Reach Out and Read

1. Reach Out and Read Literacy Promotion in Child Health Services Perri Klass, MD Medical Director, Reach Out and Read Department of Pediatrics, Boston University School of Medicine

2. 35 % OF AMERICAN CHILDREN ENTER KINDERGARTEN UNPREPARED TO LEARN, MOST LACKING THE LANGUAGE SKILLS THAT ARE THE PREREQUISITES OF LITERACY ACQUISITION NATIONAL ACADEMY OF EDUCATION, 1985

3. National Assessment of Educational Progress (2000) • 37% of 4th graders perform below basic reading levels on national standardized tests for reading

4. CHILDHOOD ROOTS OF ILLITERACY • ONE THIRD OF FIRST GRADERS PLACED IN REMEDIAL READING PROGRAMS • MOST ARE NOT DYSLEXIC • MANY WILL REMAIN IN “SLOW” READING GROUPS THROUGHOUT SCHOOL • AFTER 4TH GRADE, ALL SCHOOL SUCCESS CONTINGENT ON READING SUCCESS

5. CONSEQUENCES OF SCHOOL FAILURE • Poor self-esteem, boredom, frustration • Increased risk of absenteeism, school avoidance, truancy, dropping out • Increased risk of : early pregnancy substance abuse legal trouble

6. READING DEVELOPMENT • Neural ripening (1920’s) • Brain not ready until 6 yrs 6 mos • Reading readiness (1960’s) • Mastery of an ordered set of skills • Emergent literacy (1980’s) • Literacy development begins at birth • Critical cognitive work in first 5 years • Early literacy development in real life settings • Early exposure critical

7. Reading and Children’sBrain Development • The architecture of the brain is shaped by early experiences • Underused nerve connections are “pruned” • Repetitive use of cognitive skills associated with reading aloud—language, memory, comprehension--ensure that associated brain connections persist

8. Reading Aloud and Children’sLiteracy Development(National Research Council, 1999) • Literacy development begins prior to reading • Early language and literacy experiences form the foundation for later reading and language competencies

9. Benefits of Reading Aloud • Reading aloud to children: • Stimulates imagination • Fosters language development • Promotes reading skills • Prepares children for school success • Encourages decontextualized language • Motivates children to love books

10. Reading aloud with young children: • Increases “face time” with parents • Promotes physical contact and positive interactions • Promotes social/emotional development • May reduce television exposure • May be linked to bedtime routines

11. The Importance of Emerging Literacy (National Research Center, 1999) • Children at risk for reading difficulties are those who start school with: • lower verbal skills • less phonological awareness • less letter knowledge • less familiarity with the processes • of reading

12. Reading Aloud and School Readiness(National Center for Educational Statistics, 1999)

13. Children from Low-Income Families • Low-income status significantly predicts children’s exposure to language (Bloom, 1998) • Children from low-income families are far less likely to be read to on a daily basis (National Research Council, 1999)

14. Consequences of Poverty (Brooks-Gunn & Duncan, 1997) • In general, children living in poverty: • Are 1.3 times more likely to exhibit developmental delays • Are 1.4 times more likely to be diagnosed with a learning disability • Are 2 times more likely to repeat a grade

15. NALS STUDY--1992 • Nationally representative sample • 27,000 adults16 and over • Variety of literacy tasks • Ranked literacy levels 1-5 • Asked if received AFDC or food stamps in past year

16. NALS STUDY--RESULTS • On average, literacy skills of adults who received AFDC or food stamps much more limited than general population • More than one third performed in level 1 • Another third performed in level 2 • Annual household income correlated with literacy level

17. The Importance of a Clinic-Based Intervention Medical Providers: • Reach most parents and children • Have repeated one-on-one contact with families • Provide trusted guidance about children’s development • May serve as the only source of formalized support for poor families

18. The Mission of Reach Out and Read To make literacy promotion a standard part of pediatric primary care, so that children grow up with books and a love of reading.

19. Three Components of Reach Out and Read • Volunteers in waiting rooms read aloud to children as they wait for their appointments • Medical providers encourage parents to read aloud and offer anticipatory guidance • At every health supervision visit, a child aged 6 mos.- 5 years receives a new developmentally-appropriate book

20. The ROR Model 1. Volunteers: • Demonstrate reading aloud techniques • Underscore that reading is entertaining for children • Make waiting room experience more pleasant

21. The ROR Model 2) Anticipatory Guidance - Underscore idea that reading aloud is important even before a child can talk - Stress that reading aloud promotes the child’s love of books by linking books with the parent’s voice and attention - Encourage parent and child to read together for pleasure

22. Anticipatory Guidance • Encourage parent to read aloud and talk about the book: • Ask questions (“Where is the baby?” “What does a dog say?”) • Point and name or describe objects • Relate the book to child’s experiences (“He has a sister, just like you.”)

23. More Anticipatory Guidance • Articulate age-appropriate expectations: • 6-month-old babies put books in their mouths • 12-month-olds can point with one finger • 18-month-olds can turn board book pages • 2-year-olds may not sit still to listen to a book • 3-year-olds can retell familiar stories

24. The ROR Model 3) Books Given in Exam Room • At each health supervision visit, a child age 6 mos. - 5 years receives a new developmentally-appropriate book • Before kindergarten, a child receives 10 books • Books are introduced early in the visit and integrated into the examination within the context of other anticipatory guidance

25. High et al, 2000—Results: • 40% increase in CCLO among ROR-model intervention families compared with 16% among control families • Receptive and expressive vocabulary scores higher in older intervention toddlers • No significant differences among younger toddlers 13-17 months • Significant improvement in vocabulary scores for words in books and for words not in books

26. Reach Out and Read Statistics(January 2002) • Founded in 1989 at Boston City Hospital by • Barry Zuckerman, MD • Robert Needlman, MD • Kathleen Fitzgerald Rice, MS Ed • Over 2,000 sites • Over 24,000 providers trained • Over 2 million children from low-income families reached annually • Over 3 million books distributed per year

27. ROR National Center • Will provide technical assistance as you start your program • After application is approved, will grant start-up money and/or books • Will assist with provider training in the ROR model • “Official” ROR programs have access to book catalogue put out by ROR with Scholastic • Will help with ongoing technical assistance around program quality, fundraising, advocacy… • Will provide some amount of “sustainability” book money on an on-going basis

28. ROR in the US--Funding • National Center annual budget $7 million— • Out of these funds, provide book grants to sites (50% of first year’s book budget, 25% in subsequent years) • Federal government: $3 million this fiscal year; $4 million next fiscal year • Massachusetts $500,000 • $2 million from Foundations, grants, individuals • $1.5 million in-kind--books • Regional coalitions raise $3 million a year • Individual sites fundraise for book money--$4 million • Average cost per book=$2.50; per child=$25 over 5 years

29. Research Questions for ROR • Future Directions • Does ROR influence children’s school readiness? • Does ROR influence medical providers’ attitudes? • Does ROR influence medical providers behavior? • Current Questions • Does ROR influence parental behavior? • Does ROR influence parents’ attitudes? • Does ROR influence the home environment of children? • Does ROR influence children’s language development?

30. Clinic-based Intervention to Promote Literacy (Needlman et al., 1991) • A pilot study designed to determine if exposure to a clinic-based literacy intervention promotes parents’ reading aloud to children • Conducted waiting room interviews with 79 parents regarding children’s literacy orientation • Results indicated that parents who received a book through ROR were 4 times more likely to report reading to children

31. Literacy Promotion in Primary Care Pediatrics: Can We Make a Difference? (High, 2000) • Evaluated the impact of a clinic-based literacy program, based on the ROR model, on parent-child book sharing • Measured “Child-Centered Literacy Orientation” -reading aloud as child’s or parent’s favorite activity, or usually read at bedtime • Prospective study: 205 low-income families • 106 Intervention • 99 Control

32. Frequency of Reading Aloud (High et al., 2000)

33. Change in Parent-Child Book Sharing(High et al., 2000)

34. Attitudes Toward Reading(High et al., 2000)

35. Prescribing Books for Immigrant Children (Sanders et al., 2000) • Assessed associations between parents’ frequent book sharing and participation in a clinic-based literacy program, based on ROR model • A convenience sample of 122 predominantly Hispanic immigrant families • Results indicated that parents who received at least 1 book through the literacy program were more likely to engage in frequent book sharing with their children

36. Percent of Parents Engaging in Frequent Book Sharing (Sanders et al., 2000)

37. The Impact of a Clinic-Based Literacy Intervention on Language Development in Inner-City Preschool Children (Mendelsohn et al., 2001) • Examined the impact of an ROR program on children’s language development • Prospective controlled study: 122 participants • 49 Intervention • 73 Comparison • READ subscale on StimQ to measure parent-child activities • Child language development tested directly with One-Word Expressive and Receptive Picture Vocabulary Tests

38. Mendelsohn et al., 2001—Results: Intervention group families: • Frequency of reading to children was higher • More children’s books in home • Increased number of contacts with ROR program associated with increased reading activities on StimQ • 8.6 point increase in Receptive Vocab scores • 4.3 point increase in Expressive Vocab scores • Each contact with ROR associated with score increase

39. Children’s Expressive and Receptive Language Competencies (Mendelsohn et al., 2001)

40. Summary of Research • ROR significantly and positively influences the literacy environment of children • Parents read more to their children • Parents and children have more positive attitudes toward reading aloud • Children participating in ROR tend to have increased language development in comparison to non-participating children

41. “Anticipatory guidance for parents about sharing books with young children may be the only concrete activity of a pediatric provider that has been proven to promote child development.” • Barry Zuckerman,MD Founding Director, Reach Out and Read

42. What about parents who cannot read English? • Bilingual books, counting books, vocabulary books, wordless books • Encourage them to read/talk about books in whatever language is most comfortable • Make up stories—follow pictures • Older siblings may read the English story • Family members may use book for practice

43. Language development in bilingual families • Exposure to speech and language is important • Children may be slower to reach specific milestones • Eventually should reach all the same milestones

44. What about parents who cannot read? • We need to know who they are! • Not a risk factor that is routinely screened • Children at risk for both health and development • Many physicians not comfortable asking the question • May be more effective to include in screens • How far parent went in school • Did parent ever have learning problems • Does parent want to improve skills • How many children’s books in home

45. Literacy promotion for parents with low literacy skills • Picture books may be less intimidating than other books • Choose books with few words on page, or wordless books, alphabet books • Encourage “looking at books together,” “talking about books,” “telling stories about the pictures”

46. Literacy help for parents • Consider referral to adult or family literacy programs • Be mindful of program accessibility and availability—make referral as easy as possible • Be aware of program suitability for parents of young children • Be prepared to offer this referral repeatedly

47. Issues in international adaptation • Pediatric primary care delivery systems • Maternal literacy levels • Availability of children’s books • Culturally appropriate • Inexpensive—locally produced • Coordination with other early childhood programs

48. ROR Training Curriculum • Rationale for the program • ROR program model—3 components • Using the book in the exam room • The book as assessment tool • Research data on the intervention

49. The Book as Assessment Tool • Using the book to assess child development: • Fine motor development (maturity of grasp, hand skills) • Social/emotional interaction with others (shared attention, affect) • Cognitive skills (attention, memory) • Expressive and receptive language (vocabulary, comprehension of words) • Vehicle to offer parents concrete advice about child development

50. Book-Handling SkillsSchickedanz • Helps turn pages (7-8m) • Turns pages well (11-15m) • Hands book to adult (11-15m) • Book right-side up (11-15m) • Understands upside down picture (24m)