2022 - Artigo - Marcos Do Desenvolvimento - CDC

Evidence-Informed Milestones for
Developmental Surveillance Tools

Jennifer M. Zubler, MD,a,b Lisa D. Wiggins, PhD,a Michelle M. Macias, MD,c,* Toni M. Whitaker, MD,d
Judith S. Shaw, EdD, MPH, RN,e Jane K. Squires, PhD,f Julie A. Pajek, PhD,g Rebecca B. Wolf, MA,k
Karnesha S. Slaughter, MPH,a Amber S. Broughton, MPH,a Krysta L. Gerndt, MPH,h Bethany J. Mlodoch,h
Paul H. Lipkin, MDi,j,*
The Centers for Disease Control and Prevention’s (CDC) Learn the Signs. Act
Early. program, funded the American Academy of Pediatrics (AAP) to convene
abstract
an expert working group to revise its developmental surveillance checklists.
The goals of the group were to identify evidence-informed milestones to a
National Center on Birth Defects and Developmental
include in CDC checklists, clarify when most children can be expected to reach Disabilities, Centers for Disease Control and Prevention,
a milestone (to discourage a wait-and-see approach), and support clinical Atlanta, Georgia; bEagle Global Scientific, LLC, San Antonio,
Texas; cDivision of Developmental-Behavioral Pediatrics,
judgment regarding screening between recommended ages. Subject matter Medical University of South Carolina, Charleston, South
experts identified by the AAP established 11 criteria for CDC milestone Carolina; dDivision of Developmental Pediatrics,
Department of Pediatrics, The University of Tennessee
checklists, including using milestones most children ($75%) would be Health Science Center, Memphis, Tennessee; eVermont
expected to achieve by specific health supervision visit ages and those that are Child Health Improvement Program, Department of
Pediatrics, Larner College of Medicine, The University of
easily observed in natural settings. A database of normative data for individual Vermont, Burlington, Vermont; fCenter on Human
milestones, common screening and evaluation tools, and published clinical Development (Professor Emerita), University of Oregon,
Eugene, Oregon; gMetroHealth Medical Center, Case
opinion was created to inform revisions. Application of the criteria established Western Reserve University, Cleveland, Ohio; hAmerican
by the AAP working group and adding milestones for the 15- and 30-month Academy of Pediatrics, Itasca, Illinois; iKennedy Krieger
health supervision visits resulted in a 26.4% reduction and 40.9% replacement Institute, Baltimore, Maryland; jJohns Hopkins School of
Medicine, Baltimore, Maryland; and kNational Center on
of previous CDC milestones. One third of the retained milestones were Birth Defects and Developmental Disabilities (retired),
transferred to different ages; 67.7% of those transferred were moved to older Centers for Disease Control and Prevention, Atlanta, Georgia
*Contributed equally as co-senior authors.
ages. Approximately 80% of the final milestones had normative data from $1
sources. Social-emotional and cognitive milestones had the least normative Drs Zubler and Wiggins conceptualized and designed the
study, collected data and performed the initial analyses,
data. These criteria and revised checklists can be used to support drafted the initial manuscript, and reviewed and revised
the manuscript; Drs Lipkin, Macias, Whitaker, Squires,
developmental surveillance, clinical judgment regarding additional Pajek and Shaw critically reviewed and revised the
developmental screening, and research in developmental surveillance manuscript for important intellectual content; Ms Wolf,
Ms Slaughter, Ms Broughton, Ms Gerndt, and Ms
processes. Gaps in developmental data were identified particularly for social- Mlodoch planned and performed the research and
reviewed and revised the manuscript; and all authors
emotional and cognitive milestones. approved the final manuscript as submitted and agree
to be accountable for all aspects of the work.
The contents are those of the author(s) and do not
The American Academy of child, and applying clinical necessarily represent the official views of, nor an
Pediatrics (AAP) recommends judgment during health endorsement by American Academy of Pediatrics,
Centers for Disease Control and Prevention/US
developmental surveillance and supervision visits (HSVs). Department of Health and Human Services, or the US
screening to identify children with Developmental screening involves government.
developmental delays or the use of validated screening tools DOI: https://doi.org/10.1542/peds.2021-052138
disabilities (DDs) early, help to at specific ages or when Accepted for publication Dec 9, 2021
ensure timely interventions, and surveillance reveals a concern.1 Address correspondence to Jennifer M. Zubler, MD,
National Center on Birth Defects and Developmental
improve outcomes.1 Developmental Diagnostic evaluations are Disabilities, Centers for Disease Control and Prevention,
surveillance is a longitudinal conducted, typically by 4770 Buford Hwy NE, MS S106-4, Atlanta, GA 30341. E-mail:
wyv4@cdc.gov
process that involves eliciting developmental specialists, to
concerns, taking a developmental further evaluate and diagnose DDs
history based on milestone in children deemed at risk through To cite: Zubler JM, Wiggins LD, Macias MM, et al.
Evidence-Informed Milestones for Developmental
attainment, observing milestones surveillance and screening Surveillance Tools. Pediatrics. 2022;149(3):e2021052138
and other behaviors, examining the processes.
PEDIATRICS Volume 149, number 3, March 2022:e2021052138 SPECIAL ARTICLE

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Developmental surveillance is family addressing concerns; and early intervention. All SMEs had
centered to promote conversations developmental tips/activities. These graduate training and experience in
and trusting relationships wherein materials were developed to help research methodology and medical
families can express concerns.2 parents to recognize typical decision-making and clinical
Surveillance involves clinical development, elicit parents’ experience in developmental
judgment about when a child may concerns about their child’s surveillance, screening, and
be at risk for delays and when development, improve discussions evaluation. One SME was an editor
additional developmental screening between parents and professionals of and 2 contributed to the AAP’s
might be warranted. Milestone lists about a child’s development, and Bright Futures: Guidelines for Health
help to guide developmental support universal developmental Supervision of Infants, Children, and
surveillance, but those used for screening at recommended ages and Adolescents (4th ed).9 Two SMEs
surveillance, unlike screening and additional screenings when there were lead authors of the AAP’s 2020
evaluation tools, are not validated. are concerns. The milestones were clinical report, “Promoting Optimal
Typically, lists of milestones are adapted from Caring for Your Baby Development: Identifying Infants
uncited, are based on clinical and Young Child: Birth to Age 5 (5th and Young Children With
opinion, and/or report the average ed) to align with recommended Developmental Disorders Through
or median age a milestone should be HSVs.6 Like most milestone lists, the
Developmental Surveillance and
achieved. Moreover, ages specified original sources of the milestones
Screening”1; another had long-time
for individual milestones are were uncited, and adaptations were
inconsistent across sources.3,4 experience as a developer of
based mainly on clinical opinion, not
screening tools.
on empirically informed evidence.
Lists that cite average or median
Criteria Identification
ages at which children achieve Based on 15 years of use, 3 areas
milestones provide insight into for improving the checklists were The SMEs developed 11 criteria for
typical development but do not identified by the CDC. First, criteria CDC surveillance milestones and
provide clarity for parents, for checklists used for surveillance tools (Table 1). SMEs nominated the
pediatricians, and other early needed to be established to evaluate criteria on the basis of their clinical
childhood professionals (ECPs) the existing CDC checklists. Second, experience and use of CDC
about when to be concerned or milestones within checklists would surveillance materials. Nominations
when additional screening might be represent milestones above the 50th were discussed, and those that were
helpful.4 For example, lists based on percentile3,4,7,8 to ensure that most unanimously agreed upon were
median (50th percentile) age children would achieve the included as criteria. Of note, the
milestones might encourage a wait- milestone by a given age. Lastly, SMEs agreed that milestones should
and-see5 approach because half of new checklists for the 15- and 30- be easily observed in natural
children are not expected to achieve month HSVs were needed to settings and $75% of children
the milestone by that age. In CDC complete the series 2 months to 5 would be expected to achieve a
focus groups, parents of children years of age to improve integration milestone at a given age. The
with disabilities reported delays in of developmental surveillance across strategy ($75%) was chosen to
identification because they were early childhood HSVs. This article support clinical judgment regarding
told to wait, that children develop presents the results of these performing additional
differently, and that some take revisions. developmental screenings, with
longer than others. Milestone lists
validated screening tools as a next
need to support developmental
METHODS step to assess a child’s risk for
surveillance and clinical judgment
The AAP Systems of Services for developmental delays. This strategy
on when additional developmental
Children and Youth With Special may also prevent a wait-and-see
screening could better assess risk
Health Care Needs team identified approach because most children of
for developmental delays.
and convened 8 subject matter the same age would be expected to
In 2004, the CDC’s Learn the Signs. experts (SMEs) in different fields of achieve the milestone. To reduce
Act Early. program developed free child development. The group confusion about when to be
developmental surveillance included developmental-behavioral, concerned, developmental warning
milestone checklists that included neurodevelopmental, and general signs were eliminated because not
developmental warning signs for pediatricians; child and achieving milestones that most
parents, pediatricians, and ECPs; developmental psychologists; and a children ($75%) are expected to
messaging to “act early” by professor of special education and achieve similarly warrants more in-
2 ZUBLER et al
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TABLE 1 Criteria for Developmental Milestones and Surveillance Tools.
1. Milestones are included at the age most ($75%) children would be expected to demonstrate the milestone
2. Eliminate “warning signs”a
3. Are easy for families of different social, cultural, and ethnic backgrounds to observe and use
4. Are able to be answered with yes, not yet, or not sure
5. Use plain language, avoiding vague terms like may, can, and begins
6. Are organized in developmental domains
7. Show progression of skills with age, when possible
8. Milestones are not repeated across checklists
9. Include open-ended questions
10. Include information for developmental promotion
11. Include information on how to act early if there are concerns
Criteria developed by SMEs.
a
Milestones listed separately within CDC materials with parent messaging to act early if child has not attained them.
depth surveillance and consideration by a specific age, and limited to Milestone Evaluation
for developmental screening. children aged #5 years. Articles The following data were extracted
were excluded if evidence was from existing CDC milestones,
Milestone Identification limited to special populations (eg, articles selected for review, and
Milestones for possible inclusion in preterm infants) or risk factors. developmental resources: individual
CDC surveillance materials were Non–peer-reviewed articles, milestones, supporting references,
identified by the SMEs. Existing CDC dissertations, and books were also and any normative data or
milestones were automatically excluded. published clinical opinion for the
included for evaluation and were milestone. Milestones with
the foundation for the revised Articles were evaluated by the first
conflicting data (eg, age at which
checklists. Other milestones were 2 authors to determine if they met
most children should achieve the
identified by a literature review and inclusion criteria. Articles chosen by
milestone) were flagged for
commonly used developmental both authors, either on initial review
additional discussion.
resources. or after additional discussion and
agreement between these 2 authors, 4A comprehensive database was
Literature Review had milestone data extracted for created with information extracted
A broad literature search was review by the SME group. from CDC milestones and resources
conducted in March 2019 using for individual milestones from ages
Developmental Resources
MEDLINE, PsychInfo, and ERIC 2 months to 5 years, aligned with
databases. Search terms were SMEs nominated several additional AAP HSV ages, and shared with the
developed in collaboration with the resources for evaluation, including SME group. Original data sources,
CDC librarian after discussion of the parent resources, professional such as articles that met inclusion
objective of the literature review teaching resources, and commonly criteria and nominated
and comprised the following: (1) used screening and diagnostic developmental resources, were
milestone, normative (data, table, evaluation tools (Table 2). also shared with the SME group.
range, value) or age (range, Inclusion criteria for these SMEs collaborated through an in-
appropriate) AND (2) child resources were availability in person meeting, 6 virtual meetings,
development or infant development English and contained evidence and e-mail reviews of decision
AND (3) percentile, psychometrics, that supported at least one summaries from January to
predictive values, red flags, warning individual developmental milestone September 2019.
signs, assessment, monitor, delay, or or included published clinical
reference (standard, values). opinion (ie, consensus milestones) During meetings, the SMEs
that children exhibit the milestone discussed categorizing milestones
An article was included for by a specific age. All nominations into 4 developmental domains: (1)
evaluation if it was written in were accepted for additional social emotional, (2) language/
English, contained evidence that review. communication, (3) cognitive, and
supported at least one normed (4) motor. These domains were
individual developmental milestone CDC Milestones previously used in CDC materials
or included published clinical Existing CDC milestones served as a and could help parents to learn
opinion (ie, consensus milestones) foundation for identifying milestones about different areas of child
that children exhibit the milestone and were automatically evaluated. development (eg, social-emotional
PEDIATRICS Volume 149, number 3, March 2022 3

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TABLE 2 Additional Developmental Resources Reviewed
Parent Resources Educational/Training Resources Developmental Screening Tools Diagnostic Evaluation Toolsa
AAP Bright Futures Previsit AAP Bright Futures guidelines (4th ed)9 Ages & Stages Questionnaires Bayley Scales of Infant and Toddler
Questionnaires10 AAP Pediatrics in Review articles15–21 (3rd ed)22 Development (3rd ed)27
American Speech-Language- Ages & Stages Questionnaires: Beery-Buktenica Developmental
Hearing Association Social-Emotional23 Test of Visual-Motor Integration
development charts11 Modified Checklist for Autism in (6th ed)28
AAP brochure “Is Your One-Year- Toddlers, Revised24 BRIGANCE Early Childhood
Old Communicating With You?”12 Parents’ Evaluation of Screens III29
CDC Learn the Signs. Act Early. Developmental Status With The Capute Scales: Cognitive
checklists13 Developmental Milestones25 Adaptive Test/Clinical Linguistic
FIRST WORDS Project 16 × 1614 Survey of Well-Being in Young and Auditory Milestone Scale30
Children26 MacArthur-Bates Communicative
Development Inventories
(2nd ed)31
Mullen Scales of Early
Learning32
Peabody Developmental Motor
Scales (2nd ed)33
Preschool Language Scale-534
a
Diagnostic evaluation tools were cross referenced when there was lack of agreement supporting a milestone or age of a milestone across other data sources. Not all mile-
stones were cross referenced with diagnostic resources.
skills in addition to language/ If there was disagreement across simplified the milestones and added
communication skills). Because sources or lack of evidence examples to try to improve
milestones often represent skills supporting a milestone for a specific understanding. The CDC team then
across several domains, they were age, additional research was reviewed milestones from a cultural
placed in the domain in which the conducted, and additional evidence and health communication
SME group believed that parents was then evaluated by the SMEs perspective (eg, family friendly,
would most likely identify them. For according to the developed criteria. fifth- to sixth-grade reading level),
example, reciprocal play skills This included reviewing diagnostic and SMEs reviewed those changes
involving other people were evaluation tools (Table 2) and/or again to ensure that the milestone
categorized as social-emotional, and conducting a separate PubMed still represented the developmental
other play skills were categorized as search for a specific milestone or a construct being assessed.
cognitive. related skill. For example, additional
evidence was sought for age-specific With the use of back-translation
Milestones were reviewed for 2 to development of gestures like lifting methods, the milestones were
3 ages at a time (eg, 2, 4, and 6 arms to be picked up, waving bye- translated into Spanish by CDC
months) so that skill progression Multilingual Services and reviewed
bye, and blowing a kiss.
could be considered. Milestones by 2 native Spanish-speaking
were reviewed by the SME group SMEs used the available evidence pediatricians. Cognitive testing with
on the basis of the criteria outlined base and their clinical experience to a diverse sample of parents located
in Table 1. First, SMEs considered determine if and at what age a in different regions of the United
milestones with normative data milestone would be included in the States provided feedback on
that supported achievement by revised checklists. Only milestones relatability and clarity, which led the
$75% of children at a particular with unanimous agreement were SMEs to make additional changes to
age. Next, they considered included. wording. Results of cognitive testing
milestones from screening and will be published separately.
diagnostic tools. Finally, SMEs During the evaluation process, SMEs
considered milestones that were denoted milestones they included RESULTS
based on published clinical for surveillance but believed that Of the 1027 articles generated from
opinion. Each of these data sources additional research could improve the literature review, 34 met
was cross referenced with the age placement, quality, and/or inclusion criteria. Of those, 24
others to get a sense of the quantity of supporting evidence or contained normative data, and 10
evidence base available to support better capture the underlying contained published clinical opinion
inclusion of a milestone in revised developmental construct of the for $1 milestones. Six additional
CDC checklists. milestone. Finally, the SMEs articles were found through
4 ZUBLER et al
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independent searches to evaluate different ages. For example, Tries to Of the final 159 milestones, 127
individual milestones when SMEs use things the right way, like a (79.9%) were retained or added on
determined that the milestone was phone, cup, or book” was on both the basis of normative data, whereas
appropriate but insufficient or the 12- and 18-month checklists; 32 (20.1%) milestones were
conflicting evidence supported its this milestone was placed only at 15 included on the basis of screening
use at a specific HSV age. Of the months on the basis of supporting and evaluation tools, published
articles with normative data, 14 evidence. Additionally, eliminating clinical opinion, and SME opinion. Of
(58.3%) described populations vague terms, such as may or begins, milestones with normative data, 32
within non–English-speaking resulted in moving and changing had normative data from only 1
countries. milestones; for example, “Begins to resource. The SMEs believed that 22
pass things from one hand to anoth- (13.8%) of the final milestones were
Tables 3 to 6 list the milestones that er” was removed from the list of candidates for additional research,
SMEs included in CDC checklists milestones at age 6 months and was as noted in Tables 3–6; this subset
after critical evaluation and included as “Moves things from one includes the milestone “Sings,
unanimous decision. They are hand to her other hand” at age 9 dances, or acts for you,” the only
presented by domain with HSV age, milestone included or retained
months.
references that support the without supporting evidence on the
inclusion of the milestone at that The 1-, 2-, and 3-year-old checklists basis of SME opinion.
age, and whether the milestone was had the greatest decrease in the
an existing or new CDC milestone. number of milestones, with a $50% Of the 77 developmental warning
Supporting references are divided reduction. Approximately half of the signs listed on the old CDC
into normative data, developmental aggregate loss for these ages was checklists, 59 (76.6%) had a
screening and evaluation tools, and due to moving milestones to the corresponding milestone on the new
published clinical opinions. new 15- and 30-month checklists. checklists.
When combining all new and
Previously, CDC had 216 milestones
revised checklists for 1 to 3 years, DISCUSSION
across 10 checklists. With the
the number of milestones was The CDC checklists support
addition of 15- and 30-month
reduced by 25.7%, consistent with developmental surveillance and
checklists and the evidence review
the 26.4% reduction of milestones other important components of the
process, 159 milestones were
included across 12 checklists. This across the other age ranges. early identification process by
represented a reduction of 57 pediatricians and other ECPs,
All 4 domains had a reduction in including developmental promotion,
(26.4%) CDC milestones, with the
number of milestones. Cognitive parent education and engagement,
average number of milestones per
milestones decreased by 34 communication of developmental
checklist decreasing from 22 to 13.
(50.7%), social emotional decreased progress and concerns, and
Of the final 159 milestones that met by 16 (27.5%), language decreased developmental screening.7,5,9,72–75
the evaluation criteria, 94 (59.1%) by 4 (9.1%), and motor decreased However, variability across
were based on CDC original by 3 (6.4%). Social-emotional and surveillance resources, including the
milestones and 65 (40.9%) were cognitive domain milestones were CDC’s, can create confusion
added on the basis of the milestone the least likely to have normative regarding what constitutes a
identification and evaluation data available. The social-emotional concern and when developmental
process. One third of the 94 retained domain had 25 (59.5%) milestones screening between recommended
CDC milestones were moved to a with 0 to 1 normed references and ages might be warranted.3,4,38,76
different age on the basis of the 8 (19.0%) with $3 normed
criterion that $75% of children references. The cognitive domain An expert working group convened
would be expected to achieve the had 19 (57.6%) milestones with 0 to by AAP sought to improve CDC
milestone by that age. When moved, 1 normed references and 8 (24.2%) surveillance tools by enhancing
21 of those 31 milestones were with $3 references. In contrast, conversations among pediatricians,
transferred to an older age. More language and motor domains had 11 ECPs, and families regarding
than half (56.5%) of the original 216 (27.5%) and 10 (22.7%) milestones childhood development and guiding
milestones were eliminated with 0 to 1 normed references and clinical judgment on when to
(Supplemental Table 7) on the basis 21 (52.5%) and 30 (68.1%) conduct developmental screening
of SME criteria, including 25 that milestones, respectively, with $3 between recommended ages. These
were duplicated across checklists at normed references. tools are not intended to replace

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6
TABLE 3 Social-Emotional Milestones With Supporting Normative Data, Evaluation Tools, and Published Clinical Opinion References
Source
Developmental
Screening and Published Clinical
Social-Emotional Milestones Age CDC or New Normative Dataa Evaluation Toolsb Opinionc
Calms down when spoken to or 2 mo New Ertem et al (35) — ASHA (11), Bright
picked upd Futures (36),
Dosman et al (8),
Sharp et al (37)
Looks at your face 2 mo CDC Ertem et al (35), Sheldrick — Bright Futures (36),
and Perrin (38) Dosman et al (8),
Scharf et al (18)
Seems happy to see you when 2 mo New Ertem et al (35), Sheldrick — —
you walk up to her and Perrin (38), Thalagala
(39)
Smiles when you talk to or 2 mo CDC Bhave et al (40), Ertem et al ASQ-3 (22), PEDS-DM ASHA (11)
smile at her (35), Lejarraga et al (41), (25)
Thalagala (39)
Smiles on his own to get your 4 mo CDC Ertem et al (35) ASQ-3, PEDS-DM Bright Futures (36)
attention
Chuckles (not yet a full laugh) 4 mo New Accardo and Capute (30), ASQ-3, PEDS-DM ASHA (11), Bellman
when you try to make her Bhave et al (40), Ertem et al (42), Bright
laugh et al (35), Sheldrick and Futures (36)
Perrin (38)
Looks at you, moves, or makes 4 mo New Ertem et al (35) PEDS-DM —

sounds to get or keep your
attention
Knows familiar people 6 mo CDC Bhave et al (40), Ertem et al ASQ-3 Bright Futures (36),
(35) Dosman et al (8),
Gerber et al (20),
Scharf et al (18)
Likes to look at himself in the 6 mo CDC Bhave et al (40), Lejarraga ASQ-3 Bright Futures (36)
mirror et al (41)
Laughs 6 mo New Accardo and Capute (30), ASQ-3, PEDS-DM Bellman et al (42),
Bhave et al (40), Ertem Bright Futures
et al (35), Sheldrick and (36), Dosman et al
Perrin (38) (8)
Is shy, clingy, or fearful around 9 mo CDC Ertem et al (43), Kumar et al — Gerber et al (20),
strangers (44), Lancaster et al (45) Scharf et al (18)
Shows several facial 9 mo New Thalagala (39) — Gerber et al (20),
expressions, like happy, sad, Scharf et al (18)
angry, and surprisedd
Looks when you call his name 9 mo CDC Gladstone et al (46), ASQ-3, PEDS-DM Bright Futures (36)
Sheldrick and Perrin (38) Dosman et al (8),
ZUBLER et al
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TABLE 3 Continued
Source
Developmental
Gerber et al (20),
Scharf et al (18)
Reacts when you leave (looks, 9 mo CDC Ertem et al (43) — Dosman et al (8),
reaches for you, or cries)d Gerber et al (20),
Scharf et al (18)
Smiles or laughs when you 9 mo CDC Ertem et al (35), Lejarraga PEDS-DM Bellman et al (42),
play peek-a-boo et al (41), Sheldrick and Bright Futures
Perrin (38), Thalagala (39) (36), Dosman et al
(8), Gerber et al
PEDIATRICS Volume 149, number 3, March 2022

(20), Scharf et al
(18)
Plays games with you, like pat- 12 mo CDC Ertem et al (35), Fenson et al Bellman et al (42),
a-cake (47), Sheldrick and Perrin Bright Futures
(38) (36), Gerber et al
(20), Scharf et al
(18)
Copies other children while 15 mo CDC — — Bright Futures (36),
playing, like taking toys out Dosman et al (8)
of a container when another
child doesd

Shows you an object that he 15 mo New Crais et al (48) ASQ-3 Dosman et al (8),
likes First Words (14),
Gerber et al (20),
Scharf et al (18)
Claps when excited 15 mo New Crais et al (48), Kwon et al — —
(49)
Hugs stuffed doll or other toy 15 mo New Crais et al (48), Fenson et al — Colson and Dworkin
(47) (16), Johnson and
Blasco (15)
Shows you affection (hugs, 15 mo CDC Ertem et al (43) ASQ-SE-2 (23), Bayley III Johnson and Blasco
cuddles, or kisses you) (27) (15), Vaughan (17)
Moves away from you, but 18 mo CDC — ASQ-SE-2 Dosman et al (8),
looks to make sure you are Gerber et al (20),
close by Scharf et al (18)
Points to show you something 18 mo CDC — Bayley III, MCHAT-R (24), Bellman et al (42),
interesting PEDS-DM Bright Futures
(36), Dosman et al
(8), Gerber et al
7
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8
TABLE 3 Continued
Source
Developmental
(20), Scharf et al
(18)
Puts hands out for you to wash 18 mo New Gladstone et al (46) — —
them
Looks at a few pages in a book 18 mo New Ertem et al (35) ASQ-SE-2 Behrman et al (50),
with youd Colson and
Dworkin (16),
Vaughan (17)
Helps you dress him by 18 mo CDC — ASQ-3, PEDS-DM Bright Futures (36),
pushing arm through sleeve Dosman et al (8),
or lifting up foot Johnson and
Blasco (15)
Notices when others are hurt 24 mo New — PEDS-DM Dosman et al (8),
or upset, like pausing or Scharf et al (18)
looking sad when someone
is crying
Looks at your face to see how 24 mo New — ASQ-SE-2, MCHAT-R, Bright Futures (36),
to react in a new situation PEDS-DM Dosman et al (8),
Johnson and
Blasco (15)

Plays next to other children 30 mo CDC Lancaster et al (45), ASQ-SE-2, PEDS-DM Bright Futures (36),
and sometimes plays with Lansdown et al (51) Dosman et al (8),
them Gerber et al (20),
Johnson and
Blasco (15), Scharf
et al (18)
Shows you what she can do by 30 mo New Sheldrick and Perrin (38) — —
saying, “Look at me!”
Follows simple routines when 30 mo New — ASQ-SE, PEDS-DM Colson and Dworkin
told, like helping to pick up (16), Gerber et al
toys when you say, “It’s (20), Johnson and
clean-up time.” Blasco (15), Scharf
et al (18), Vaughan
(17)
Calms down within 10 min 3y CDC — — Dosman et al (8),
after you leave her, like at Johnson and
child care drop offd Blasco (15)
Notices other children and 3y New Lansdown et al (51) ASQ-SE-2, PEDS-DM Dosman et al (8),
joins them to play Gerber et al (20),
Scharf et al (18)
4y CDC Ertem et al (43) ASQ-3, PEDS-DM
ZUBLER et al
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TABLE 3 Continued
Source
Developmental
Pretends to be something else Behrman et al (50),
during play (teacher, Bright Futures
superhero, dog) (36), Dosman et al
(8)
Asks to go play with children if 4y CDC Gladstone et al (46) — —
none are around, like “Can I
play with Alex?”d
Comforts others who are hurt 4y CDC — ASQ-3, PEDS-DM Dosman et al (8)
or sad, like hugging a crying

friendd
Avoids danger, like not jumping 4y New — ASQ-SE-2 —
from tall heights at the
playground
Likes to be a “helper” 4y New Gladstone et al (46), PEDS-DM Gerber et al (20),
Haltiwanger and Coster Scharf et al (18)
(52)
Changes behavior on the basis 4y New Gladstone et al (46) ASQ-SE-2, PEDS-DM —
of where she is (place of
worship, library, playground)
Follows rules or takes turns 5y CDC Gladstone et al (46), ASQ-3, PEDS-DM Bright Futures (36),

when playing games with Haltiwanger and Coster Colson and
other children (52), Kumar et al (44), Dworkin (16),
Sheldrick and Perrin (38) Dosman et al (8),
Gerber et al (20),
Scharf et al (18)
Sings, dances, or acts for youd 5y CDC — — —
Does simple chores at home, 5y New Gladstone et al (46), PEDS-DM —
like matching socks or Haltiwanger and Coster
clearing the table after (52)
eating
ASHA, American Speech-Language-Hearing Association; ASQ-3, Ages & Stages Questionnaires (3rd ed); ASQ-SE-2, Ages & Stages Questionnaires: Social-Emotional (2nd ed); Bayley III, Bayley Scales of Infant and Toddler Development (3rd
ed); MCHAT-R, Modified Checklist for Autism in Toddlers, Revised; PEDS-DM, Parents’ Evaluation of Developmental Status With Developmental Milestones. —, Empty cells indicate that type/category of data was not available to support
inclusion of that milestone.
a
Provides baseline distribution data for age of attainment of a milestone for a given population.
b
Some commonly used developmental screening and diagnostic evaluation tools (not all available tools are represented).
c
Uncited on the basis of clinical opinion and/or report of the average or median age that a milestone should be achieved.
d
SME agreement that additional research would be beneficial.
9
validated screening tools but instead recommended that most children may identify those types of
to promote optimal child ($75%) should be expected to concerns. For example, the act early
development and encourage achieve milestones by a given age. message was retained, and new
professionals to act early through open-ended questions were added
surveillance and screening as SMEs believed that using 50th to encourage parents to ask about
outlined in the AAP’s clinical percentile milestones for other concerns.
report.1 Results indicate substantial surveillance would not support
changes were made developing and clinical decision-making for Use of this same strategy is intended
applying criteria for surveillance developmental screening because to discourage the wait-and-see
milestones and tools, adding 15- and only half of children would be approach and could prevent worry
30-month checklists, and expected to achieve an individual for children older than the average
incorporating evidence-informed milestone by a given age. Using age of attainment of a milestone but
milestones. milestones that 85% or 90% of not likely to be at risk for delays.1,5
children would be expected to It could also eliminate the confusion
Clinicians have used attainment of achieve may limit opportunities for families had with milestones and
developmental milestones for almost additional screening for too many warning signs on the same checklist
a century77 to determine if a child is children at risk for developmental and repetition of milestones across
developing typically. Pediatricians delays. A $75% criterion was thus checklists.
have reported increasing use of agreed upon to balance informed
milestone checklists from 53.0% in clinical decision-making regarding The application of additional criteria
2002 to 89.6% in 2016, in addition developmental screening and (Table 1) to improve clarity in the
to their report of increased provide opportunities to identify revised milestones may help
developmental screening.78 children at risk for delays as soon as parents, pediatricians, and other
However, these surveillance possible. Pediatricians are ECPs to recognize when missing
milestone checklists are likely based encouraged to follow AAP milestones might indicate the need
on published clinical opinion due to recommendations to screen a child, for developmental screening.
the lack of published normative using validated screening tools, Although milestones typically span
milestone data and the lack of when surveillance reveals a concern several developmental domains,
citations of original sources on or anytime a concern is raised, to SMEs believed that keeping domain
checklists. The domain tables identify and refine the risk for labels could improve awareness of
generated from this work linking developmental delays.1 the less commonly known social-
developmental milestones to emotional and cognitive
empirically informed evidence and The criterion (Table 1) for development milestones of young
published clinical opinion could milestones representing those that children. Showing progression of a
improve training of professionals most children ($75%) would be skill, like walking, could
and methods for surveillance,4,7,8 expected to achieve eliminated the demonstrate how earlier milestones
such as incorporation of the CDC’s need for the CDC’s previous warning lay the foundation for later ones.
open access milestones/checklists signs because most are now Adding the open-ended question, “Is
into electronic health records. represented as milestones. Using there anything your child is doing or
this strategy, SMEs agreed that a is not doing that concerns you?”
Milestone checklists used in child not meeting a milestone may encourage parents to discuss
surveillance are intended to prompt should be considered for screening the quality with which a child
conversations, review similar to children demonstrating exhibits a milestone, milestones not
developmental history and progress, warning signs. Less than a quarter listed within the sample, and
and elicit concerns. The CDC of warning signs could not be atypical behaviors difficult to
checklists should not replace replaced with an evidence-informed capture through a list.42 Finally,
universal developmental screening, milestone. Examples not including information on
provide a risk categorization, or represented as new milestones developmental promotion and acting
diagnose DDs. To determine if include subjective items such as early may empower families to
concerns about milestones should “shows extreme behavior (unusually support their child’s development
prompt a more in-depth fearful, aggressive, shy or sad)” and and to ask about screening if they
developmental history, observation, items that may be better recognized have concerns.
and examination along with during a physical examination, such
consideration for assessing actual as “stiff or tight muscles.” Additional Surveillance of social-emotional
risk by screening, the SMEs features of the surveillance tools and cognitive milestones supports
10 ZUBLER et al
by guest
by guest
TABLE 4 Language and Communication Milestones With Supporting Normative Data, Evaluation Tools, and Published Clinical Opinion References
Source
Language/ Developmental
Communication Screening and
Milestones Age CDC or New Normative Dataa Evaluation Toolsb Published Clinical Opinionc
d
Makes sounds other 2 mo CDC Dosman et al (8), ASQ-3 (22), PEDS-DM Blackwell and Baker (53),
than crying Sheldrick and Perrin (25) Bright Futures (36),
(38) Gerber et al (20), Scharf
et al (18)
Reacts to loud 2 mo New — — Accardo and Capute (30),
soundse ASHA (11), Bellman et al
(42), Bright Futures (36)
Makes sounds like 4 mo CDC Accardo and Capute ASQ-3 ASHA (11), Bright Futures
“oooo” and “aahh” (30), Ertem et al (36), Dosman et al (8),

(cooing) (35) Gerber et al (20), Scharf
et al (18)
Makes sounds back 4 mo New Ertem et al (35), Den ASQ-3 Bellman et al (42)
when you talk to Ouden et al (54),
him Kumar et al (44)
Turns head toward 4 mo CDC Accardo and Capute — Bellman et al (42), Dosman
the sound of your (30), Bhave et al et al (8), Gerber et al
voice (40), Den Ouden (20), Johnson and Blasco
et al (54), Sheldrick (15), Scharf et al (18)
and Perrin (38)
Takes turns making 6 mo CDC Kumar et al (44), — Dosman et al (8), Gerber

sounds with you Lejarraga et al (41) et al (20), Scharf et al
(18)
Blows “raspberries” 6 mo New Accardo and Capute — Blackwell and Baker (53),
(sticks tongue out (30) Gerber et al (20), Scharf
and blows) et al (18)
Makes squealing 6 mo New — ASQ-3 Bellman et al (42), Blackwell
noises and Baker (53), Gerber
et al (20), Scharf et al
(18)
Makes different 9 mo CDC Accardo and Capute ASQ-3, PEDS-DM ASHA (11), Bright Futures
sounds like (30), Bhave et al (36)
“mamamama” and (40), Den Ouden
“babababa” et al (54), Lancaster
et al (45), Lejarraga
et al (41), Sheldrick
and Perrin (38)
Lifts arms up to be 9 mo New Ertem et al (35), — ASHA (11), Bright Futures
picked up Fenson et al (47), (36), Dosman et al (8),
Gladstone et al (46), First Words (14), Gerber
Kwon et al (49), et al (20), Scharf et al
Sheldrick and Perrin (18)
(38)
11
by guest
12
TABLE 4 Continued
Source
Waves “bye-bye” 12 mo CDC Accardo and Capute — ASHA (11), Bright Futures
(30), Crais et al (48), (36), First Words (14),
Den Ouden et al Gerber et al (20), Scharf
(54), Ertem et al et al (18)
(35), Fenson et al
(47), Kwon et al (49)
Calls a parent 12 mo CDC Accardo and Capute — AAP (12), Bright Futures
“mama” or “dada” (30), Crais et al (48), (36), Gerber et al (20),
or another special Sheldrick and Perrin Scharf et al (18)
name (38)
Understands “no” 12 mo CDC Accardo and Capute Bayley III (27) Blackwell and Baker (53),
(pauses briefly or (30), Ertem et al Dosman et al (8), Gerber
stops when you (35), Gladstone et al et al (20), Scharf et al
say it) (46), Lancaster et al (18)
(45), Lejarraga et al
(41), Thalagala (39)
Tries to say 1 or 2 15 mo New Gladstone et al (46), ASQ-3, PEDS DM Bright Futures (36), Johnson
words besides Lancaster et al (45), and Blasco (15), Sharp
mama or dada, Tamis-Lemonda et al and Hillenbrand (37)
like “ba” for ball (55)

or “da” for dog
Looks at a familiar 15 mo CDC Ertem et al (35), ASQ-3 Gerber et al (20), Scharf
object when you Lancaster et al (45), et al (18)
name it Sheldrick and Perrin
(38)
Follows directions 15 mo New Accardo and Capute ASQ-3 Bright Futures (36), Johnson
given with both a (30), Ertem et al and Blasco (15)
gesture and words. (35), Gladstone et al
For example, he (46)
gives you a toy
when you hold out
your hand and say,
“Give me the toy.”
Points to ask for 15 mo CDC Ertem et al (43), Kwon ASQ-3 AAP (12), Gerber et al (20),
something or to et al (49), Lancaster Johnson and Blasco (15),
get help et al (45) Scharf et al (18)
Tries to say $3 18 mo CDC Accardo and Capute ASQ-3 Bellman et al (42), Blackwell
words besides (30), Ertem et al and Baker (53), Bright
mama or dada (35), Gladstone et al Futures (36), Dosman
(46), Lancaster et al et al (8), Gerber et al
(20), Scharf et al (18)
ZUBLER et al
by guest
TABLE 4 Continued
Source
(45), Sheldrick and
Perrin (38)
Follows 1-step 18 mo CDC Accardo and Capute — ASHA (11), Dosman et al (8),
directions without (30), Ertem et al Gerber et al (20), Scharf
any gestures, like (35), Gladstone et al et al (18)
giving you the toy (46), Lancaster et al
when you say, (45), Sheldrick and
“Give it to me.” Perrin (38)
Points to things in a 24 mo CDC Accardo and Capute ASQ-3 ASHA (11), Bellman et al

book when you (30), Lejarraga et al (42), Blackwell and Baker
ask, for example, (41) (53), Bright Futures (36),
“Where is the Gerber et al (20),
bear?” Johnson and Blasco (15),
Scharf et al (18)
Says at least 2 words 24 mo CDC Accardo and Capute ASQ-3 AAP (12), ASHA (11),
together, like (30), Den Ouden Bellman et al (42), Bright
“More milk.” (54), Ertem et al Futures (36), Dosman
(43), Gladstone et al et al (8), Gerber et al
(46), Sheldrick and (20), Scharf et al (18)
Perrin (38)

Points to at least 2 24 mo CDC Accardo and Capute ASQ-3, PEDS-DM ASHA (11), Bellman et al
body parts when (30), Muluk et al (42), Blackwell and Baker
you ask him to (56), Sheldrick and (53), Bright Futures (36),
show you Perrin (38) Johnson and Blasco (15)
Uses more gestures 24 mo New Fenson et al (47), Kwon — Dosman et al (8), First
than just waving et al (49) Words (14)
and pointing, like
blowing a kiss or
nodding yes
Says 50 words 30 mo New Accardo and Capute ASQ-3 AAP (12), Bright Futures
(30), Lancaster et al (36), Gerber et al (20),
(45), Tamis-Lemonda Johnson and Blasco (15),
et al (55) Scharf et al (18)
Says $2 words, with 30 mo New Accardo and Capute ASQ-3, Bayley III Blackwell and Baker (53),
1 action word, like (30), Ertem et al Dosman et al (8), Gerber
“Doggie run.” (35), Lancaster et al et al (20), Johnson and
(45), Tamis-Lemonda Blasco (15), Scharf et al
et al (55) (18)
Names things in a 30 mo New Lancaster et al (45), ASQ-3, Bayley III Gerber et al (20), Scharf
book when you Sheldrick and Perrin et al (18)
point and ask, (38)
“What is this?”
13
by guest
14
TABLE 4 Continued
Source
Says words like I, me, 30 mo CDC Accardo and Capute ASQ-3, Bayley III Bright Futures (36), Colson
or we (30), Ertem et al and Dworkin (16), Gerber
(35), Lancaster et al et al (20), Johnson and
(45), Sheldrick and Blasco (15), Scharf et al
Perrin (38) (18)
Talks with you in 3y CDC — Bayley III —
conversation using
at least 2 back-
and-forth
exchangese
Asks who, what, 3y New Ertem et al (43), Nair — ASHA (11), Colson and
where, or why and Russell (57), Dworkin (16)
questions, like Sheldrick and Perrin
“Where is mommy/ (38)
daddy?”
Says what action is 3y New Gladstone et al (46) ASQ-3, Bayley III Gerber et al (20), Knobloch
happening in a et al (58), Scharf et al
picture when (18)
asked, like
running, eating, or

playing
Says first name when 3y CDC Gladstone et al (46), ASQ-3 Gerber et al (20), Knobloch
asked Haltiwanger and et al (58), Scharf et al
Coster (52), Lansdown (18)
and Perrin (38)
Talks well enough for 3y CDC Ertem et al (35), Bayley III ASHA (11), Bellman et al
others to Gladstone et al (46), (42), Blackwell and Baker
understand, most Lancaster et al (45) (53), Bright Futures (36),
of the time Dosman et al (8), Gerber
et al (20), Johnson and
Blasco (15), Scharf et al
(18)
Says sentences with 4y New — ASQ-3 ASHA (11)
$4 wordse
Says some words 4y CDC — — Colson and Dworkin (16)
from a song, story,
or nursery rhymee
Talks about at least 1 4y New — — ASHA (11)
thing that
happened during
ZUBLER et al
by guest
TABLE 4 Continued
Source
his day, like “I
played soccer.”e
Answers simple 4y New Ertem et al (43), ASQ-3 ASHA (11), Gerber et al (20),
questions, like Gladstone et al (46), Scharf et al (18)
“What is a coat Lejarraga et al (41),
for,” or “What is a Nair and Russell
crayon for?” (57), Sheldrick and
Perrin (38)
Tells a story she 5y CDC McCabe and Rollins — Gerber et al (20), Scharf

heard or made up (59), Sheldrick and et al (18)
with at least 2 Perrin (38)
events, like a cat
stuck in a tree and
a firefighter saving
it
Answers simple 5y New — — ASHA (11)
questions about a
book or story after
you read or tell it
to himd

Keeps a conversation 5y New — — ASHA (11)
going with >3
back-and-forth
exchangee
Uses or recognizes 5y New — PEDS-DM ASHA (11), Gerber et al (20),
simple rhymes Scharf et al (18)
(bat-cat, ball-tall)
ASHA, American Speech-Language-Hearing Association; ASQ-3, Ages & Stages Questionnaires (3rd ed); Bayley III, Bayley Scales of Infant and Toddler Development (3rd ed); PEDS-DM, Parents’ Evaluation of Developmental Status With Devel-
opmental Milestones. —, Empty cells indicate that type/category of data was not available to support inclusion of that milestone.
a
b
c
Uncited on the basis of clinical opinion and/or report the average or median age that a milestone should be achieved.
d
Dosman et al8 contained both published clinical opinion and normative data.
e
15
early identification of children with Regardless of supporting data type, confidence to assess concerns
intellectual and social-emotional all revised milestones had raised.
disorders, including autism unanimous SME support for their
spectrum disorder. In our review, inclusion in a surveillance tool. CONCLUSIONS
milestones included in the social- When normative data existed, Early identification and
emotional domain had the fewest limitations remained in the intervention for the 1 in 6 children
normed references per milestone, availability of milestones that met with DDs have been shown to
followed by the cognitive domain, other criteria. For example, improve outcomes.79–83 However,
language domain, and motor sometimes it was difficult to find less than a quarter of children with
domain. When social-emotional naturally observable milestones DDs receive early intervention
milestones were available, they compared with milestones services before age 3 years,84,85
were often self-help rather than demonstrated during standardized and most children with emotional,
social engagement and emotional testing. Although the milestones behavioral, and developmental
regulation skills. These results are evidence-informed using conditions, other than autism
highlight the need for additional international sources and cognitive spectrum disorder, do not receive
research on social-emotional testing with parents was done, services before age 5 years.86
milestones. For example, can there is no certainty that these Developmental surveillance is an
social-emotional function be new milestones will resonate with important part of early
assessed using milestones during
all families or that they are the identification1,87 and facilitates
developmental surveillance at
most relevant milestones for education, communication, and
HSVs, and what factors influence
developmental surveillance. These relationship building among
the timing and development of
checklists and others have not parents, pediatricians, and ECPs.
social-emotional skills? Despite
been tested to see whether they Research in early identification has
relatively more evidence in the
indeed lead to appropriate focused primarily on
language domain, SMEs believed
developmental screening between developmental screening, not
that more research is needed in
recommended ages and improve surveillance. Improvements in
the intersection of the social-
early identification. surveillance tools and processes
emotional and language domains to
recognize and monitor the could help to identify concerns and
There are other gaps in support clinical judgment
development of social language in
developmental surveillance regarding developmental screening
young children.
research. Best practices for to allow more timely referral to
Limitations conducting the recommended 6 early intervention services and
components1 of surveillance are additional evaluation. The methods
There were limitations with the
not available. There are described herein led to substantial
revision process. SMEs’ opinions
determined which HSV was most limitations in the use of revisions of CDC resources to
appropriate for a milestone, given milestones, even evidence- better support developmental
existing evidence and the goal that informed ones, as the sole surveillance. Best practices for
most children ($75%) would be component of developmental surveillance and improvements in
expected to achieve it by that age. surveillance. Milestones/milestone surveillance tools could be
For example, if there was evidence checklists can support some supported by additional research
that 50% of children reach a components, such as taking a on individual normed milestones,
milestone at 11 months and 90% developmental history and particularly social-emotional and
reach it at 16 months, it was eliciting concerns, but surveillance cognitive milestones; how parents,
placed on the 15-month checklist. also involves observation, pediatricians, and ECPs learn and
Eighty percent of the revised examination, education, understand milestones; which
milestones had normative data to communication, and clinical milestones are most likely to lead
support their inclusion on a decision-making. Moreover, to appropriate screening; whether
specific HSV age checklist. trusting relationships may develop the use of milestones that most
However, it was necessary to use through the longitudinal process children ($75%) would be
data such as published clinical of surveillance and improve expected to achieve is appropriate
opinion to represent milestones in parents’ confidence in sharing for surveillance; whether
all domains across all ages. concerns and pediatricians’ categorizing milestones into
16 ZUBLER et al
by guest
by guest
TABLE 5 Cognitive Milestones With Supporting Normative Data, Evaluation Tools, and Published Clinical Opinion References
Source
Developmental
Cognitive Milestones Age CDC or New Normative Dataa Evaluation Toolsb Opinionc
Watches you as you 2 mo CDC Accardo and Capute ASQ-3 (22) —
move (30), Atkinson et al
(60), Bhave et al
(40), Ertem et al
(35), Sheldrick and
Perrin (38)
Looks at a toy for 2 mo New Kumar et al (44) — Accardo and Capute
several seconds (30), Bellman et al
(42)

If hungry, opens 4 mo New Carruth and Skinner ASQ-3, PEDS-DM (25) Gerber et al (20),
mouth when she (61), Thalagala (39) Johnson and
sees breast or Blasco (15), Scharf
bottle et al (18)
Looks at his hands 4 mo New Den Ouden et al (54), — Bellman et al (42),
with interest Ertem et al (35), Gerber et al (20),
Lejarraga et al (41) Johnson and
Blasco (15), Scharf
et al (18)
Puts things in her 6 mo CDC Ertem et al (35) ASQ-3 Gerber et al (20),
mouth to explore Scharf et al (18)

them
Reaches to grab a toy 6 mo CDC Den Ouden et al (54), ASQ-3 Dosman et al (8),
he wants Kumar et al (44) Gerber et al (20),
Johnson and
Blasco (15), Scharf
et al (18)
Closes lips to show 6 mo New — PEDS-DM —
she does not want
more foodd
Looks for objects 9 mo New Accardo and Capute — Bright Futures (36),
when dropped out (30), Ertem et al Dosman et al (8),
of sight (like his (35) Gerber et al (20),
spoon or toy) Johnson and
Blasco (15), Scharf
et al (18)
Bangs 2 things 9 mo CDC Ertem et al (35), ASQ-3 Bellman et al (42),
together Gladstone et al (46), Bright Futures
Sheldrick and Perrin (36), Gerber et al
(38) (20), Scharf et al
(18)
12 mo CDC Accardo and Capute ASQ-3
(30), Gladstone et al
17
by guest
18
TABLE 5 Continued
Source
Developmental
Puts something in a (46), Lancaster et al Bright Futures (36),
container, like a (45), Thalagala (39) Gerber et al (20),
block in a cup Scharf et al (18)
Looks for things he 12 mo CDC Accardo and Capute — Bright Futures (36),
sees you hide, like (30), Ertem et al Gerber et al (20),
a toy under a (35), Gladstone et al Scharf et al (18)
blanket (46)
Tries to use things 15 mo CDC — — Dosman et al (8),
the right way, like Johnson and
a phone, cup, or Blasco (15)
bookd
Stacks at least 2 15 mo New — Beery VMI (28) —
small objects, like
blocks
Copies you doing 18 mo CDC Den Ouden et al (54), ASQ-3, PEDS-DM Bellman et al (42),
chores, like Fenson et al (47) Dosman et al (8),
sweeping with a Gerber et al (20),
broom Scharf et al (18)
Plays with toys in a 18 mo CDC Ertem et al (43), ASQ-3 Bellman et al (42),
simple way, like Gladstone et al (46) Dosman et al (8),

pushing a toy car Lancaster et al (45) Gerber et al (20),
Johnson and
Blasco (15), Scharf
et al (18)
Holds something in 1 24 mo New Kimmerle et al (62) — —
hand while using
the other hand, for
example, holding a
container and
taking the lid offd
Tries to use switches, 24 mo CDC Ertem et al (35) ASQ-3 Bright Futures (36),
knobs, or buttons Colson and
on a toy Dworkin (16),
Dosman et al (8),
Gerber et al (20),
Scharf et al (18)
Plays with >1 toy at 24 mo New — PEDS-DM —
the same time, like
putting toy food on
a toy plate
30 mo New — ASQ-3
ZUBLER et al
by guest
TABLE 5 Continued
Source
Developmental
Uses things to Bright Futures (36),
pretend, like Dosman et al (8),
feeding a block to Gerber et al (20),
a doll as if it were Scharf et al (18)
food
Shows simple 30 mo New Lancaster et al (45) ASQ-3 —
problem-solving
skills, like standing
on a small stool to

reach something
Follows 2-step 30 mo CDC Accardo and Capute Bayley III (27) AAP (12), Bright
instructions, for (30), Ertem et al Futures (36),
example, “Put the (35), Gladstone et al Dosman et al (8),
toy down and (46) Lancaster et al Gerber et al (20),
close the door.” (45) Scharf et al (18)
Shows that he knows 30 mo New Accardo and Capute — Knobloch et al (58)
at least 1 color, (30), Sheldrick and
like pointing to a Perrin (38)
red crayon when
you ask, “Which

one is red?”
Draws a circle when 3y CDC Accardo and Capute ASQ-3 Behrman et al (50),
you show him how (30), Egan and Bellman et al (42),
Brown (63) Bright Futures
(36), Colson and
Dworkin (16),
Dosman et al (8),
Gerber et al (20),
Scharf et al (18)
Avoids touching hot 3y New Haltiwanger and Coster ASQ-SE (23) —
objects, like a (52)
stove, when you
warn herd
Names a few colors 4y CDC Accardo and Capute ASQ-3, Bayley III, PEDS- Gerber et al (20),
of items (30), Lejarraga et al DM Scharf et al (18)
(41), Sheldrick and
Perrin (38)
Tells what comes next 4y CDC — — Gerber et al (20),
in a well-known Scharf et al (18)
storyd
4y CDC Lejarraga et al (41), ASQ-3, PEDS-DM
19
by guest
20
TABLE 5 Continued
Source
Developmental
Draws a person with Bright Futures (36),
$3 body parts Gerber et al (20),
Scharf et al (18)
Counts to 10 5y CDC — ASQ-3 Dosman et al (8),
Gerber et al (20),
Scharf et al (18)
Names some 5y CDC Williams and Lerner PEDS-DM ASHA (11), Gerber
numbers between (64) et al (20), Scharf
1 and 5 when you et al (18)
point to them
Uses words about 5y CDC Sheldrick and Perrin PEDS-DM Colson and Dworkin
time, like (38) (16), Gerber et al
yesterday, (20), Scharf et al
tomorrow, (18)
morning, or night
Pays attention for 5y New — ASQ-SE —
5–10 min during
activities, for
example, during
story time or

making arts and
crafts (screen time
does not count)d
Writes some letters in 5y CDC Sheldrick and Perrin ASQ-3, PEDS-DM Dosman et al (8),
her name (38) Gerber et al (20),
Scharf et al (18)
Names some letters 5y New Williams and Lerner ASQ-3 Gerber et al (20),
when you point to (64) Scharf et al (18)
them
ASHA, American Speech-Language-Hearing Association; ASQ-3, Ages & Stages Questionnaires (3rd ed); ASQ-SE, Ages & Stages Questionnaires: Social-Emotional; Bayley III, Bayley Scales of Infant and Toddler Development (3rd ed); Beery
VMI, Beery-Buktenica Developmental Test of Visual-Motor Integration; PEDS-DM, Parents’ Evaluation of Developmental Status With Developmental Milestones. —, Empty cells indicate that type/category of data was not available to support
inclusion of that milestone.
a
b
c
Uncited on the basis of clinical opinion and/or report the average or median age that a milestone should be achieved.
d
ZUBLER et al
by guest
TABLE 6 Motor Milestones With Supporting Normative Data, Evaluation Tools, and Published Clinical Opinion References
Source
Developmental
Motor Milestones Age CDC or New Normative Dataa Evaluation Toolsb Opinionc
Holds head up when 2 mo CDC Accardo and Capute — Bright Futures (36),
on tummy (30), Carruth and Dosman et al (8),
Skinner (61), Den Gerber et al (20),
Ouden et al (54) Scharf et al (18)
Moves both arms and 2 mo New — ASQ-3 (22) Bright Futures (36)
both legs
Opens hands briefly 2 mo New Accardo and Capute ASQ-3 Bright Futures (36)
(30), Ertem et al

(41)
Holds head steady 4 mo CDC Ertem et al (35), PEDS-DM (25) Bright Futures (36),
without support Lejarraga et al (41), Gerber et al (20),
when you are Sheldrick and Perrin Scharf et al (18)
holding her (38)
Holds a toy when you 4 mo CDC Dosman et al (8)d — Bellman et al (42),
put it in his hand Gerber et al (20),
Scharf et al (18)
Uses her arm to 4 mo CDC Bhave et al (40), — Gerber et al (20),
swing at toys Dosman et al (8), Scharf et al (18)
Ertem et al (43),

Kumar et al (44)
Brings hands to 4 mo CDC Den Ouden et al (54), — Bright Futures (36),
mouth Ertem et al (35), Dosman et al (8)
Lejarraga et al (41),
Sheldrick and Perrin
(38)
Pushes up onto 4 mo CDC Accardo and Capute — Gerber et al (20),
elbows/forearms (30), Lejarraga et al Scharf et al (18)
when on tummy (41), Thalagala (39)
Rolls from tummy to 6 mo CDC Accardo and Capute ASQ-3 Gerber et al (20),
back (30), Den Ouden Scharf et al (18)
et al (54), Dosman
et al (8), Ertem et al
(35)
Pushes up with 6 mo CDC Accardo and Capute — Gerber et al (20),
straight arms (30), Carruth and Scharf et al (18)
when on tummy Skinner (61),
Thalagala (39)
Leans on hands to 6 mo CDC Accardo and Capute ASQ-3 Gerber et al (20),
support himself (30), Carruth and Scharf et al (18)
when sitting Skinner (61),
21
by guest
22
TABLE 6 Continued
Source
Developmental
Dosman et al (8),
Ertem et al (35),
Kitsao-Wekulo et al
(41)
Gets to a sitting 9 mo CDC Accardo and Capute — Gerber et al (20),
position by herself (30), Bhave et al Scharf et al (18)
(40), Gajewska et al
(66), Sheldrick and
Perrin (38)
Sits without support 9 mo CDC Accardo and Capute — Bellman et al (42),
(30), Bhave et al Gerber et al (20),
(40), Cox et al (67), Scharf et al (18)
Dosman et al (8),
Ertem et al (35),
Gladstone et al (46),
Lancaster et al (44),
Lejarraga et al (41)
Uses fingers to “rake” 9 mo New Accardo and Capute ASQ-3 Bright Futures (36),
food toward (30), Carruth and Gerber et al (20),

himself Skinner (61), Ertem Scharf et al (18)
et al (43), Gladstone
and Perrin (38)
Moves things from 1 9 mo CDC Accardo and Capute ASQ-3 Bright Futures (36),
hand to her other (30), Carruth and Dosman et al (8),
hand Skinner (61), Cox Gerber et al (20),
et al (67), Den Scharf et al (18)
Ouden et al (54),
Gladstone et al (46),
Kitsao-Wekulo et al
(65), Lancaster et al
(41), Sheldrick and
Perrin (38),
Thalagala (39)
Pulls up to stand 12 mo CDC Accardo and Capute — Bellman et al (42),
(30), Bhave et al Gerber et al (20),
(40), Den Ouden Scharf et al (18)
et al (54), Dosman
et al (8), Ertem et al
ZUBLER et al
by guest
TABLE 6 Continued
Source
Developmental
(43), Gladstone et al
(46), Lancaster et al
(41), World Health
Organization (68)
Walks, holding onto 12 mo CDC Accardo and Capute — Bellman et al (42),
furniture (30), Ertem et al Gerber et al (20),
(43), Lejarraga et al Scharf et al (18)
(41), World Health

Organization (68)
Drinks from a cup 12 mo New Gladstone et al (46), ASQ-3, PEDS-DM Bright Futures (36),
without a lid, as Lancaster et al (45) Gerber et al (20),
you hold it Johnson and
Blasco (15), Scharf
et al (18)
Picks things up 12 mo CDC Ertem et al (43), — Bright Futures (36),
between thumb Gladstone et al (46), Dosman et al (8),
and pointer finger, Kumar et al (44), Gerber et al (20),
like small bits of Lancaster et al (45), Scharf et al (18)
food Lejarraga et al (41)

Takes a few steps on 15 mo CDC Ertem et al (43), — Bright Futures (36)
his own Gladstone et al (46),
Noller and Ingrisano
(69)
Uses fingers to feed 15 mo New Carruth and Skinner — Bright Futures (36),
herself some food (61), Dosman et al Gerber et al (20),
(8), Kumar et al Scharf et al (18)
(41)
Walks without holding 18 mo CDC Accardo and Capute ASQ-3, PEDS-DM Bellman et al (42),
onto anyone or (30), Bhave et al Bright Futures
anything (40), Gladstone et al (36), Dosman et al
(46), Kitsao-Wekulo (8)
et al (65), Lancaster
and Perrin (38)
Scribbles 18 mo CDC Accardo and Capute ASQ-3 Bright Futures (36),
(30), Ertem et al Dosman et al (8),
(43), Kitsao-Wekulo Gerber et al (20),
et al (65), Lancaster Johnson and
23
by guest
24
TABLE 6 Continued
Source
Developmental
et al (45), Lansdown Blasco (15), Scharf
et al (51), Lejarraga et al (18)
et al (41)
Drinks from a cup 18 mo CDC Den Ouden et al (54), ASQ-3 Bright Futures (36),
without a lid and Ertem et al (43), Dosman et al (8),
may spill Gladstone et al (46), Gerber et al (20),
sometimes Lancaster et al (45) Johnson and
Blasco (15), Scharf
et al (18)
Feeds herself with 18 mo New Carruth and Skinner — Bright Futures (36),
her fingers (61), Dosman et al Gerber et al (20),
(8), Kumar et al Scharf et al (18)
(41)
Tries to use a spoon 18 mo New Ertem et al (43), ASQ-3 Bellman et al (42),
Gladstone et al (46) Bright Futures
(70), Dosman et al
(8), Gerber et al
(20), Johnson and
Blasco (15), Scharf

et al (18)
Climbs on and off a 18 mo CDC Carruth and Skinner — Bright Futures (36),
couch or chair (61), Kitsao-Wekulo Colson and
without help et al (65), Lancaster Dworkin (16),
et al (45), Lejarraga Gerber et al (20),
et al (41) Johnson and
Blasco (15), Scharf
et al (18)
Kicks a ball 24 mo CDC Ertem et al (43), ASQ-3 Bellman et al (42),
Gladstone et al (46), Bright Futures
Lancaster et al (45), (36), Colson and
Lejarraga et al (41), Dworkin (16),
Sheldrick and Perrin Dosman et al (8),
(38), Thalagala (39) Gerber et al (20),
Johnson and
Blasco (15), Scharf
et al (18)
Runs 24 mo CDC Accardo and Capute ASQ-3 Bellman et al (42),
(30), Gladstone et al Bright Futures
(46), Sheldrick and (36), Colson and
Perrin (38) Dworkin (16),
Dosman et al (8),
ZUBLER et al
by guest
TABLE 6 Continued
Source
Developmental
Gerber et al (20),
Scharf et al (18)
Walks (not climbs) up 24 mo CDC Bhave et al (40), Ertem ASQ-3, PEDS-DM Bellman et al (42),
a few stairs with et al (43), Sheldrick Bright Futures
or without help and Perrin (38) (70), Colson and
Dworkin (16),
Dosman et al (8),
Gerber et al (20),
Johnson and

Blasco (15), Scharf
et al (18)
Eats with a spoon 24 mo CDC Dosman et al (8), — Bright Futures (36),
Ertem et al (43), Colson and
Gladstone et al (46), Dworkin (16),
Muluk et al (56) Dosman et al (8),
Gerber et al (20),
Johnson and
Blasco (15), Scharf
et al (18)
Uses hands to twist 30 mo CDC Lancaster et al (45) MSEL (32) Bright Futures (36),

things, like turning Johnson and
doorknobs or Blasco (15)
unscrewing lids
Takes some clothes 30 mo CDC Dosman et al (8), ASQ-3, PEDS-DM Bellman et al (42),
off by himself, like Ertem et al (43), Bright Futures
loose pants or an Gladstone et al (46) (36), Gerber et al
open jacket (20), Johnson and
Blasco (15), Scharf
et al (18)
Jumps off the ground 30 mo New Gladstone et al (46), ASQ-3 Bright Futures (36),
with both feet Kitsao-Wekulo et al Colson and
(65), Lejarraga et al Dworkin (16),
(41), Sheldrick and Gerber et al (20),
Perrin (38) Johnson and
Blasco (15), Scharf
et al (18)
Turns book pages, 1 30 mo CDC — MSEL Bright Futures (36),
at a time, when Knobloch et al (58)
you read to her
Strings items 3y New Gladstone et al (46) ASQ-3 Gerber et al (20),
together, like large Knobloch et al
beads or macaroni
25
by guest
26
TABLE 6 Continued
Source
Developmental
(58), Scharf et al
(18)
Puts on some clothes 3y CDC Dosman et al (8), ASQ-3, PEDS-DM Bellman et al (42),
by himself, like Ertem et al (35) Bright Futures
loose pants or a (36), Gerber et al
jacket (20), Johnson and
Blasco (15), Scharf
et al (18)
Uses a fork 3y CDC Dosman et al (8) ASQ-3 Bellman et al (42),
Bright Futures (36)
Catches a large ball 4y CDC — ASQ-3 Bright Futures (36),
most of the time Gerber et al (20),
Scharf et al (18)
Serves himself food 4y CDC — ASQ-3 Gerber et al (20),
or pours water, Scharf et al (18)
with adult
supervision
Unbuttons some 4y New Ohtoshi et al (71) — Bright Futures (36),
buttons Gerber et al (20),
Scharf et al (18)

Holds crayon or 4y New Egan and Brown (63), ASQ-3 Bright Futures (36),
pencil between Ertem et al (43) Dosman et al (8),
fingers and thumb Knobloch et al (58)
(not in a fist)
Buttons some buttons 5y New Ohtoshi et al (71) ASQ-3 Bright Futures (36),
Gerber et al (20),
Scharf et al (18)
Hops on 1 foot 5y CDC Gladstone et al (46), ASQ-3 Bellman et al (42),
Kitsao-Wekulo et al Bright Futures
(65), Nair and (36), Gerber et al
Russell (57) (20), Scharf et al
(18)
ASQ-3, Ages & Stages Questionnaires (3rd ed); MSEL, Mullen Scales of Early Learning; PEDS-DM, Parents’ Evaluation of Developmental Status With Developmental Milestones. —, Empty cells indicate that type/category of data was not
available to support inclusion of that milestone.
a
b
c
Uncited, based on clinical opinion, and/or report the average or median age that a milestone should be achieved.
d
Dosman et al8 contained both published clinical opinion and normative data.
ZUBLER et al
developmental domains is helpful; criteria agreed upon by SMEs. The
ABBREVIATIONS
and whether cultural differences CDC milestones and checklists can
exist in surveillance milestones be used in continued efforts to AAP: American Academy of
and processes.1,3–5,7 Nevertheless, improve developmental Pediatrics
based on review of milestone data surveillance. CDC: Centers for Disease Control
and clinical experience, the SMEs and Prevention
agreed that most typically ACKNOWLEDGMENTS DD: developmental delay or
developing children would achieve We thank Mary Cogswell, RN, DrPH, disability
the developmental constructs for her review of earlier versions of ECP: early childhood professional
represented. To our knowledge, the manuscript and pediatricians HSV: health supervision visit
this attempt is the first to align Natalia Benza, MD, and Jose O. SME: subject matter expert
empirically informed milestones on Rodriquez, MD, MBA, for their
parent-completed surveillance review of the Spanish milestone
tools with objectively defined translations.
Copyright © 2022 by the American Academy of Pediatrics

FUNDING: This project is supported by the Centers for Disease Control and Prevention of the US Department of Health and Human Services as part of a financial assistance
award totaling $100,000, with 100% funded by the Centers for Disease Control and Prevention/US Department of Health and Human Services.
CONFLICT OF INTEREST DISCLOSURES: Dr Squires is a developer of the Ages & Stages Questionnaires and receives royalties from Brookes Publishing, the company that publishes
this tool; the other authors have indicated they have no conflicts of interest relevant to this article to disclose.
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Evidence-Informed Milestones for

Developmental Surveillance Tools

developmental delays or the use of validated screening tools DOI: https://doi.org/10.1542/peds.2021-052138

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