DOI: 10.1542/peds.2014-1384; originally published online June 23, 2014; 2014;134;404Pediatrics

COUNCIL ON EARLY CHILDHOODPractice

Literacy Promotion: An Essential Component of Primary Care Pediatric  

  http://pediatrics.aappublications.org/content/134/2/404.full.html

located on the World Wide Web at: The online version of this article, along with updated information and services, is

 

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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POLICY STATEMENT

Literacy Promotion: An Essential Componentof Primary Care Pediatric Practice

abstractReading regularly with young children stimulates optimal patterns ofbrain development and strengthens parent-child relationships at a criticaltime in child development, which, in turn, builds language, literacy, andsocial-emotional skills that last a lifetime. Pediatric providers havea unique opportunity to encourage parents to engage in this importantand enjoyable activity with their children beginning in infancy. Researchhas revealed that parents listen and children learn as a result of literacypromotion by pediatricians, which provides a practical and evidence-based opportunity to support early brain development in primary carepractice. The American Academy of Pediatrics (AAP) recommends thatpediatric providers promote early literacy development for children be-ginning in infancy and continuing at least until the age of kindergartenentry by (1) advising all parents that reading aloud with young childrencan enhance parent-child relationships and prepare youngminds to learnlanguage and early literacy skills; (2) counseling all parents about devel-opmentally appropriate shared-reading activities that are enjoyable forchildren and their parents and offer language-rich exposure to books,pictures, and the written word; (3) providing developmentally appropriatebooks given at health supervision visits for all high-risk, low-incomeyoung children; (4) using a robust spectrum of options to supportand promote these efforts; and (5) partnering with other child advocatesto influence national messaging and policies that support and promotethese key early shared-reading experiences. The AAP supports federaland state funding for children’s books to be provided at pediatric healthsupervision visits to children at high risk living at or near the povertythreshold and the integration of literacy promotion, an essential com-ponent of pediatric primary care, into pediatric resident education. Thispolicy statement is supported by the AAP technical report “SchoolReadiness” and supports the AAP policy statement “Early ChildhoodAdversity, Toxic Stress, and the Role of the Pediatrician: TranslatingDevelopmental Science Into Lifelong Health.” Pediatrics 2014;134:404–409

STATEMENT OF NEED

Reading aloud with young children is one of the most effective ways toexpose them to enriched language and to encourage specific earlyliteracy skills needed to promote school readiness. Indeed, early, regularparent-child reading may be an epigenetic factor associated with laterreading success.1,2 Yet, every year, more than 1 in 3 American children

COUNCIL ON EARLY CHILDHOOD

KEY WORDSliteracy promotion, reading aloud, early brain development,language development, child development, school readiness

ABBREVIATIONSAAP—American Academy of PediatricsROR—Reach Out and Read

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.

Policy statements from the American Academy of Pediatricsbenefit from expertise and resources of liaisons and internal(AAP) and external reviewers. However, policy statements fromthe American Academy of Pediatrics may not reflect the viewsof the liaisons or the organizations or government agenciesthat they represent.

The guidance in this statement does not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.

All policy statements from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

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PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2014 by the American Academy of Pediatrics

404 FROM THE AMERICAN ACADEMY OF PEDIATRICS

Organizational Principles to Guide and Define the ChildHealth Care System and/or Improve the Health of all Children

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start kindergarten without the languageskills they need to learn to read. Read-ing proficiency by the third grade is themost important predictor of high schoolgraduation and career success. Approx-imately two-thirds of children eachyear in the United States and 80% ofthose living below the poverty thresholdfail to develop reading proficiency by theend of the third grade. Children fromlow-income families hear fewer wordsin early childhood and know fewerwords by 3 years of age than do chil-dren from more advantaged families.Children from low-income families havefewer literacy resources within thehome, are less likely to be read to reg-ularly, and are more likely to experienceearly childhood adversity and toxicstress at an early age, all resulting ina significant learning disadvantage, evenbefore they have access to early pre-school interventions.3–6

The 2011–2012 National Survey of Chil-dren’s Health found that 60% of Americanchildren from birth to 5 years of agefrom families whose incomes were400% of the federal poverty thresholdor greater were read to daily, and only34% of children from families whoseincomes were below 100% of thepoverty threshold were read to daily.7

These numbers indicate that, even inhigher-income families, many childrendo not experience the enhanced en-gagement and language-rich parent-childinteractions, including book handling,print exposure, and other early liter-acy experiences, afforded by dailyshared reading. All families face issuesof limited time, limited parental un-derstanding of the key role of readingaloud, and competition for the child’sinterest and attention from other sourcesof entertainment, such as electronicmedia.8 In contrast to often either passiveor solitary electronic media exposure,parents reading with young children is avery personal and nurturing experiencethat promotes parent-child interaction,

social-emotional development, and lan-guage and literacy skills during thiscritical period of early brain and childdevelopment.

LANGUAGE AND LITERACYDISPARITIES

Reading with children in their infancy andpreschool years is associated with higherlanguage skills at school entry and withchildhood literacy acquisition.9–11 Aftercontrolling for family education and so-cioeconomic status, the literacy-relatedqualities of a child’s home are associ-ated with language skill development.12,13

Earlier age of initiation of reading aloudwith a child has been shown to be as-sociated with better preschool languageskills and increased interest in reading.14

Reading aloud with young children hasbeen found to increase the richnessof the vocabulary to which they are ex-posed as well as the complexity ofsyntax.15 In addition, books and earlyconversations and play around booksand reading stimulate increased in-teraction between the adult and child.16

These interactions build nurturing rela-tionships that are critical for the child’scognitive, language, and social-emotionaldevelopment.17

Hart and Risley5 identified dramatic dif-ferences in early language exposure of1- and 2-year-olds in low-income familiescompared with children in higher-incomefamilies. Cognitive and linguistic differ-ences in children from talkative versustaciturn families were impressive by 3years of age and persisted into schoolage. Indeed, 60% of the variance in vo-cabulary in these children at 8 and 9years of age could be explained by theirexposure to language at home, beforethey were 3 years old. Book sharing hasbeen shown to promote social interactionbetween caregiver and child and to en-courage literacy development.16,17 Chil-dren’s literacy skills at school entry andin kindergarten and first grade oftenpredict their later reading success.18–20

Children from low socioeconomic back-grounds are significantly more likely tohave reading problems, to repeat a grade,and to have learning disabilities di-agnosed.21,22 Poor reading skills in adultsare associated with poor economic po-tential and with the perpetuation of cyclesof poverty, poor health, and dependencyacross the life course.23

DATA LINKING HEALTH TOLITERACY

Health literacy is “the degree to whichindividuals can obtain, process, and un-derstand basic health information andservices needed to make appropriatehealth decisions.”24 The 2003 NationalAdult Assessment of Literacy estimatedthat 14% of US adults had below basicliteracy and 22% more had only basicliteracy, which results in more than 90million adults in the United States whomay lack the literacy needed to effec-tively negotiate the health care system.25

Research has revealed compelling as-sociations of diminished disease knowl-edge, decreased utilization of preventiveservices, increased hospitalization, pooreroverall health status, poorer control ofchronic illness, and higher mortality inadults with limited health literacy.26–30

This interplay of health and develop-ment means that low literacy and re-lated low health literacy in parents ofyoung children pose a range of addi-tional risks, with studies showing in-creased developmental risk for childrenassociated with reduced reading aloudand increased health risk related tomedication dosing errors and lower ratesof adherence to medical regimens.31,32

DATA SUPPORTING OFFICE-BASEDPRACTICE OF LITERACYPROMOTION AS AN EFFECTIVEINTERVENTION

There are many literacy programs thatpromote reading to children. ReachOut and Read (ROR) is the most widelystudied and disseminated model of

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literacy promotion in the child’s med-ical home. Multiple studies in high-risk populations show that the RORmodel, which includes advising parentsof infants, toddlers, and preschool-agedchildren about the importance of read-ing aloud, counseling parents aboutspecific book-related strategies, mod-eling, and providing developmentallyappropriate books to children at healthsupervision visits, results in parents be-ing more likely to read with their chil-dren regularly.1,33–35 In addition, thesechildren are more likely to have signifi-cantly improved language developmentby the age of 24 months compared withtheir peers who did not participate inthese programs.1 Parents participatingin ROR reported a more positive atti-tude toward books and reading. Forexample, when asked to name favoriteactivities with their child or their child’sfavorite activities, parents were signifi-cantly more likely to mention looking atbooks and reading aloud than wereparents in control groups who hadnot received the ROR intervention. Thissignificant increase in parents viewingreading with young children as a fa-vorite activity has been found inEnglish- and Spanish-speaking parents,including recent immigrant popula-tions.1,35,36 One study evaluated familieswho spoke languages in which nobooks were available. These familieswere given English books and stillshowed increased positive attitudesand practices.37

Well-designed studies using appropri-ately matched comparison families orrandomized controlled trials of ROR haverevealed differences in children’s ex-pressive and receptive language.1,2,36,38

In one study, there was a 6-month de-velopmental increase in receptive lan-guage skills of children (average age, 4years) whose families were participat-ing in ROR, and children with morecontacts with ROR had larger increasesin their language skills.2 In another

study, larger vocabulary size was evi-dent in intervention children by thetime they were 18 to 25 months old.1

ROR has also been found to contributepositively to a child’s home literacy en-vironment.39 A multicenter study of 19primary care sites in 10 states beforeand after introducing ROR showed in-creased parental support for readingaloud after the program was imple-mented.40 In addition, a program mod-eled after ROR for implementation incollaboration with the Special Supple-mental Nutrition Program for Women,Infants, and Children (WIC) was shownto be associated with improved schoolreadiness.41 A recent randomized con-trolled trial of enhanced interventionbuilding on ROR showed that additionalintervention during the first 6 monthsof life leads to increased reading ac-tivities in infancy, reduced infant elec-tronic media exposure, and increasedparent-child interactions in childrenfrom low-income, immigrant, inner-cityfamilies. This reduced media exposurewas a direct result of the increase inreading activities.42,43

Research, in summary, shows that inpopulations at risk, participation in theROR intervention is associated withmarkedly more positive attitudes towardreading aloud, more frequent readingaloud by parents, improved parent-childinteractions, improvements in the homeliteracy environment, and significantincreases in expressive and receptivelanguage in early childhood.44

PROGRESS INTEGRATING LITERACYPROMOTION INTO PRIMARY CAREAND THE NEED FOR ADVOCACY

The ROR model has been voluntarilyadopted by more than 5000 pediatricprimary care sites serving children atrisk and has thus been field testedwidely and found to integrate effectivelyinto primary care in a variety of set-tings. The model includes training in thetechniques for using books to enrich

and expedite primary care visits. Thistraining is already incorporated into themajority of pediatric residency pro-grams, so newly trained pediatriciansare likely to have learned pediatric lit-eracy promotion as part of how todeliver quality primary care, again re-flecting the evidence base supportingthe efficacy of the intervention. Initia-tives partnering with the AAP are cur-rently underway to increase literacypromotion and the adoption of the RORmodel to serve several important groups,including American Indian, Native Ha-waiian, and Alaska Native populations.45

Another initiative, partnering with theAAP Section on Uniformed Services, isdeveloping ways to foster literacypromotion in medical facilities servingmilitary families. Local and nationalpartnerships with public libraries, adultand family literacy programs, child careproviders, schools, and businesses canhelp pediatricians connect families tomore books, more skills, and moreopportunities to facilitate the safe, sta-ble, and nurturing relationships asso-ciated with long-term academic successand health.

Support and advocacy from the AAP willmake it more likely that financial supportcan be found for pediatricians who wantto follow this model. Many pediatriciansbelieve that their patients could benefitfrom this intervention, but ongoing booksupply is often a barrier, as are the timepressures already crowding the primarycare visit. Costs in both books and timecan be offset in great measure by themany ways that a book can enrich theinteractions among children, parents,and pediatric providers at visits. Thesimple practice of incorporating a bookinto the health supervision visit allowsfor direct observation of emergent lan-guage and literacy skills and parent-childinteractions around shared reading, aswell as an opportunity to provide concreteguidance around language, development,and daily routines. In addition, books and

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the guidance that accompanies themimprove families’ satisfaction withthe care and advice they receive andstrengthen their bond with their pri-mary care provider and medical home.46

RECOMMENDATIONS FORPEDIATRICIANS

The AAP recommends that pediatricproviders promote early literacy de-velopment as an important evidence-based intervention at health supervisionvisits for children beginning in infancyand continuing at least until the ageof school entry by engaging in thefollowing:

1. Advising all parents that readingaloud with their young childrencan enrich parent-child interactionsand relationships, which enhancestheir children’s social-emotional de-velopment while building brain cir-cuits to prepare children to learnlanguage and early literacy skills.

2. Counseling all parents about devel-opmentally appropriate reading ac-tivities that are enjoyable for thechild and the parents and offerlanguage-rich exposure to booksand pictures and the written word.

3. Providing developmentally, cultur-ally, and linguistically appropriatebooks at health supervision visitsfor all high-risk, low-income chil-dren and identifying mechanismsto obtain these books so that thisdoes not become a financial bur-den for pediatric practices.

4. Using a robust spectrum of optionsto support and promote these ef-forts, including wall posters andparent information materials thatare culturally competent and acces-sible to those with limited literacyskills themselves, as well as infor-mation about the locations of andservices offered by their local pub-lic libraries and mechanisms foraccessing books for distribution.The AAP provides a literacy toolkit

(available at www2.aap.org/literacy/index.cfm) for pediatric and educa-tional professionals and for parentsto support this work.

5. Partnering with other child advo-cates to influence national messag-ing and policies that support andpromote these key early shared-reading experiences.

In addition, as described in the AAPtechnical report “School Readiness,”pediatric providers can also promotethe “5 Rs” of early education:

1. Reading together as a daily funfamily activity;

2. Rhyming, playing, talking, singing,and cuddling together throughoutthe day;

3. Routines and regular times formeals, play, and sleeping, which helpchildren know what they can expectand what is expected from them;

4. Rewards for everyday successes,particularly for effort toward worth-while goals such as helping, realiz-ing that praise from those closest toa child is a very potent reward; and

5. Relationships that are reciprocal,nurturing, purposeful, and enduring,which are the foundation of a healthyearly brain and child development.3

RECOMMENDATIONS FOR POLICYMAKERS

1. The AAP supports incorporation ofliteracy promotion and training re-lated to language and literacy de-velopment into pediatric residenteducation. The integration of liter-acy promotion as a key componentof primary care should be taughtin resident continuity experiencesand evaluated as an element ofcompetency-based pediatric medi-cal education.

2. The AAP supports federal and statefunding for children’s books to be pro-vided at pediatric health supervisionvisits for children at high risk as

well as the incorporation of fundingfor children’s books in managedcare and government insuranceprograms for children at high risk.

3. The AAP supports research on theeffects of pediatric early literacypromotion on child health and edu-cational outcomes and research onbest practices for literacy promotionin the context of both pediatric prac-tice and of residency education.

SUMMARY

Providing books at pediatric primarycare visits to families at economic andsocial risk, together with developmen-tally appropriate anticipatory guidanceencouraging parents to read aloud withtheir children, has a powerful effect onthe home environment of young chil-dren. It directly affects language de-velopment, a major factor in schoolreadiness, during the critical period ofearly brain development. The costs ofthese books, of training primary careproviders, and of incorporating thesestrategies into the primary care visitconstitute an investment in infants, tod-dlers, and preschool children directed attheir language, literacy, social-emotional,and life course development. As Pro-fessor James Heckman argued in hiskeynote address at the 2007 AAP NationalConference and Exhibition, programsthat invest in children at the earliest ageshave the highest rates of return. By ini-tiating early support for reading aloud,modifying the home environment to bericher in print, and advising parentsabout enjoyable and playful book-relatedstrategies that will increase their chil-dren’s language and early literacy skillswithin the context of their critically im-portant nurturing relationships withtheir parents and caregivers, pediatricproviders can leverage their uniqueopportunity to influence children in thevery early years of life and to createimportant long-term relationships withfamilies.

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All families need to hear the importantmessage that reading aloud to theirchildren is crucial, especially in an erain which competing entertainment im-peratives, such as screen time (television,cinema, video games, and computers),may limit family interactions and livelanguage exposures of even very youngchildren.47,48 Although most researchhas focused on literacy promotion forfamilies of lower socioeconomic sta-tus, pediatricians should rememberto educate all families about the im-portance of reading aloud to youngchildren because even in affluent andeducated families with plenty of booksat home, many parents do not readwith their children on a daily basis.Promoting literacy with parents ofchildren beginning in infancy supportsthe recommendations of the AAP thatchildren younger than 2 years not viewelectronic media and that older chil-dren and youth have no more than 2

hours daily of media exposure byoffering parents a positive alterna-tive for entertaining young children,for nurturing early relationships, andfor developing healthy bedtime rou-tines. The positive reinforcement ofrepeated developmentally appropri-ate encouragement in the contextof the primary care visit reminds par-ents again and again of the importanceof their “face time,” interactive con-versations, and their own evolving andessential relationship with their chil-dren, which is critical to setting ayoung child’s developmental trajectoryand life course.

LEAD AUTHORPamela C. High, MD, FAAP, Past Chairperson,Committee on Early Childhood, Adoption, andDependent Care

CONTRIBUTING AUTHORSPerri Klass, MD, FAAP, New York University andReach Out and Read

COUNCIL ON EARLY CHILDHOOD,2013–2014Elaine Donoghue, MD, FAAP, Co-chairpersonDanette Glassy, MD, FAAP, Co-chairpersonBeth DelConte, MD, FAAPMarian Earls, MD, FAAPDina Lieser, MD, FAAPTerri McFadden, MD, FAAPAlan Mendelsohn, MD, FAAPSeth Scholer, MD, MPH, FAAPElaine E. Schulte, MD, MPH, FAAPJennifer Takagishi, MD, FAAPDouglas Vanderbilt, MD, FAAPP. Gail Williams, MD, FAAP

LIAISONSLauren Gray – National Association for theEducation of Young ChildrenClaire Lerner, LCSW – Zero to ThreeBarbara Hamilton – Maternal and Child HealthBureauAbbey Alkon, RN, PNP, PhD – National Associationof Pediatric Nurse PractitionersKarina Geronilla – Section on Medical Students,Residents, and Fellows in Training

STAFFCharlotte O. Zia, MPH, CHESJeanne VanOrsdal, MEd

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