Every parent has been there. Maybe you are sitting across from your GP, trying to stop little Susie from sticking a tongue depressor up her left nostril. Maybe it’s a visit to the child health nurse, or a free immunisation clinic, or your paediatrician. Maybe you are sitting in a park with your Mother’s Group, drinking your third coffee and praying your child isn’t the biter today. Maybe, like me, you are prone to 2am Google searches with queries like “when should my baby wave bye bye” or “three year old won’t use toilet”.
Milestones. That little checklist of physical, emotional and cognitive stepping stones that lead a little person from totally dependent infant to independent adult. Although well intentioned, they are a common cause of anxiety for many parents who worry their child is not keeping up with their peers. Like sitting an exam, you can’t help but have the sense there is a definite right and wrong answer, and find yourself pouring through your memory, scrambling for half marks when asked by a health professional if your child has ticked all that month’s boxes.
Should you be worried about your child hitting their milestones at the right time? Is the age a child does (or does not) walk or talk a good reflection of their developmental progress and capacity?
Milestones: The Good
At most reviews with a health care provider you have a maximum of 20-30 minutes, usually less, to discuss a whole host of complex and often sensitive issues. With the majority of developmental concerns, early intervention is key to minimising the long term impact on function and participation. A quick milestone checklist (“can he sit without support? Does he seem anxious when you leave him with a stranger? Does he point to things he wants? Does he imitate actions and sounds?”) is an easy way to quickly identify who might have a significant developmental issue. The role of this type of screening is to make sure no one slips through the cracks – unfortunately, this also leads to a lot of “false positives”, or typically developing children flagged as delayed.
Milestones: The Bad
Typically developing children do not achieve a particular skill at a certain age, but over a time period. For example, most children learn to walk between 11-18 months, quite a large range of normal variance. If you ask most people when a child learns to walk, a standard response would be a little over 12 months – milestones are often given as discrete time periods which are the “average”, with a lot of children falling above or below that time point.
Developmental check points are a reflection of a developing brain and body, but they are not the only sign to look for. Milestones are quantitative – the “what” not the “how”. With motor development, how you move is just as important as how much you move. Children who are ticking the Yes/No boxes but are moving with atypical movement patterns may not be developing the strength, endurance and control needed to build future more complex motor skills. When it comes to development, the journey is just as important as the destination!
“Children’s learning is ongoing and each child will progress towards the outcomes in different and equally meaningful ways. Learning is not always predictable and linear."
My child is behind in their milestones – what now?
Take a deep breath – many children go on a slightly different journey and make it to the same destination with only the occasional helping hand. Other children may need more support, and delayed milestones are the first sign that intervention is needed. So how do you know which is which?
Look at the big picture
Development is a combination of a child’s intrinsic characteristics (personality, muscle tone, sensory systems, neural connections) and environment (the opportunity to practice and obtain skills). To put it very simply, a little bit of nature, a little bit of nurture. As a physio, I am usually more interested in the HOW than the WHAT, and the journey then the destination. For example,
Chloe is 16 months old and she isn’t walking yet. Her grandmother is convinced something is wrong with her as her father walked at 10 months. She is a bit of a cautious character, she takes things slow and steady, and tends to enjoy watching others rather than leaping straight into the fray. She is the first grandchild on both sides and is doted upon, they joke that she has a full staff of personal assistants. She cruises along furniture, can stand on her own for several seconds, and has a terrible habit of rearranging the dining room furniture by pushing it around the room. She is often happy sitting on the floor playing with a few favourite toys, but you should see the speed she can get up crawling when she chases the dog! Her Mum is extremely proud of her rapidly expanding vocabulary, she's a real Chatty Cathy.
Verdict – Almost there! Chloe is showing all the building blocks for independently walking. The combination of a more reserved nature and a ready supply of helpers to cater to her every whim is the likely underlying reason she isn’t running around the block just yet. An assessment shows there is nothing abnormal in her muscles, nerves and sensory systems. Her Mum and Dad are given a few fun new activities to motivate and challenge Chloe to step out of her comfort zone – and a week later she was taking her first steps.
So when should I see a professional?
Here are some red flags that warrant investigation and shouldn’t be ignored.
A quite significant delay in a particular area (e.g. not sitting independently at 9 months)
Asymmetry (difference in movement or sensation between sides or arms and legs)
Does not appear to react typically to sound/visual stimuli/touch
Showing a degree of delay across all areas of development
Feels very stiff or very floppy
Doesn’t interact or show interest with care givers
Showing loss of skills
Any concerns when there are significant risk factors e.g. very premature birth, significant illness, family history
If it just doesn’t feel right – parental intuition is a powerful thing!
If you are unsure, see a medical or allied health professional. Best case scenario you will get some much needed reassurance and some new play ideas to take home. Just keep in mind the big picture – milestone acquisition is just one piece of the developmental puzzle, and Dr Google feeds on the fear of new parents at 2am.