Literacy: Beyond just BooksFebruary 2015

Pediatric Continuity Clinic CurriculumCreated by: Rebekah Soto

Objectives

• Review benefits of early introduction to reading for infants and toddlers

• Understand how reading and looking at books together can be used to help encourage developmental milestone progression

• Discuss ways to encourage families to read together• Learn practical techniques to include reading

recommendations in your well child checks while addressing parental concerns

• Evaluate parental concerns regarding learning or reading skills

Case #1

You are seeing a 2 month old healthy infant for WCC. When you ask how the family is adjusting to the new baby, MOC states they are doing well except for the older 4 year old sibling who is struggling to adjust to having a new baby at home and starting into pre-K (which is his first school experience away from mom). Mom reports she plans to keep this baby at home for now, but “doesn’t want to make the same mistakes again” because she feels her older child was not prepared to start school this year.

Case #1 Discussion Questions

• What advice could you provide this mother with regard to “school preparation” for her new infant?

• How could books be used as a helpful tool for this family?

• What does the AAP recommend with regard to reading with young children?

What advice could you provide this mother with regard to “school preparation” for her new infant?

• It’s never too early to start reading books with your little one.

• Reading books aloud with your baby has been shown to have a positive effect on parent-child bonding, early language skills, and literacy development.

• Children who are read to as infants and toddlers have better language skills and interest in reading when they start school.

• Building positive associations with reading as a young child helps foster a lifelong love for reading and learning.

How could books be used as a helpful tool for this family?

• Reading books together can be a fun activity to bring the whole family together and create lifelong memories.

• A special reading time or library trip with just the older sibling can help him to maintain a bond with his parents and prevent him from feeling like he is competing with the new baby for attention.

• Reading books about a new baby, bedtime routines, and going to school can help this child understand some of the new changes in his life.

• Allowing him to pick out books and read to his younger sibling is a good way to build sibling relationships and build confidence as big brother “helps” mom and dad with caring for the baby in a safe and age appropriate way.

What does the AAP recommend with regard to reading with young children?

Pediatric providers promote early literacy development for children beginning in infancy and continuing at least until the age of kindergarten entry by • (1) advising all parents that reading aloud with young children can enhance

parent-child relationships and prepare young minds to learn language and early literacy skills;

• (2) counseling all parents about developmentally appropriate shared-reading activities that are enjoyable for children and their parents and offer language-rich exposure to books, pictures, and the written word;

• (3) providing developmentally appropriate books given at health supervision visits for all high-risk, low-income young children;

• (4) using a robust spectrum of options to support and promote these efforts; and

• (5) partnering with other child advocates to influence national messaging and policies that support and promote these key early shared-reading experiences.

Case #2

• A 12 month old presents for his 1 year WCC. While he appears to be developing well in other areas, his mother is concerned that he is not as vocal as his older sister was at this age. – What are normal communication skills for a child

this age? – How do you answer mom’s questions about “why

he doesn’t talk as much as his sister?” – What can mother do to help encourage his

vocalizations?

What are expected communication skills for a 1 year old child?

• 1 year olds can generally say “mama,” “dada,” and possibly a few other favorite words.

• May point to something they want (proto-imperative pointing).

• May use gestures with vocalizations (i.e. reaching or waving at something).

• Can generally follow a one step command provided with a gesture.

• May recognize an object when it is named and look toward that object.

“Why doesn’t he talk as much as his sister?”

• Remind mom that each child has their own pace of development and personality traits.

• Let her know you will evaluate all domains of his development to ensure he is developing appropriately in other areas. Reassure her if these are all appropriate for age.

• Don’t forget to assess for hearing concerns or failure to respond to sounds appropriately, as these may present with speech delay.

• Review birth history and family history for any risk for hearing loss and ensure he passed his newborn hearing test. *

What can mother do to help encourage his vocalizations?

• This mother is motivated to do something to help her child with speech so take the opportunity to advise her on the lifelong benefits of reading!

• By reading stories and looking at books together daily, he will hear words and sounds and begin to mimic them.

• Incorporate singing, rhyming, and “having conversations” within the daily routine to encourage his vocalizations.

• Responding to his sounds and gestures with eye contact and talking back provides feedback and attention that he craves to keep attempting sounds.

Don’t forget!• The local library is a great FREE resource for finding age

appropriate books and other family oriented activities allowing children to interact with their community in a safe, supportive environment.

• There are books available on a number of topics that you would never expect. Encourage families to look into topics that they express concern about (ie dealing with bullying, death of a loved one, non-traditional families, suicide, potty training, children with disabilities, etc).

• Families can look up Alachua County Library District online to find the library location closest to them and fun events taking place as well as look up books/movies/etc in the online catalog. Check it out at www.aclib.us!

Case # 3

7 year old male presents for a urgent visit with his mother due to “school concerns” because his grades at school are dropping. His teachers report he is doing well with basic math and answers questions verbally during class time, but struggles with finishing assignments at school. His mother is concerned that he has always been a “slow reader” and now seems to have increasing difficulty and frustration with completing homework at home. Furthermore, the teacher has noticed he will sometimes “act out” or “become a class clown” during group reading activities. He is an otherwise well behaved and articulate child.

Case # 3 Discussion

• What additional history should you obtain at this visit?

• Mom asks you, “do you think he has a learning disability?”

• What guidance can you provide this concerned mother regarding her child’s future school performance?

• What interventions or work-up should be initiated today?

What additional history should you obtain at this visit?

• Because learning impairments or disability can be attributable to a number of factors, a thorough history is necessary to help determine the cause of learning problems:– Current and past school history (including current interventions or

individualized education plans/504 and if the learning or behavior issues are limited to a certain class, teacher, or time of day)

– Prenatal/birth history (in utero exposures/infections)– Developmental milestones attainment or delays (was the child

ever evaluated for delay or receiving any therapies?)– Social history – Past medical history (including consideration of vision or hearing

issues which may impact learning) – Family history of learning disability or intellectual disability

(including history of family member who dropped out of school or had difficulty obtaining and maintaining a job)

“Do you think that he has a learning problem?”

• Around 3 million children 6-11 years old are affected by learning disability. Disability can be in mathematics, written expression, or most commonly in reading disability or dyslexia.

• Reading disability accounts for 80% of learning disability cases and affects 5-10% of the general pediatric population.

• Males are more commonly affected than females and the degree of disability varies from child to child.

• Children may be able to cope with or overcome their disability for a period of time, but tend to struggle during the transition from “learning to read” to “reading to learn” when reading comprehension becomes necessary for building skills.

• Children may “act out” or clown around in class to distract from their embarrassment with their inability to complete work. They may also be at higher risk for suspension, poor self-esteem, or getting into fights at school due to bullying, and ultimately at higher risk for being held back grades and dropping out of school.

What guidance can you provide this concerned mother regarding her child’s future school performance?

• Reading proficiency by 3rd grade is the most significant predictor of high school graduation and career success, yet 2/3 of U.S. 3rd graders lack competent reading skills.

• Many children with disabilities can excel in school (and in adult life) with the proper interventions to support learning.

• Because of the high morbidity of untreated learning disability and the lifelong detrimental effects, it is essential to begin addressing problems immediately.

What interventions or work-up should be initiated today?

• Work up should be guided by the history & physical• As the PCP, rule out/consider other causes of learning problems

(see notes)• Interventions at school to promote achievement can be put into

place prior to “having a diagnosis” and should be initiated ASAP to prevent child from falling further behind.

• Children with suspected learning disability should undergo psychoeducational testing (through school or private psychologist) to determine disability and most appropriate interventions to facilitate learning.

• The medical home should advocate for appropriate educational interventions (IEP/504 plan) and referrals for subspecialty evaluation or therapies as needed.

PREP Question

PREP Question

• Answer: C. 24 Months• The child described in the vignette exhibits

normal cognitive/behavioral milestones for a 24 month old: combines words into 2-3 word phrases, points to pictures named, uses vocabulary of 50+ words and uses “I” “me” and “mine” in speech.

PREP Question

PREP Question• Answer: D. Learning Disability• The girl described in the vignette has evidence of a learning

disability with difficulty in reading. • In order for a learning disability to be diagnosed, there must be a

significant discrepancy between the child’s achievement scores in reading, writing, or math and the child’s cognitive ability (IQ). The discrepancy must impact the child’s educational success.

• To confirm the diagnosis of a learning disability, a psychoeducational evaluation is performed that includes cognitive and academic testing. A comprehensive speech and language evaluation and audiologic examination will help clarify if there is an underlying language disorder or hearing deficit. When there is a concern that a student may have a learning disability, public law requires a psychological and educational evaluation.

PREP Question

PREP Question• Answer: A. Learning Disability. • The infant in the vignette has congenital hearing loss due to connexin gene

mutation. • These infants are at increased risk for learning disabilities and a low reading

level. Even children with mild or unilateral hearing loss will have more difficulty listening when there is background noise, as is often the case in a school classroom.

• The child in this vignette has an isolated hearing loss and is therefore not likely to have a significant intellectual disability (ID). However, children who have hearing loss due to prenatal infections are at increased risk for ID and neurodevelopmental delays, including learning or language difficulties, inattention, or behavioral disturbances.

• Congenital or acquired hearing loss has been linked to lifelong deficits in speech and language acquisition, poor academic performance, personal-social maladjustments, and emotional difficulties.

Resources

• Literacy Promotion: An essential component of primary care pediatric practice (2014 AAP Policy Statement)

• Parents who read to their children nurture more than literacy skills- AAP News June 2014

• Reach Out and Read Website• Reading is Fundamental Website• Alachua Country Library District Website • Hearing Loss in Children-Peds in Review • Learning Disability and School Failure-Peds in Review