Where's My Manual?

It is a huge milestone when your baby turns one.

Every baby grows tremendously over that first year - even though each baby is different. They have gotten longer and bigger. They might have gotten hair or first teeth. They all seem to have razor sharp nails that you can never ever file down properly.

But that first year is also an amazing achievement for you as a parent -- you've fed your baby using breast, bottle, formula, or tube; you've helped them learn to sleep outside the comfort of the womb in a bassinet, a crib, or your bed; you've been by their side as they learn to move their bodies, engage with their environment, and communicate with others. You've held them during their first colds, kissed their first bumps and bruises, and listened to way too many renditions of Baby Shark.

You've kept them alive for a year -- a tiny baby that needs you for everything -- with absolutely no manual.

It's the hardest job I've ever had.

But let's talk about that manual for a second. Seriously, where is the manual?

Why is it that many parents turn to Instagram creators for tips and tricks for helping their baby sleep? For information about how to encourage crawling or walking? For ways to help their kids finally say those first words?

Where. Is. Our. Manual?

The Role of Pediatricians

For most families, especially before social media, the "manual" came in the form of the highly popular baby books -- What to Expect: First Year -- and, of course, the standard visits to the pediatrician.

Your pediatrician checks your overall baby's health and development. This means looking at their growth chart, doing a head-to-toe physical exam, and asking general questions about baby: sleep, feeding, motor, and communication. This is also an important time for children to receive their immunizations against deadly childhood diseases.

But pediatricians are generalists, not specialists. So, while pediatricians are helpful for broad health questions and understanding basic milestones, they are not experts in things beyond physical health. That is why pediatricians will refer families to specialists when they are struggling with sleep, feeding, motor, or communication challenges.

This is something that has become a bit more worrisome with the recent change in the CDC guidelines in early 2022. While the CDC encourages families and providers to "Learn the Signs. Act Early", their recent changes to milestones were not based in recent research, especially in the fields of occupational therapy and speech language pathology. They also did not consult experts in these fields (OTs and SLPs). The change in milestones MAY lead to pediatricians waiting longer to refer to experts rather than sooner -- something that has many providers and parents worried.

The First Year Visit

While there are many many well visits in the first year of life, the big one is the one-year-old visit because 12 months is a time where there are many milestones that are expected to be hit. It's a great time to see if your child is on-track and to determine if there are any supports the family will need moving forward.

(Before I begin, let me just say that I truly do like the doctors that I see for my children. I think they are smart, kind, and caring. I also want to say that I appreciate how difficult it has been over the past three years during the Covid pandemic. This blog post is not a reflection on them as much as it is a general reflection of the healthcare system and the disconnect between what parents need and what they often receive)

Quite honestly, my son's one-year-old appointment was a complete shitshow. It was the beginning of Covid, and this was the first in-person appointment we had during the pandemic. We were still actively in quarantine that May and when I showed up at the door, it was locked. Apparently there had been some sort of miscommunication and I had been scheduled for a virtual visit that day instead of in-person. I stood there, near tears, with my very unhappy one year old in my sling who was trying very hard to pull the mask off my desperately frightened face. This was the first place we had gone inside since the pandemic began a few months before.

After lots of apologies, they managed to get our doctor to come see us. We waited for a long time, and by this point all I wanted to do was get the shots, get his blood draw, and then leave. I don't remember what they asked me about his development. I don't remember what I asked them -- if anything at all. All I remember is that I finally got to leave without the goddamn blood draw because they didn't have anyone to pick up the blood that day (since ... we weren't supposed to have been there at all).

Just another wonderful day in the life of a pandemic parent.

My daughter's one-year-old appointment was thankfully so much better. Three years into the pandemic, I still wore a mask but the office was open and running smoothly. This time, I was prepared to ask questions and answer them.

When I went in, I got a clipboard with a general visit form asking what concerns I had with a small checklist of "skills" for the 12 month old visit.

The paper asked: Is your child ...

• Pulling to stand

• Cruising/walking

• Playing peekaboo

• Using a cup

• Using pincer grasp

• Feeding self

• Saying mama or dada specifically

My SLP mind started buzzing, and I'm sure my eyes narrowed as I read the list, scanning the skills that were assessing communication development.

• Playing peekaboo is a pretty good communication milestone to assess. Sure, it's a bit specific and dependent on a caregiver introducing the game to their child. Why not ask if your child engages in social routines, like peekaboo or tickle games or rolling a ball back and forth.
  

• Saying mama or dada specifically is obviously looking for first words. And true, most kids learn "dada" and occasionally "mama" first. But what about signs? What about kids who learn other words first.

But where were all the PRECURSORS for language:

• gesture use like pointing or waving

• babbling

• imitation of actions, sounds, and words

Gosh they didn't even ask a single question about receptive language -- an extremely important area for assessing children who will need more communication support.

Okay, I thought, this must just be a form to get the conversation going.

But when the doctor came in, she started by going down that list to assess development. Yes, it's true, the doctor knows that I am an SLP. And I am also well-versed in child development so I automatically provide lots of information about my child without prompting.

But what if I had sent my husband who I love very much but is horribly bad at offering information unprompted, especially in a medical setting?

As it turned out, my daughter was the opposite of my son. I had no concerns about her communication while I had many reservations about my son. The conversation was short because there wasn't much to say. So we went down the list, checked off the skills, and she added a few follow-up questions before moving on to the physical exam.

But I know of way too many parents who go to these appointments feeling lost. And either they are given the "wait and see" approach or they don't even know what questions to ask to begin with.

Where is their manual?

Outdated Information

The big take-away I've had as a parent over three years of doctor's visits is that research and new learning takes a long time to make its way across the healthcare system. The new information that I am learning as a speech pathologist is mostly unknown by pediatricians -- for example, when I brought up scripting and gestalt language acquisition, my pediatrician asked me to fill out the M-CHAT parent survey to rule out autism.

(It's true that most autistic children are gestalt language processors but not all gestalt language processors are autistic. Gestalt processing is a common and natural way to learn language! But my doctor, without knowing much about this type of language acquisition, jumped to the conclusion that scripting was synonymous with autism.)

But I am not blaming the doctors, here. As I mentioned before, pediatricians are generalists. It is not possible for them to be up to date on every aspect of development. And for family doctors, imagine doing this across the entire lifespan!

To put it in perspective, when I left my one-year-old visit, I was handed a Bright Futures parent handout endorsed by the American Academy of Pediatrics. In small print on the bottom, the copyright says 2010. That is over TWELVE years ago. So much has changed in twelve years.

Just to give you an idea of the language in this handout -- here are a few of the items that caught my eye. Commentary in italics is my own.

• "Try not to hit, spank, or yell at your child." Try not to ...?
  

• "Use short time-outs when your child is behaving poorly." Time outs are out. Time ins are in. What even is "behaving poorly" for a one year old?
  

• "Play with and read to your child often." Oh excellent. That's specific and helpful. Not stressful at all.
  

• "Distract your child with something he likes during bad behavior" Wait what? Sure, let's not help our child learn emotional regulation & coping strategies
  

• "Avoid having your child watch TV and videos"

• "Avoid watching TV during family time." Screen time is NOT all the same. While research shows tablets and phones can be problematic, TV can be an incredibly social time for families and in moderation there is often no reason to cut it out completely.

And once again, not a single real helpful sentence about how to encourage communication.

What Should We Expect?

Parenting still doesn't come with a manual. But maybe we can still help.

We made these communication expectations to help parents know whether their child is generally on track with expectations. These skill lists are not exhaustive. There are many things your child will be doing at every age. And remember, not every child learns skills at the same pace or in the same order. If your child isn't doing one or a few of these things, it's ok!

Please note: these milestones are not appropriate for autistic children and many other neurodivergent populations. Word milestones are also not appropriate for gestalt language learners. Also keep in mind that signs and word approximations count as words.

12 month skills

• Uses early gestures (e.g., points, reaches, waves)

• Imitates sounds and simple actions

• Understands simple commands with gestures

• Says at least 1-2 words

• Babbles frequently with a variety of consonants

• Follows along with routines/songs

• Gives, bangs, pats, throws objects

15 month skills

• Uses jargon (sentence-like phrases)

• Shakes head no

• Identifies body parts, objects, and actions

• Requests help

• Imitates sounds in play

• Says ~3-5 words

• Discovers toy operations

• Uses a variety of gestures independently

18 month skills

• Uses language for different purposes Requesting, labeling, protesting, refusing, greeting, etc

• Social rituals emerge

• Begins to claim objects

• Imitates words and learns new words frequently

• Follows one-step directions independently

• Says at least 10 words

• Isolated pretend actions

• Solitary (onlooker) play

• Speech is ~25% intelligible

24 month skills

• Responds to yes/no questions

• Combines two words/signs

• Understands spatial concepts (e.g., in/on)

• Parallel play (near others)

• Says at least 50 words

• Elaborated play schemas

Your Communication Manual

I can't offer you a full manual, of course. Each kid is different and communication is as nuanced as it comes.

But here are some good first steps:

Questions for your Doctor

• What should I expect my child to be understanding at this age?

• How should my child be communicating at this age?

• How should my child be playing at this age?

• I have some concerns. What is the plan for monitoring my child over the next three months before our next check-up?

• My child is not hitting milestones and research does not support a "wait and see" method. What is the process for getting an evaluation or other supports?

Parent Resources

1. Early Intervention is a free service If you are concerned about your child's development and not seeing these skills emerging, we recommend you to seek out a speech language pathologist. Early intervention services are free in Massachusetts.

2. Check out our Parent Modules! Here at Talk Time, we are passionate about educating and empowering families about communication development and communication support.

• ​Five recorded modules divided into short videos so you can learn at a time that is convenient for you

• A private facebook group where you can meet other parents and interact with Talk Time SLPs

• A weekly coffee chat to discuss the videos, answer questions, and support your family in a small group setting

3. Book a Parent Consultation Call. Each child is different. Email us at info@talktimeboston.com today and book a 30 minute or 60 minute call to discuss your child's communication profile and make a plan. Written recommendations are emailed to you within 2 business days based on our conversation!

4. Follow us on our instagram account: @talktimeboston. It's not quite a manual, but it's pretty close. Tips and tricks, what to expect, breaking down myths, parent strategies, and lots and lots of information about communication. All free!

So congrats, parents. You're doing something incredibly difficult -- without a manual, no less. But hopefully this made the journey just a tiny bit easier because, sometimes, it's nice to stop playing on hard mode.