaction, and both fine and gross motor skills), or whose overall trajectory is notably delayed, further evaluation is warranted.  Detecting these cases is why developmental screens were developed.  Similarly, if your daughter won’t leave the house unless the seam of her socks is exactly straight across her toes, then there’s reason to be concerned about a disorder along the lines of obsessive-compulsive disorder or another anxiety-type disorder.  If the child’s quality of life is obviously compromised, then clearly things have crossed from “quirk” to “problem that warrants further investigation.”

But if your child is a month behind in mono-syllabic babbling, it almost certainly doesn’t mean anything.  If your son wants you to cut all the tags out of his shirts but otherwise moves happily through the world, you probably don’t have anything to worry about.  If your daughter hates the feel of velvet, then buy her dresses in some other material.  You probably don’t need to invest your time in occupational therapy.  Oftentimes outlying behaviors are nothing more than the aspects of your child that make them their own person, and it serves no purpose to call them disorders.

23 thoughts on “The tyranny of developmental milestones

  1. Our son (now 4) was born at the 75th percentile for weight and then dropped to the 10th where he remains today. For every well visit we went to there was a lot of head shaking and talk about referring him up to a specialist and doing some bloodwork to check his metabolic rates etc etc.

    Then we looked at ~my~ baby books. I had the same length weights at the same times he did. I turned out a comfortable 5’10” and now 180lbs. Some people just develop differently.

    Also, I hate velvet. Makes my hands sweat. No idea why.

    And the dark thought of the morning:

    I had an idea for a real money maker of a website. Think of face book only you register your precious on it. Then as the kid goes along you check off their milestones in the same style as a Baby Book. So you build a timeline of when that first tooth shows up, how long they were at what age, etc etc. And then you can easily track it against your friends and ~their~ kids. Show off a little that you’re potty training already, or that the little one used a spoon on her own, or that the baby finally slept through the night for 4 nights in a row (one’s a fluke).

    So where’s the money? Easy. You tie in products to mile stones and target advertising to people who are either near that mile stone or to really cash in falling behind it. There’s a user who’s 12 month old isn’t walking yet? Hey look at these cruiser assistants. Hmm… still not using a spoon on her own? Maybe you should try one of these specially made easy to hold spoons.

    And there.. taht sound… is a bit of my soul dying….

    • I would be flabbergasted if the idea you describe isn’t already in development. Seriously.

      And growth curves are another area of perpetual fixation and anxiety, often with the same outcomes you describe. Guidelines limn the boundaries of normal, but within those boundaries are found lots and lots of variation! When guidelines become requirements, things get a little too referral-happy for my taste.

      • Yeah… not so much yet. I keep trying to find a web developer to work with on it since I haven’t heard of it if it is out there and I imagine that if it were it’d be popular with parents for the “Keep up with the Jones” as well as the “How’s my kid doing?” factors.
        • There are such sites out there (I know we signed up for one that sent us weekly updates on where our kid “should be” and “might be” and certainly came with plenty of attached advertising) but none of the things I saw when baby girl was born were half as interesting as what you’re saying
  2. This is the same problem that we have with the sociopathy test, really (heh: I just wanted to mention sociopathy in a thread about child development).

    Benchmarks for organic beings are commonly mis-mapped in people’s heads to be like benchmarks in a factory process.

  3. Yesterday, I went to a kid’s birthday party at a bowling alley. One father commented, “This is a great idea. The kids can learn about counting and turn-taking.” Or they can fishing bowl!
  4. They said this in an email??? I would never recommend such steps in anything short of a face-to-face conference.
      • As you noted, such an email can be incredibly anxiety inducing. Without an opportunity to respond and get a response immediatey, that can just grow. And even the most nicely written email is more open to misinterpretation of language/tone/intent/everything than a face to face.

        I’d also ideally have the school learning specialist or other such person in the meeting, after having seen the concerning behavior, to offer a second opinion and one better versed in the need for services, if they really are required. Does your son’s school have one such person? My current school does not, though we are finally seeking one. The absence is a HUGE problem.

        • I don’t believe there’s a school learning specialist, though I could be wrong.

          And to be totally fair to the teacher (who, I would like to say again, I think is really wonderful), when the Better Half and I deferred further evaluation at this time, she was entirely respectful of that decision and made no effort to push back or suggest we change our minds.

  5. Russell, I really love these types of posts. You’ve got exactly the type of pragmatic, let’s-pay-close-attention-but-not-get-too-overwrought approach that my kids’ first doctor had, and that I valued so much.

    I know only a few things about developmental milestones, but I understand the basic concepts of statistics enough to understand that every average contains very normal variance, so I never had the tendency to panic if my kids were a bit slow on things, or if they temporarily reverted, and I always struggled between irritation with and sympathy for those parents who did freak out.

    Heh, and like A Teacher, my kids were born big, but rapidly fell to low percentiles in weight. Our current pediatrician seems to find this worriesome, but not just my wife and I, but all four grandparents were pretty thin as kids. We just nod our heads politely when he tells us to buy whole milk, and quietly ignore the advice.

    • I second James’ adulation of the post (and I’d posit that the slow comments might have been because the site seemed down for a little while there).

      Juxtaposed against parents who freak out if their kid is in anything less than the 108th percentile, your perspective, as both a father and a doctor, is refreshing. Some parents make a huge deal out of everything; some struggle to ever see or hear that a very real problem might exist; and the rest get it. You, sir, get it.

  6. there is a lot of step by step paranoia out there. some of it is overconcerned parents; some of it is driven by the folks who have set up shop to feed on their fears. some of the gibberish that comes out of my wife’s facebook “friends” is monumentally silly. (most of these people have advanced degrees in the humanities, which fits well with whatever stereotypes people have along those lines)

    “He has been doing quite well in general, though he still has a tendency to grab things he wants and run away with them.”

    this has been the story of our last 15 trips to the playground. it doesn’t help that the kids’ parents laugh as he runs away yelling “no no no no no no no” or “thank you you’re welcome”.

  7. As a pediatric occupational therapist, I believe sensory issues can be serious and may limit a child’s ability to participate meaningfully in his or her world. If that child who needs all his tags cut out of his shirts finds all light touch uncomfortable he may avoid playing with children on the playground for fear of being bumped into. As such, he will miss out on important developmental opportunities. In cases like that, an OT can often help. Unfortunately though, in the eagerness not to miss the child who does need help, normal difference in children’s development may be pathologized depending on the culture of the family and the school. I try to teach my students that developmental milestones are a useful guideline, but they are only one piece of the developmental puzzle and it is our job as therapists to discern which children are being functionally impacted by a difference in how they are developing. Early intervention for children who do have developmental delays can be absolutely crucial but we must be careful in how we screen for such delays so that we neither over nor under-identify the children who can most benefit from helping services.
    • I don’t disagree with anything you’ve said. For patients whose sensory intolerance is having a negative impact on quality of life in a meaningful way, then I wholeheartedly agree that OT can be of significant value. But I am concerned with the rush to define as pathological or disordered those children whose lives are minimally impacted by the minor variations in behaviors or preferences I’ve described.

      Which is probably a longer way of saying “I think we agree on this” than it needed to be.

  8. Solid post, Doc. The Mileston obsession is as irritating as it is damaging. It encompasses so much of what people want to talk about regarding children, so much of doctor visits and is just more of this let’s-compare-kids-to-judge-who’s-doing-the-best.

    They may be useful, but they’re dangerous in most people’s hands.

  9. Great post, thank you. The milestones obsession is really an annoyingly prominent feature of contemporary parenting, as I’m observing as I care for grandkids.

    But with my other hat, the autism advocate one, I do appreciate the CDC’s “Learn the signs, act early” campaign.

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