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.