Reach Out and Read

1. Reach Out and Read Reach Out and Read in the Exam Room: Making it Work Perri Klass, MD National Medical Director, Reach Out and Read Professor of Journalism and Pediatrics, New York University

2. 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

3. Where we are now: • Now over 4100 sites in all 50 states, DC, Guam, Puerto Rico, US Virgin Islands • 34 city, state, and regional coalitions • Over 50,000 doctors and nurses trained • Over 3.5 million children from low-income families reached annually • 80% below 2x poverty level • Over 5.7 million books distributed per year • Over 20 million books distributed since 1989

4. So, after 20 years, and 20 million books, what have we learned? I. About the problem of children growing up without books and reading II. About making it work in the exam room III. About what happens when doctors promote early literacy IV. About what books mean in children’s lives V. About policy and advocacy VI. About next steps

6. Reading Difficulties in Low SES Children 55% % With Reading Difficulties (4th grade) 24% <185% >185% poverty poverty level level NCES, 2003

7. I. The problem: children growing up without books and reading • Many children are not being read to regularly • Children growing up in poverty are less likely to be read to • Minority children and children in non-English-speaking households are less likely to be read to • Starting school without early literacy skills puts children at risk for school failure

8. 35 % OF U.S. CHILDREN ENTER KINDERGARTEN UNPREPARED TO LEARN, MOST LACKING THE LANGUAGE SKILLS THAT ARE THE PREREQUISITES OF LITERACY ACQUISITION NATIONAL ACADEMY OF EDUCATION, 1985

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

10. Early reading problems: skill deficit vs. developmental gap • Juel 1988—tracked 54 children 1st-4th grade • the poor first-grade reader almost invariably remains a poor reader by the end of fourth grade • Francis et al 1996—tracked 403 students 1st-9th grade • low-achieving students (reading scores below 25th %) and reading disabled-discrepant students (reading<<IQ scores) did not catch up • Shaywitz et al 1999—extended through 12th grade • poor readers in elementary school never caught up • little improvement after 6th grade

11. US 12th graders • 23% do not have basic reading skills • Only 40% considered proficient Source: US Dept of Ed, NCES, 2000

12. II. Making it work in the exam room: changing pediatric practice • Primary care context • Behavior and development • “new morbidity” • Making the program practical and doable in the clinic, the office, the exam room • Helping primary care providers use their time with patients more efficiently • Thanking and appreciating providers!

13. 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

14. The ROR Model 1. Literacy-Rich Waiting Room: • Volunteer readers demonstrate reading aloud techniques • Displays about books, libraries, family literacy opportunities • Gently used books

15. 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

16. 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

17. Introduce the Book Early in the Exam • What to say: • (Child’s name) is chewing on the book. Young kids like to do that. • Even babies really like to look at pictures. • Would you (the child) like to look at this book with me?

18. 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

19. II. Making it Work In the Exam RoomAt every checkup 6 months - 5 years: • Give a developmentally appropriate book-8 -10 books before Kindergarten! • Introduce the book early in the exam. • Tailor the book and anticipatory guidance to the child you are seeing. • Use the book to support the guidance you offer about other issues. • Use the book as an evaluation tool. • Model reading aloud when possible.

20. The adult helps the CHILD become the teller of the story. In the Exam Room Dialogic Reading : Concept based on the writings of Dr. Grover Whitehurst of the Stony Brook Reading and Language Project.

21. In the Exam Room Anticipatory Guidance • Reading Aloud: • Stimulates language development even before a child can talk • Promotes a love of books • Links books with a parent’s voice/attention • Is fun for parent and child

22. In the Exam RoomAnticipatory Guidance • Helps parents with 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 re-tell familiar stories.

23. In the Exam Room: Book Selection • Know your population! • Be sensitive to the literacy level of the parent. • Can talk about looking at the book or naming pictures, rather than reading it. • Be cognizant of child and parent’s life and community or cultural background. • Let older children choose which book they want.

24. Which Books to Choose: 6-12 months • Board pages • Pictures and faces • Bright colors • Familiar objects • Limited text / small size Suggested Title: Smile!

25. 6 month visit Teachable moment: Talk to your baby, read to your baby! Bright Futures Guidelines Socio-Emotional • Is socially interactive with parent Communicative • Uses a string of vowels together Cognitive • Continues to use visual exploration to learn about the environment but is also beginning to use oral exploration

26. What We Just Saw: 6 Months .

27. 9 month visit Teachable moment: Books are familiar, fun Bright Futures Guidelines Socio-Emotional • Seeks parent for play and comfort and as a resource Communicative • Uses a wide variety of repetitive consonants and vowel sounds • Starts to point out objects Cognitive • Looks at books and explores environment, physically and visually

28. What We Just Saw: 9 Months

29. Which Books to Choose: 12-24 months Board pages Familiar objects Routines (naptime, bedtime) Rhyming words New concepts (zoo animals, shapes, colors) Suggested Title: Goodnight Moon

30. Early Toddler: 12-15 months Teachable moment: Books as an important part of family life and routines Bright Futures Guidelines Socio-Emotional • Hands you a book when he wants to hear a story; listens to a story • Has a strong attachment with parent or caregiver Communicative • Demonstrates protodeclarative pointing • Speaks 1-3 words • Jabbers with inflection of normal speech Cognitive • Follows simple directions

31. What We Just Saw 12-15 Months

32. Late toddler: 18-36 months Teachable moment: Language explosion! Bright Futures Guidelines Socio-Emotional • Explores alone but w/ parent in close proximity Communicative • Vocalizes and gestures; speaks 6-50 words • Uses 2 word phrases • Asks parent to read a book Cognitive • In response to “where is__?” points to object or animal in a book • Follows simple instructions w/o gestured cues to 2 step commands • Knows the name of his favorite books • Completes sentences and rhymes in familiar books

33. What We Just Saw 18-36 months

34. Which Books to Choose 24-36 Months • Paper pages • Rhyming words • Humorous/silly books • More advanced themes (big/small, over/under) Suggested Title: Is Your Mama a Llama?

35. Which Books to Choose: 36-60 months Folk tales and legends Alphabet and counting books Books and illustrations that exercise the child’s imagination Suggested Title: Eating the Alphabet

36. Preschool Visit: 36-48 months Teachable moment: Increasing comprehension and ability to retell stories Bright Futures Guidelines Socio-Emotional • Describes himself including gender, age, interests and strengths • Listens to stories • Engages in fantasy play Communicative • Is clearly understandable w/ most speech efforts Cognitive • Names 4 colors • Tells you what he thinks is going to happen next in a book

38. What We Just Saw36-48 months

39. Pre-Kindergarten Visit: 48-60 Months Teachable moment: The child who loves books is ready for school Bright Futures Guidelines Socio-Emotional • Social readiness to separate from parent easily and get along with other children Communicative • Clearly understandable with most speech efforts • Gives first and last name Cognitive • Knowledge of the alphabet, numbers • Curious!

41. What We Just Saw: 48-60 months

42. Summary of ROR Intervention

43. III. Evidence base for literacy promotion in primary care: what happens when providers intervene? • Do parental attitudes change? • Do parental practices change? • Are there other changes in the home environment? • Do children’s attitudes change? • Do children’s skills change?

44. 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

45. 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

46. 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

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

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

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

50. 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