Promoting Early Literacy in the Pediatrician’s Office: What Have We Learned?
Heavy television use in a household can interfere with a child’s language development likely because parents spend less time talking to their child. In turn, children who live in households with heavy media use spend less time being read to. In the short-term, children younger than 2 years who spend a significant amount of time watching television or videos have higher chances of having a language delay [21–23]. Children who are exposed to infant videos also develop fewer language skills than children who are read to [24,25]. What is clear from all of this work is that young children learn best by interacting with the caring people in their lives, not with screens.
Given these facts, the AAP continues to discourage media use among children younger than 2, encourages parents to spend time reading and playing with their children, and discourages parents from having the TV or other electronics on as “background noise” when their children are present, since it decreases the amount of talking and interacting between parents and their children [16].
Benefits of the Reach Out and Read Model
For the past 25 years, pediatricians have been promoting early literacy in their practices following the ROR model, which consists of the following components:
- Giving a new, colorful, age-appropriate book to babies, toddlers, and preschoolers at every well child visit starting at 6 months of age
- Providing anticipatory guidance to parents on the benefits of reading aloud to children starting at birth
- Having a literacy-rich waiting room area (which at times includes volunteers reading to the children)
The data supporting this very simple, inexpensive intervention is robust. Multiple studies have shown that children exposed to the ROR model have improved language skills when compared to children who are not. Parents also report a much higher frequency of reading with their children when exposed to ROR than parents who are not [26–28].
In a randomized controlled study of literacy promotion in Hispanic families, when parents were asked open-endedly “What are your 3 most favorite things to do with your child?,” parents who had received literacy-promoting anticipatory guidance and books reported “reading with my toddler” significantly more often than parents who had not (43% intervention vs. 13% controls). When asked about the frequency of reading to their toddlers, intervention parents were significantly more likely to report reading books with their children at least 3 days/week than controls (66% intervention vs. 24% controls). Applying a multiple logistic regression model controlling for child and parent age, parent reading habits, and English proficiency, we found that the odds of parents reading to their child at least 3 days/week were 10 times greater in intervention families (odds ratio [OR] 10.1, 95% confidence interval 4.0–25.6) than in controls [29].
In a parallel study with English-speaking low income families, when parents were asked open-endedly, “What are your child’s 3 most favorite activities?,” parents who had been exposed to the intervention, were significantly more likely to report “reading books” as one of their toddler’s 3 favorite activities than parents who were not exposed (27% intervention vs. 12% controls). Toddler expressive and receptive vocabulary scores were higher in intervention families and were associated with more frequent shared reading [30].
A multicenter study (19 clinical sites in 10 different states) that compared 730 children aged 6 to 72 months exposed to the ROR model with a comparison group of 917 matched children who did not participate in this literacy promoting model found significant associations between exposure to ROR and reading aloud as a favorite parent activity (adjusted OR 1.6, P < 0.001); reading aloud at bedtime (adjusted OR 1.5, P < 0.001); reading aloud 3 or more days per week (adjusted OR 1.8, P < 0.001); and ownership of 10 or more picture books (adjusted OR 1.6, P < 0.001) [31].
Across the world, others have been replicating and testing the ROR model. Interestingly, studies conducted in Taiwan and with immigrants from Latin America and Asia have all shown similar effects on parental literacy behaviors and on the development of children’s early oral language skills [32–35].
Parent-Child Bonding from Sharing Books
According to the 2014 AAP policy statement, literacy promotion is an essential component of pediatric primary care [3]. The statement emphasizes that parent-child shared reading is a “very personal and nurturing experience that promotes parent-child interaction, social-emotional development, and language and literacy skills during this critical period of early brain and child development.” It recognizes the importance of shared reading as a bonding experience that could start in early infancy. These early nurturing relationships are critical to promoting healthy child development [36].
Most studies of practice-based literacy promotion have asked parents what their favorite things are to do with their child. All of these studies have shown that parents who have received guidance around the importance of reading together and high-quality books to share with their infants, toddlers, and preschoolers include reading aloud as one of their 3 most favorite activities, compared to control families who did not receive this intervention [28–31]. When activities are favorites, they are enriched by this shared enjoyment and are far more likely to occur often and perhaps become treasured family routines. Children’s books and early play and discussions around the themes in these books stimulate increased interaction between caregivers and children [37]. These interactions build secure relationships that are key to children’s healthy cognitive, language, and social-emotional development [38–40].
The Effects on the Brain From Listening to Stories
In a recent study, 48 children aged 6 to 11 years were classified as early talkers (16), on-time talkers (16), or late talkers (16) by parental report [41]. Group assignments were based on whether the parent recalled their child making 2- to 3-word sentences early, on-time, or late. None of the “early talkers” had spoken their first sentences after 24 months, and none of the “late talkers” had spoken sentences before age 2. Utilizing functional MRI, researchers analyzed talker group differences in processing of speech and print and functional activation differences on auditory stimuli and when visualizing print. The groups were matched by age, gender, and performance IQ. This study showed strong group differences in the activation of several regions of the brain, including the left superior temporal gyrus, left putamen, globus pallidus, right putamen, left insula, and thalamus. In each of these areas, late talkers demonstrated significantly less activation that early talkers in both speech and print conditions (P < 0.001). Talker group status was strongly related to neural activation patterns during simple linguistic tasks. These cortical differences in activation are consistent with other studies that demonstrate the role of these regions in understanding speech [42] and processing print [43,44]. These findings highlight the importance of early language development on the formation of critical language and reading circuits and how these neural pathways are affected many years later [41].
In another study of nineteen 3- to 5-year-olds, researchers used functional MRI to examine the relationship between home reading environment and brain activity during a story listening task. The study showed that while listening to stories, children with greater home reading exposure exhibited higher activation of left-sided brain regions involved with processing of meaning. Higher reading exposure at home as measured by the StimQ-P Reading subscale score, was positively correlated with neural activation in the left-sided parietal-temporal-occipital association cortex, a region of the brain supporting semantic language processing, when controlling for household income (P < 0.05) [45].
