The 18-month checkup questionnaire: What parents need to know | RaisedGrounded

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Many pediatricians ask parents to fill out a questionnaire during each or some of the well-visits (or ask those questions verbally). The 18-month checkup is one where the American Academy of Pediatrics (AAP) recommends screening¹². A central part of the questionnaire is the developmental milestone checklist. While some parents find the milestones helpful even between doctor visits, for others they can cause a lot of stress. Pediatricians even have coined a special term for that: “milestone anxiety”¹. Even talking to other parents can be quite confusing if you don’t know that there are several milestone checklists from different sources. And they have substantial differences regarding what they demand of your child.

So in this article, I’m going to cover several commonly used 18-month checkup questionnaires. You’re also going to see what these questionnaires are useful for so that you can help your child thrive – without ‘milestone anxiety’.

What does the 18-month checkup questionnaire include?

This depends on your pediatrician’s practice. Some don’t use a questionnaire at all but interview you instead. The AAP recommends²:

• Oral Health Risk Assessment (if you don’t have a dentist yet)
• Behavioral/Social/Emotional Assessment, with something called the “Preschool Pediatric Symptom Checklist” or a part of the “Ages & Stages” questionnaire (see below).
• Child Development (Milestones) with something like the PEDS, PEDS:DM, ASQ3, or SWYC (see below)
• Autism Screening, e.g. with a questionnaire such as the M-CHAT-R

Additionally, your pediatrician might ask questions about the home environment ² with a questionnaire such as the SWYC. This includes areas such as smoking, drinking, or how often you read to your child. ³

9, 18, and 30 months are the recommended screening times. Thus, even if your pediatrician doesn’t do a questionnaire at every well-visit, you will likely get one at 18 months.¹²

What is your child supposed to be able to do at 18 months?

This depends on which milestone checklist your pediatrician is using.

The most commonly used milestone checklists ² in the U.S. are:

• the ASQ 3 (Ages and Stages)⁸
• the SWYC (Tufts)³
• the PEDS:DM ⁹ and
• PEDS ¹⁰.
• Parents often use the CDC milestone checklists⁷. I mean hey, it’s the CDC. It’s one of the first results in Google if you look up 18-month milestones. However, the CDC checklist is not a screening tool ¹³ and is not part of the AAP recommendations ¹⁴. Therefore, pediatricians usually don’t use it. Because it has an empirical foundation, it still contains useful information and I therefore included it in the overview below.  

Not all practices use the same checklist at every visit. For instance, one hospital uses the ASQ3 at 12 months, but the SWYC at 18 months¹¹.

The milestones are about what your child can do, not about what s/he wants to do at a particular moment. As the ASQ3 phrases it: “At this age, many toddlers may not be cooperative when asked to do things. You may need to try the following activities with your child more than one time. […] If your child can do the activity but refuses, mark “yes” for the item.”⁸

Before we get to what your child is supposed to be able to do at 18 months, it is important to know that the milestone checklists have very different approaches.

What approaches do commonly used milestone checklists have?

CDC

The checklist shows what “75% or more” of children can do by 18 months. You should discuss even “one missing milestone” with your pediatrician, e.g., to see about further “screening and possible referral”¹³.

PEDS

The PEDS screening does not provide a milestone list. Instead, the tool asks parents whether they have “any concerns” in a number of areas¹⁰.

PEDS:DM

This screening tool is available in two versions: paper and online. 

The paper version has milestones specific to 18 months. The child is expected to do everything on the list. “Failure on an item, predicts difficulties in that domain, with cutoffs tied to the 16th percentile and below”¹⁵. Pass criteria vary. Often only the highest answer, such as yes, gives a pass. But sometimes also the middle answer, such as ‘sometimes’ gives a pass¹⁶. 

The online version is adaptive. Thus, the system continues to ask milestone questions until it establishes a floor and ceiling. Thus, the tool reports the results as age-equivalent skills. For instance, a child might e.g., have language skills that are age-equivalent to a 33-month-old, but fine motor skills equivalent to a 9-month-old.¹⁷  The online version is not publicly available. 

ASQ3

This screening tool has milestones specific to 18 months, split into 5 different areas. Children are not expected to be able to do everything. Each “yes” gets 10 points, each “sometimes” gets 5 points, and each “not yet” 0 points. The maximum for each area is 60. Each area has a different cut-off value (between 13.06 and 37.38). There’s an additional grey area above that where children are supposed to be monitored.⁸ So your child is only supposed to reach a bit more than half, or in some areas even much fewer, of the milestones.

SWYC

This screening tool has several milestones specific to 18 months. Similar to the ASQ3, children are not expected to be able to do everything. Each “very much” gets 2 points, each “somewhat” gets 1 point and each “not yet” gets 0 points. The maximum score is 20. The cut-off value depends on the age of the child, e.g., for a child who’s 18 months old it would be 9. But for a child who’s 19 months old, it would be 11. For those children who score below, there are two ranges: “further investigation” and “us[ing] clinical judgment”¹⁸. So at 18 months, the child is expected to be able to do less than half of what’s on the list.

What are the 18-month developmental milestones?

Here’s the comparison:

Similarities and differences between the different 18-month checkup questionnaires

As you can see, there are some similarities. For instance, both PEDS:DM and ASQ3 expect children to stack at least 3 blocks.

But what really stands out are the differences, such as:

• The PEDS does not have any milestones.

• The checklists that do have milestones differ widely in how many they have: 6 (PEDS:DM), 10 (SWYC), 15 (CDC), or 30 (ASQ3).
• The checklists often differ substantially in what they demand of your child. Let’s look at two examples.

Example 1: Walking & running

The CDC just wants the child to “Walk[] without holding on”. In the ASQ3 they have to be already able to “walk well and seldom fall”. And in the SWYC they need to be able to “Run[]”. The PEDS:DM doesn’t have a milestone for walking.

The normal range for beginning to walk independently starts between 7 to 11 months and ends at 18 months^{19, 1, 23}. Yes, that’s a 7- to 11-month range for children who aren’t even 2 years old! At 18 months, according to one study, about 90% of children can walk without holding on¹⁹. Thus, if your child is only starting to walk independently at 17 1/2 months, s/he’s completely normal!

What if s/he isn’t walking independently by 18 months? In one study, “some babies didn’t walk until they were nearly 20 months old. Yet all of those children experienced healthy, normal outcomes”. A different study looking specifically at ‘late walkers’ found that “nearly one-third of cases” had a “clinical or neurological condition”²⁰.

However, if your child started to walk independently close to 18 months, s/he might not yet be running at the time of the 18-month checkup questionnaire. In fact, in one study it took several months after learning to walk to start to run²¹. After all, “[t]ime walking”, i.e. “[t]he amount of elapsed time […] since walk onset”, “strongly predicts improvements in infants’ walking skill, […] more so than infants’ test age […]”²³.

Example 2: Speaking

How many words is your child supposed to say at 18 months? The PEDS:DM does not make any demands in terms of speaking. The others exclude ‘mama’ and ‘dada’ from their count. For the CDC, it’s trying to say 3 words. For the ASQ3 it’s 8 words (plus imitating 2-word phrases and saying 2-3 word phrases themselves). And for the SWYC it’s 5 objects, 5 body parts, and me/mine – so at least 11 words. But they’re also supposed to say 2-word phrases and ask for help using words. Likely they’ll need much more than 11 words for that.

Just like walking, language development differs widely. According to one German-language study, 10% of children said 3 words (besides those for mom and dad) at 8 months. 90% did so at 18 months. Saying 50 words happened between 15 and 24 months. Saying a two-word phrase happened between 15 and 25 months.¹⁹

What are milestone checklists useful for?

Prepare for the discussion with your pediatrician

The main purpose of the milestone checklists is to initiate a conversation with your pediatrician and identify any developmental delays. If there is a developmental delay, interventions such as therapy can really help the child. Earlier intervention is generally better²². Knowing about the different milestone checklists and how they are scored can help you prepare for the well-visit and make better-informed decisions.

Check whether your child already reached the milestones

For instance, if you don’t have stairs where you live, you can try to find some at a friend’s house, a playground, the library, etc., to see whether your child can already walk up/down with help. This can then help you fill out the questionnaire or answer questions your provider might have at the checkup. During the checkup, it’s often not easy to remember everything. So, for instance, you can also make a list beforehand of all the words your child is already trying to say.

Don’t give in to milestone-anxiety

One major source of milestone anxiety is “[t]he constant comparison with other children and the worry that your baby isn’t doing “enough””, as one pediatrician puts it.¹ Knowing what’s actually on the milestone checklists, and that for all these skills there are ranges that can be spanning many months, can help you focus on your specific child instead of a comparison. So, for instance, just because all the other children in your toddler’s playgroup already walked independently by 14 months doesn’t mean that you need to be anxious regarding your 15-month-old toddler who isn’t walking independently yet. S/he still has at least 3 more months to go, and much can change in that time! Just focus on the child “who is thriving right in front” of you.¹

Provide your child with relevant experiences to thrive

Knowing what your pediatrician is going to ask about can help you provide your child with relevant experiences in the months leading up to the next well-visit. For instance, show him/her how to throw a ball. Give him/her blocks to practice stacking. Sing songs, read books, and play games involving the naming of body parts. These are all related to 18-month milestones. Even for walking, research comparing different cultures has found that opportunities for movement (such as lots of time stepping/walking while holding on versus spending a lot of time in a car seat, sling, etc.) can make a difference of several months in the average age of when children start to walk ^20,23.

What about the behavioral/social/emotional assessment at the 18-month checkup questionnaire?

Besides the developmental milestones, there might also be a Behavioral/Social/Emotional Assessment. Often, pediatricians use the “Preschool Pediatric Symptom Checklist” (PPSC) (which is also included as part of the 18-month SWYC questionnaire) or a part of the “Ages & Stages” questionnaire, according to the AAP². You can see the full questionnaire when clicking on the links. The two questionnaires are quite different in length: the ASQ-SE has 31+3 questions, and the PPSC only 18. The questionnaires also differ in some of the areas covered. For instance, the ASQ-SE also has questions relating to sleep, while the PPSC does not. Conversely, the PPSC probes whether it’s “hard to… Know what your child needs” which is an area the ASQ doesn’t explicitly cover.^3,5

But whichever (if any) of the questionnaires your pediatrician chooses, there are several points to remember.

Think age-appropriate development

As the PPSC calls it: “Think about what you would expect of other children the same age […]”³. So for instance, one question on the PPSC is “Is your child … Fidgety or unable to sit still?”³. But an 18-month-old is just an 18-month-old. Children that age aren’t expected to be able to sit still for long. For instance, one children’s therapy site recommends that “16-19 month olds should be able to attend to a structured activity for 2-3 minutes”.⁴ Yes, only 2 minutes! So if your toddler gets fidgety soon after you start a video call with grandma or you hand him/her some crayons and paper – that’s totally normal. The parent thus would mark the question with “Not at all”.

Think usual behavior

The ASQ instructs: “Answer questions based on your child’s usual behavior, not behavior when your child is sick, very tired, or hungry.”⁵

It’s a scale

Both questionnaires work as a scale. Here, in contrast to the developmental milestones, fewer points are better. For the PPSC, each “Not at all” gets 0 points, each “Somewhat” 1 point, and each “Very much” 2 points. A “total score of 9 or greater indicates that a child is “at risk” and needs further evaluation”⁶. For the ASQ, of the first 31 questions: Each “rarely or never” gets 0 points. Each “sometimes” or area marked as concern gets 5 points. And each “often or always” gets 10 points (or reversed if the item is phrased in the opposite direction). Children with more than 50 points should be monitored. Those with a score of 65 or more should be referred to a specialist. Children below 50 points are considered “no or low risk”.⁵

It’s not a school test

In some situations in life, if you don’t choose one of the options for a question, you don’t get a point and thus fail. In contrast, the 18-month checkup questionnaire is meant for your pediatrician to be able to address any issues that might affect your child’s health and development. So, it’s okay to make a note so that you can discuss things with your provider and, if needed, ask for resources. For instance, one item of the PPSC is whether it’s hard to “Keep your child on a schedule or routine”. Your toddler might in fact thrive on a schedule, as you have noticed whenever you managed to implement it. But right now it might be hard for you to offer a consistent schedule because of your current situation (e.g., preparing for or just recently having moved). So make a note.

References:
1 Amin, M. (2021). MILLENNIAL PARENTS ARE FEELING ‘MILESTONE ANXIETY,’ PEDIATRICIAN SAYS. https://www.intheknow.com/post/millennial-parents-are-feeling-milestone-anxiety-pediatrician-says/ (last checked Dec 1, 2023)
2 AAP (2023). Bright Futures Toolkit: Links to Commonly Used Screening Instruments and Tools  https://publications.aap.org/toolkits/resources/15625/Bright-Futures-Toolkit-Links-to-Commonly-Used?autologincheck=redirected (last checked Dec 1, 2023)
3 Tufts - SWYC 18 months  https://www.aucd.org/meetings/205/15318/18 Month_3-11-14 (1).pdf  (last checked Dec 17, 2023)
4 Helping Hands Children's therapy services (2015) How long should my child sit still. https://www.helpinghandstherapy.org/news/long-child-sit/ (last checked Dec 4, 2023) 
5 ASQ:SE2 18 Month Questionnaire https://www.socfc.org/SOHS/Disabilities%20Mental%20Health/ASQ/ASQ%20SE%2018%20Months.pdf (last checked Dec 4, 2023)
6 PPSC Scoring Directions https://pediatrics.tuftsmedicalcenter.org/-/media/Brochures/Floating-Hospital/SWYC/V2/English/PPSC/PPSC-Scoring-v106.ashx?la=en&hash=A7A5785527E9D40DBFE0223744D135ABEE3A2CFE (last checked Dec 4, 2023)
7 CDC your child at 18 months https://www.cdc.gov/ncbddd/actearly/pdf/checklists/Eng.-18-mo-Milestone-Moments-Checklist-2021-P.pdf (last checked Dec 13, 2023)
8 Ages and Stages 3: 18 month https://musckids.org/-/sm/kids/f/foster-care/ages-and-stages-18-months-questionairre.ashx (last checked Dec 13, 2023)
9 PEDS: DM https://naustinpeds.com/wp-content/uploads/2019/10/PEDS-DM-Developmental-Milestone-Survery.pdf (last checked Dec 13, 2023)
10 PEDS https://www.rch.org.au/uploadedFiles/Main/Content/ccch/PEDS-Brief-Administration-and-Scoring-Guide.pdf (last checked Dec 13, 2023)see also PEDS certification https://www.azpedialearning.org/pdf/PEDS%20Certification%20for%20AZPediaLearning.pdf. 
11 South Peninsula Hospital Homer Medical Center. Developmental Screening. https://www.homermedical.org/pediatrics/developmental-screening/ (last checked Dec 13, 2023)
12 Lipkin, P.H., Macias, M.M. (2020) Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening https://publications.aap.org/pediatrics/article/145/1/e20193449/36971/Promoting-Optimal-Development-Identifying-Infants?autologincheck=redirected (last checked Dec 15, 2023)
13 CDC Key points about CDC's Developmental Milestone Checklists https://www.cdc.gov/ncbddd/actearly/about.html#points 
14 AAP Supplemental Table 1: Developmental Screening Tests https://aap2.silverchair-cdn.com/aap2/content_public/journal/pediatrics/145/1/10.1542_peds.2019-3449/7/peds_20193449supplementarydata.pdf?Expires=1705458158&Signature=mhaKHZ0blZPNUDnwKK4VNqW3DQ6zYCDIPrlKR87XA2DOsu-jJA7LwP-S2MVpaAM9GolKXY-SnAOPtc4t6trXjrmhEZEpYqCL9Jc3cFG~E2F8zpXp2v4-H71~0EipjT0K-KT2gXbWl0Fk6MR0uxoKeKa0jmzVrMRVsJnptq8eOLsSHJiQQsfC97iWEA7cMTZe2A8z1n1qewlgwS0Tg3gR7bKn1n9qlOUQ4vwnIQjQZe0xl-RXz0qsWV-e-5YmtV~95HbvZQ57tIVADxbJLSP2bVbW1DE0bgyGQTEuoqYlTE5pBCMV2CyDC6t0~B-MVkMwhZuPpFksZzWV6MleNiN9Fw__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA 
15 PEDS What is PEDS:DM? https://pedstest.com/about-our-tools/learn-about-pedsdm/  
16 Brothers, K., Glascoe, F.P., Robertshaw, N.S. (2007). PEDS: Developmental Milestones - An accurate Brief tool for surveillance and screening https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=da9ce22f6865dba6d9effcbff661379c14a84e6d
17 PEDS PEDS Tools Online: PEDS, PEDS:DM, PEDS:DM-AL https://pedstest.com/peds-tools-online/
18 SWYC Milestones Scoring Sheet https://docsfortots.org/wp-content/uploads/2017/01/Scoring-the-SWYC-with-ranges.pdf (last checked Dec 15, 2023)
19 Jenni, O. (2022). Meilen- und Grenzsteine der Entwicklung. Was Kinderärztinnen und Kinderärzte wissen müssen. https://link.springer.com/article/10.1007/s00112-022-01547-z (last checked Dec 17, 2023)
20 first study: Jenni et al. (2013), second study: Chaplais and McFarlane (1984) cited in Dewar, G. (2022). When do babies start walking, and how does it develop? (An illustrated guide) https://parentingscience.com/when-do-babies-start-walking/ (last checked Dec 17, 2023)
21 Zacher, V. (2010). Die frühkindliche Ontogenese des grobmotorischen Verhaltens. Altersabhängige Entwicklung der zeitlichen Zusammensetzung des grobmotorischen Verhaltens von Säuglingen und Kleinkindern. https://refubium.fu-berlin.de/bitstream/handle/fub188/5335/Zacher-Diss-UB.pdf;jsessionid=6E10145EBAFA6917AF5A4CCF241BF315?sequence=1 (last checked Dec 17, 2023)
22 CDC Why Act Early if You're Concerned about Development? https://www.cdc.gov/ncbddd/actearly/whyActEarly.html#:~:text=Early%20intervention%3A&text=May%20include%20speech%20therapy%2C%20physical,success%20in%20school%20and%20life. (last checked Dec 17, 2023)
23 Hospodar, C.M., Hoch, J.E., Lee, D.K., Shrout, P.E., Adolph, K.E. (2022). Practice and Proficiency: Factors that Facilitate Infant Walking Skill https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8550266/  (last checked Dec 17, 2023)

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