For the last nine years, Erie Family Health Center has been a partner with the Reach Out and Read program, a national program designed to encourage parents to read to their children, from infancy through age 5. When Erie established a new clinic at 1285 Hartrey Ave. in Evanston in 2013, the program was implemented there.
Under the program, doctors or nurse practitioners give families who bring in their children, ages 0-5, an age-appropriate book and help them understand the importance of reading aloud to their children. Importantly, they give parents suggestions on ways to interact with their children while reading.
Reach Out and Read is used in more than 5,000 health care sites throughout the country. Last year the program served 4 million children and distributed 6.5 million books.
Erie has 13 clinics in the Chicago area, through which it delivers health care to more than 70,000 medical patients and 12,000 dental patients – regardless of a patient’s ability to pay. All except three of Erie’s clinics – those located in high schools – participate in the program.
“By age five, there’s a disparity in literacy skills between the children of low-income families and their counterparts in a more affluent setting,” said Hannah Chi, manager of community programs at Erie.
“Only 34% of children from families below the federal poverty level are read to daily, and that actually impacts their cognitive development and their readiness for school,” Ms. Chi said. “Research has found that reading to children in their infancy and pre-school years is associated with higher language skills by the time they get to school, and it supports early childhood literacy acquisition.”
“We think it’s as important as any health intervention that we do,” said Aimee Crow, a pediatrician at Erie’s clinic in Evanston and a pediatric hospitalist at Evanston Hospital. “I think almost any pediatrician would tell you that. It’s as important as anything we do here.”
In August 2014 the American Academy of Pediatrics endorsed the Reach Out and Read program in a policy statement recommending that pediatricians encourage all parents to read aloud with their children beginning in infancy and continuing through the time they enter school. The academy also recommends that the providers give a developmentally appropriate book to families of high-risk, low-income children at all health-supervision visits.
A study conducted 30 years ago by Betty Hart and Todd R. Risley found that by the time children were 4 years old, children from low-income families heard 30 million fewer words than children from professional families. The quantity of words heard was one issue, but there were also qualitative differences. Children in lower-income homes were exposed to less back-and-forth interaction, less conversation, and less complex vocabulary. Significantly, Hart and Risley found that these differences correlated with differences in vocabulary skill at age 4, and that they also correlated with differences in vocabulary, IQ and test scores in third grade.
“There’s a growing body of evidence that kids who live in lower-income homes hear fewer words by the time they reach school than kids from higher-income homes,” said Dr. Crow. “It’s hard to catch up after that. So you start a little bit behind. Basically what the studies show is the more words you hear, the quicker your language development progresses and the more prepared you are to learn and read and write when you get to kindergarten. It’s a critical window of brain development.’’
Neuroscience explains from a scientific perspective what Hart and Risley observed empirically. In a 2012 report, the National Scientific Council on the Developing Child (NSCDC) concluded that what it calls “serve-and-return” interactions between a caregiver and an infant or child actually affect the formation of neural connections and the circuitry of the developing brain and shape the physical architecture of the developing brain.
“When an infant or young child babbles, gestures, or cries, and an adult responds appropriately with eye contact, words, or a hug, neural connections are built and strengthened in the child’s brain that support the development of communication and social skills. Much like a lively game of tennis, volleyball, or Ping-Pong, this back-and-forth is both fun and capacity-building. When caregivers are sensitive and responsive to a young child’s signals and needs, they provide an environment rich in serve-and-return experiences,” says NSCDC.
Reach Out and Read addresses the 30 million word gap, and provides a tool that facilitates serve-and-return interactions between a caregiver and an infant or child, Dr. Mariana Glusman told the RoundTable. She is the medical director of Reach Out and Read Illinois, an assistant professor of pediatrics at Northwestern University Feinberg Medical School, and an attending physician at Ann and Robert H. Lurie Children’s Hospital of Chicago’s Uptown Clinic.
Dr. Glusman said reading aloud to children, from infancy to 5 years old, exposes children to more words and oftentimes different and more complex words than they would otherwise be exposed to.
In addition to exposing children to more words, Dr. Glusman said parents teach their children by “scaffolding” (e.g., if a baby says “ba” a parent might respond “ball”), and “by back-and-forth interactions,” in which “the caregiver picks up on the cues of a child and then responds to them.”
“Reading is a great tool that parents can use to encourage the serve-and-return interactions that are so important for brain development,” said Dr. Glusman. “That’s where Reach Out and Read comes in. It’s not just a book. It’s an interaction. What we want to teach parents is that a book is a tool to help you talk more, to interact more, to have more intricate conversations with your child.”
Dr. Crow said the serve-and-return interactions do not take place when a child is watching television or watching a computer screen. “It can’t be from screens,” she said. “It’s supposed to be from human interaction, talking, singing, playing or reading.
“The goal is to reach kids in the 0-5 range to expose them to words and reading as much as possible to help with the language development and get them ready for school.” This really makes a difference in terms of school readiness and school success.”
The Reach Out and Read Program
The program is built into “well-child” visits. At each well-child visit, doctors or nurse practitioners give a developmentally appropriate book to the parent or child to take home, and they explain to parents why it is important to read aloud to the infant or child and explain how the parent may interact with the child while reading the book.
As children get older, they may be allowed to choose a book from a small selection of books.
At the Erie clinic in Evanston, four pediatricians, one pediatric nurse practitioner, and two family medicine doctors see patients in the 0- to 5-year old range. All are part of the Reach Out and Read program, said Dr. Crow, and all have completed the online training provided by Reach Out and Read. The training gives doctors pointers on how to incorporate a book into their well-child visits and to suggest ways parents can use a book as a tool to promote their child’s development.
Ideally, the routine is followed in all well-child visits, said Dr. Crow. She said there are eight well-child visits in the first year of life, three in year two, two in year three, and then once a year after that. “We have lots of visits in that critical window,” said Dr. Crow.
In the visit, “I try to emphasize what we know about language development,” and tell parents “if they read aloud with their children regularly, they will see a big difference in language development and how well their children will do when they get to school. I let them know that this could help their children do better in school for the entirety of their careers,” said Dr. Crow. “Parents really hear that.”
“We try to encourage them to incorporate reading into every day, so that they set up rituals around reading, maybe before nap or bedtime, maybe another time that works for them, but that it’s something they do regularly,” said Dr. Crow.
She also explains, “It’s not just about reading word for word, it’s about interacting with the book.” For example, Dr. Crow said, a parent can point out the eyes and nose of people pictured in a book, or ask children to point out things, such as ‘Where’s the dog?’ As children get older, parents can start asking them questions about the story, and as time goes on, parents can extrapolate more and ask children about things in their world that connect to the story.
“Many of our families are already doing this and benefit from our support and encouragement. For some parents, this may be new information. If I sense that a parent is not reading to his or her kids because of a lack of confidence in their own reading ability, I model how to make up a story using the pictures, and how to ask their child questions based on what they see.”
Kate Brady, a pediatrician who used the Reach Out and Read program for eight years at the Child and Adolescent Center at Evanston Hospital, told the RoundTable that a nurse would oftentimes leave a selected book in an office where a parent and child would wait for the pediatrician. When she entered the office, Dr. Brady said, she would sit down with the child and mother or father and observe the parent reading to the child or she would read to the child together with the parent. She used that process as a starting point to reinforce what the parent was doing or to offer suggestions. She said she talked about the importance of reading every day, trying to read every night, and incorporating reading into a lifestyle.
“I used it as a vehicle to talk about parenting in general – sort of emphasizing reading as a way to connect with their child,” Dr. Brady said. “I would talk to them not only about the importance of reading, but the importance of talking to their children and turning off the screens, the distractions.”
“I think there’s a value in not just talking about reading books to you child, but showing them how to do it, reinforcing it, and letting them leave with a book so they actually can do it,” said Dr. Brady. “When we say read to your children regularly and then give them a book, it’s very reinforcing for a positive life change.”
“Our message is, ‘Read to your child, share books with your child, talk about pictures, talk about words,’” said Dr. Glusman. “What makes Reach Out and Read unique is that the doctor doesn’t just say, ‘Read 13 minutes a day,’ they actually use the book to show parents how to do it.”
While the time for a well-child visit is short, “It’s actually very, very simple to work the book into a visit,” said Dr. Glusman. She said giving a book to a child at the beginning of a visit can help put a child at ease, and a pediatrician can use the book to help gauge a child’s development and the parent’s ability to respond to the child’s cues. “It doesn’t take a lot of extra time.”
Dr. Brady gave similar comments. She added, “I think the medical home is a place where a lot can be done besides just medicine. More than half of what a pediatric visit consists of is providing a parenting education space. Reading is probably the healthiest thing a child and family can do for brain development, for imagination, for children learning to focus, for children to build their self-esteem, for interactions between families and groups. I think Reach Out and Read is a phenomenal program.”
Erie’s clinic in Evanston promotes literacy in other ways. The waiting room has an area set aside with children’s books. The clinic also has a small room with a table, chairs and bookshelves stocked with some books. After a visit, kids can go to the room and, if books are available, pick out a book as a treat, says Dr. Crow. As many as 100 families may pass through the reading room on a busy day.
“Reach Out and Read is one of the few interventions in primary care pediatrics that has research behind it,” said Dr. Glusman.
In its policy statement, the American Academy of Pediatrics summarized the research saying, “Research, in summary, shows that in populations at risk, participation in the ROR intervention is associated with markedly more positive attitudes toward reading aloud, more frequent reading aloud by parents, improved parent-child interactions, improvements in the home literacy environment, and significant increases in expressive and receptive language in early childhood.”
One study found that children who participated in Reach Out and Read had advanced six months more in receptive language skills and three months more in expressed language skills by age 4 than their peers who did not participate in the program. See “The Impact of a Clinic-Based Literacy Intervention on Language Development in Inner-City Preschool Children” (2001) by Mendelsohn, et al.
Significantly, these results stem from relatively short interventions in about 10 or 12 well-child visits over a five-year period. The actual benefits are achieved by parents reading aloud with their children and interacting with them, in what many feel is a fun activity, and for the some the most enjoyable thing they do together.
Perhaps the program is effective because a doctor, a person who is trusted and considered knowledgeable in early child development, is the one giving the message to parents and the one who gives the child a book.
“When the pediatrician says it’s important, it’s a very powerful message because it comes from a very important source,” said Dr. Glusman. “As a pediatrician, I feel I’m in a privileged position to give this message to families.”
Maintaining a supply of books is a challenge nationally and at the local level too. In 2014, Erie in Evanston provided 1,526 well-child visits for children, ages 0-5, and received 1,128 books to give to the families. In 2015, Erie in Evanston provided 2,981 well child visits for children, ages 0-5, and was able to distribute only 481 books to families because of a reduction in funding both nationally and locally.
“In 2015 we were short by about 2,500 books just for the 0-5 age group,” said Dr. Crow. “We don’t have enough books to meet the fundamental goal of the program, which is one book for every child at every well-child visit for ages 0-5.
“I think the program suffers when I don’t have a book to give to the child,” Dr. Crow added. “I will still go through the importance of reading, but it doesn’t have the impact. When we do have the books, though, Reach Out and Read is an amazing program. It can work really, really well.”
Dr. Crow added that if Erie had enough books, they could also give books to children when they came in for a sick-visit, and they could give books to siblings and to older kids. If the small reading room at the clinic was fully stocked with books, many children could take additional books home to add to their libraries.
An intern at Erie, Ashleigh Knoeferl, coordinates books coming in from Erie headquarters and reaches out to the Evanston and Skokie libraries and members of the community to solicit new and gently used books for the program. The number of books collected still falls far short of the number needed.
Ms. Chi said Erie tries to provide as many books to its clinics as possible. “Unfortunately the supply of books we have available to distribute through Erie’s own book purchases, as well as the generosity of Reach Out and Read’s national headquarter’s donations, are not enough to meet the needs of our clinics.
“This is a program that Erie really loves and is invested in and we hope as we continue to apply for more grants and look for more support around this program that we will be able to make it far more robust than it is now,” said Ms. Chi. “It’s very important to us to continue supporting the development of young children in our community.”
“We talk a lot in our community about the achievement gap,” said Dr. Crow. “It’s frustrating to play catch up once kids get to school. This is one way the community could invest in giving kids the best shot to narrow the gap…. What we need most of all are new or gently used books, for 0-5 years old, in both English and Spanish.”
How to Donate Books or Money for Books
Anyone who is interested in making a donation to support the Reach Out and Read program at Erie Evanston/Skokie Health Center may send a check payable to “Erie Family Health Center” with “Evanston/Skokie ROR” in the memo line to: Erie Family Health Center, attn.: Development Office, 1701 W. Superior Street, 3rd FL, Chicago, IL 60622. Or, donate online at eriefamilyhealth.org/support-erie. On the donation form, choose “Designation: Other” and fill in “For Evanston/Skokie ROR.” Erie’s clinic in Evanston also accepts donations of new and gently used books, which may be dropped off at the front desk of Erie Family Health Center, 1285 Hartrey Ave., Evanston.
The AAP’s Policy Statement
In April 2014, the American Academy of Pediatrics adopted a 20-page policy statement in which it recommends that pediatricians encourage parents to read aloud with their children, beginning at infancy and continuing through age 5. A portion of the academy’s summary of the policy statement states:
“”Reading regularly with young children stimulates optimal patterns of brain development and strengthens parent-child relationships at a critical time in child development, which, in turn, builds language, literacy, and social-emotional skills that last a lifetime. Pediatric providers have a unique opportunity to encourage parents to engage in this important and enjoyable activity with their children beginning in infancy. Research has revealed that parents listen and children learn as a result of literacy promotion by pediatricians, which provides a practical and evidence-based opportunity to support early brain development in primary care practice. The American Academy of Pediatrics (AAP) recommends that pediatric providers promote early literacy development for children beginning in infancy and continuing at least until the age of kindergarten entry …””‘Serve-and Return’ Interactions Build Sturdy Brain Circuits
Research shows that an environment that is nurturing, responsive and language-rich fosters healthy development. This can be found in the home, in a childcare center, or even in a casual local program.
In a report, “”The Science of Neglect: The Persistent Absence of Responsive Care Disrupts the Developing Brain”” (2012), the National Scientific Council on the Developing Child (NSCDC) says, “”Beginning after birth, a strong foundation for human well-being requires responsive environments and supportive relationships to build sturdy brain circuits, facilitate emerging capabilities, and strengthen the roots of physical and mental health.””
A “”major ingredient”” of a responsive relationship is what NSCDC calls “”serve-and-return”” interactions between a child and adults. “”Beginning shortly after birth, the typical ‘serve and return’ interactions that occur between young children and the adults who care for them actually affect the formation of neural connections and the circuitry of the developing brain. Over the next few months, as babies reach out for greater engagement through cooing, crying and facial expressions – these reciprocal and dynamic exchanges literally shape the architecture of the developing brain.””
As children get older, more sophisticated “”serve and return”” interactions with a child, reading on a regular basis to a child and exposing a child to more cognitive language have positive impacts. The stimulation that occurs in the brain through these activities “”can result in epigenetic changes that establish a foundation for more effective learning capacities in the future,”” says NSCDC in its report, “”Early Experiences Can Alter Gene Expression and Affect Long-Term Development”” (2010).
Wide Achievement Gap at Kindergarten
In its achievement report presented on Jan. 25, School District 65 provisionally defined “”kindergarten ready”” as scoring above the 50th percentile on at least four of the five snapshots of the Illinois Snapshot of Early Learning (ISEL) that assess a child’s foundational skills in literacy.
Under that definition, only 26% of the students from a low-income household who entered kindergarten at District 65 in 2015 were kindergarten ready, compared to 72% of other students. See also 2015 Joint District 65/202 Achievement Report.
There is “”a wide gap between foundational literacy skills of students living in low-income households and those living in higher-income households,”” says the District 65 Report. “”This gap persists throughout elementary and middle school, and it is even more pronounced for black and Hispanic students living in low-income households.””