Laurel M. Wills, MD Lynne Burke Reach Out and Read: Pearls from the Exam Room

Children's CME 12/11/2008 1

The program will take up to one hour to complete.

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This program is designed for primary care physicians.

Other health care professionals working with patients and their families may also find this program of interest.

Target Audience

It is the policy of Children’s Hospitals and Clinics of Minnesota to ensure balance, independence, objectivity, and scientific rigor in all its educational programs. Our faculty have been asked to disclose to our program audience any real or apparent conflicts of interest related to the content of their presentation. They have also been requested to let you know when any product mentioned in their presentation is not labeled for the use under discussion or is still under investigation.

Faculty Disclosure Laurel M. Wills, MD and Lynne Burke has disclosed no actual or potential conflict of interest in relation to this educational activity.

During this educational activity Dr. Wills andMs. Burke will not be discussing the use of any commercial or investigational product not approved for any purpose by the FDA.

Faculty Disclosure

Laurel M. Wills, MD, FAAPStaff Pediatrician, Hennepin County Medical Center, Minneapolis, MN; Assistant Professor, University of

Minnesota, Minneapolis, MNLynne Burke

Program Coordinator for Reach Out and Read -Minnesota

Reach Out and Read: Pearls from the Exam Room

A lecture about the advantages of physicians encouraging reading and book sharing between parents and

young children.

Reach Out and Read: Pearls from the Exam Room

Laurel M. Wills, MD Lynne Burke Reach Out and Read: Pearls from the Exam Room

Children's CME 12/11/2008 2

Program ObjectivesUpon completion of this program, participants should be able to:

• Review pediatric research-based strategies to enhance development of speech/language and literacy skills in very young children as part of anticipatory clinic guidance

• Recognize a provider’s ability to influence parents’ attitudes and behavior around book sharing, reading aloud, and becoming involved with children’s pre-academic progress

• Recognize a provider’s ability to evaluate child development and parent-child social-emotional interaction using children’s books

Disclaimer

Children’s Hospitals and Clinics of Minnesota accepts no responsibility for the materials presented through these Grand Rounds seminars. Each professional host assumes all responsibility for maintaining confidentiality or obtaining authorization, in accordance with all applicable laws.

AccreditationChildren’s Hospitals and Clinics of Minnesota is accredited by the Minnesota Medical Association to provide continuing medical education for physicians. Children’s Hospitals and Clinics of Minnesota designates this educational activity for a maximum of 1 AMA PRA Category 1 CreditsTM toward the AMA Physician’s Recognition Award. Each physician should only claim those credits that he/she actually spent in the activity.

Receiving CME Credit

To receive CME credit you must view the entire program and complete the evaluation form at the end.

Children’s Hospitals & Clinics

Pediatric Grand Rounds

December 9 & 11, 2008

Laurel Wills & Lynne Burke

Pearls

from the

Exam Room

The Mission of Reach Out and ReadTo make literacy promotion a standard part of pediatric primary care, so that children grow up with books and a love of reading.

Laurel M. Wills, MD Lynne Burke Reach Out and Read: Pearls from the Exam Room

Children's CME 12/11/2008 3

Founded in 1989 in Boston, MA> 50,000 providers trained.

>3,800 clinic sites—nation wide

>3.7 million children reached / yr

>5.5 million books distributed / yr

Minnesota Program55 clinics statewide

23% of low income kids reached

New MMA Resolution on literacy

Vital StatisticsMinnesota Medical Association Resolution on Reading to Young

Children• Speak to parents about the importance of

reading to children

• Encourage clinics to develop programs to foster reading to children

• Actively seek community partners in this effort in order to make books available to families, increase use of libraries, and encourage others to support reading to children

Training ObjectivesDescribe details of the ROR model of

pediatric literacy promotion

Present research / evidence base

Review milestones of children’s early language and literacy development

Explain anticipatory guidance for parents about book-sharing and reading: “Pearls”

Three Components of Reach Out and Read

Literacy-rich clinic environment

Well child check-ups: 6 mos.- 5 years

developmentally-appropriate books

10 new books by kindergarten

Anticipatory guidance:

“book-sharing” and reading aloud

Literacy-Rich Waiting Rooms

Displays and provides information about libraries, reading aloud, and adult and family literacy organizations

Gently used books should be available

Volunteer readers (when available and where appropriate)

Laurel M. Wills, MD Lynne Burke Reach Out and Read: Pearls from the Exam Room

Children's CME 12/11/2008 4

Reach Out and Readin the

Exam Room–The book is given EARLY in the visit

–Providers model “book-sharing”

–Celebrate parent-child interactions in “real time”

–Tool to assess development: motor, cognitive, social-emotional, speech-language

Anticipatory GuidanceSharing books is important even before a child can talk

Having books at home promotes comfort with & love of books

Parents are baby’s first teachers—set the stage for future learning

Keep it fun and playful!

Language, Reading, and Early Brain Development

Early language evolves via parent-child interactions

By kindergarten, middle income kids have 20K receptive vocabulary vs. 3K for low SES children (Hart & Risley, 1995)

By age 2, language development predicts later cognitive functioning

ROR = a remarkable “capture opportunity”

Children from Low-Income FamiliesFar less likely to be read to on a daily basis(National Research Council, 1999)

Average 13 books in the home for middle income kids, vs. one for every 300 kids in poor neighborhoods(Dickinson and Neuman, 2005)

Twice as likely to repeat a grade, and 1.3-1.4 times as likely to be diagnosed LD(Brooks-Gunn & Duncan, 1997)

0

10

20

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Percentage of children read to

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Reading Aloud and School Readiness(National Center for Educational Statistics, 1999)

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Perc

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Recognizeall letters

Count to 20 Write name Pretend toread/recite a

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Have master3-4 skills

Less than 3 times3 times or more

Influences language development (Mendelsohn et al: Pediatrics 107:130-134,2001

n=122, case-control, urban inner city

Receptive and Expressive Language Scores

ROR Research Summary:An Evidence-Based Intervention

Influences the literacy environment of children(High et al: Pediatrics 104:927-934,2000)

Parents read more to their children

Parents and children have more positive attitudes toward reading aloud

7476788082848688909294

Voca

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Receptive language Expressive language

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Num

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Days/week Nights/week

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1 of 3 favoriteactivities of parents

1 of 3 favoriteactivities of children

InterventionControl

Laurel M. Wills, MD Lynne Burke Reach Out and Read: Pearls from the Exam Room

Children's CME 12/11/2008 5

Receptive / Expressive Languageor

Comprehension vs. Production

(Picture Vocabulary Task--Bayley)

Reach Out and Readin the Exam Room

Introduce the book early in the visit

Observe and comment on a child’s actions & behaviors:

– “Jessica is chewing on the book. That’s OK---Babies like to do that.”

– “Babies like to look at pictures of babies.”

Encourage parent and siblings to talk about the baby using the books:

– “Where’s the baby?”“Where’s the baby’s nose?”

– Point, name or label, describe objects

– Relate the book to the child • “He has a sister,

just like you.”– With older kids,

expand vocabulary purposefully

Questions / Suggestions

– Have you and (child’s name) begun to look at books yet? What does he/she enjoy most about it? Do you have a favorite book?

– What are some things that you and (child’s name) do together at bedtime?

– Encourage a bedtime routine that includes books.

What to expect when you’re book-sharing!

Laurel M. Wills, MD Lynne Burke Reach Out and Read: Pearls from the Exam Room

Children's CME 12/11/2008 6

The Book as One Tool to Assess a Child’s Developmental Accomplishments

Fine Motor Development-grasp, pointing, motor planning (e.g. page turning)

Social-Emotional Development-eye contact, joint

attention, reciprocity

The Book as Assessment ToolLanguage Skills:

receptive (comprehension)

expressive (vocabulary)

pragmatics

(social communication)

Cognitive skills:

attention, memory, creativity,

problem solving, critical thinking

Books to Choose: 6-12 months of age

Board and Cloth books

Pictures and faces

Bright colors

Familiar objects

Limited text / small size

6-12 MonthsChild

– Reaches for book

– Puts book in mouth

– Sits in lap

– Communicates through gestures, babbling, and “jargon”

– Begins to understand a few words

Parent– Lets child explore

book

– Holds child in lap

– Responds verbally

– Labels / Names

– Talks during routines

– Follows baby’s lead

Books to Choose: 12- 24 months of age

Board/sturdy pages

Familiar objects

Relevant to child’s life

Rhyming words

Animal, color, or shape-focused

12-18 MonthsChild

– Holds book

– Turns pages

– Turns book right side up (give it upside down)

– Points when asked “where is--?”

– Imitates parent’s vocals

Parent– Lets child control book

– Asks “where is---?”

– Labels/describes

– Sings songs/rhymes

– Reads as part of routine

Laurel M. Wills, MD Lynne Burke Reach Out and Read: Pearls from the Exam Room

Children's CME 12/11/2008 7

18- 24 MonthsChild

– Turns pages

– Carries book around

– Fills in words of stories

– Recites parts of stories

– Reads to dolls

– Begins to combine words

Parent

– Lets child control book

– Re-reads favorite stories!!

– Engages in verbal turn-taking

– Labels /describes

– Points and asks “What’s that?” “Which one does X?”

– Relates books to child’s own experiences

Books to Choose: 24-36 months of age

Paper pages

Routine focused(naptime, bedtime)

Rhyming words / lyrics

Relevant to child’s life

More advanced themes (opposites: big/small, prepositions: on/under, pre-academic skills: colors)

24-36 Months

Child– Turns paper pages

– Protests (notices) when pages are skipped

– Recites familiar parts of stories

– May know 320 words

– Requests same book repeatedly

Parent– Lets child control

book

– Points out letters and reads as part of routine (e.g., street signs)

– Reads to assist with daily routines

– Asks child to name objects

– Relates books to child’s experiences

Books to Choose: 3-5 years of age

Folk tales and legends

Alphabet and counting books

Exercise the child’s imagination

Books can be chosen by the child (in clinic, let child choose from 2-3)

3 – 5 YearsChild

– Understands more complex stories

– Anticipates outcomes

– Attempts writing

– Begins recognizing letters

– Asks “why” questions

– Attempts to use sentences and grammar

Parent– Asks “What

happened?”

– Lets child tell story

– Encourages writing

– Points out letters and sounds

– Responds/expands on child’s questions

Responsive or “Dialogic”

Reading

–Repeating and expandingreinforces a child’s communicative attempts and offers advanced language

–Labeling and describingemphasizes that objects have names (“symbolic representations”)

–Questioning promotes verbal exchanges between parent and child, “What will happen next?”

–Emphasizing sounds and letters increases a child’s “phonological” awareness

Laurel M. Wills, MD Lynne Burke Reach Out and Read: Pearls from the Exam Room

Children's CME 12/11/2008 8

Book Selection: Additional Points

– Consider culture and community, e.g. imagery in illustrations

– Be sensitive to the language and literacy level of the parent

– Celebrate bilingualism

– Children with Special Needs / Developmental Delay--Ask the parent what book might be best for their child

Who Benefits from ROR?Children receive all the early literacy benefits of book sharing and have 10 books of their own by 5 years of age.

Parents receive essential information about book sharing and suggestions for parent-child interactions.

Clinic provider and staff use books as valuable assessment and patient education tools, and establish a stronger Medical Home for families.

Thank Youfor all you do! Comments

andQuestions

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The following studies have been published in peer-reviewed, scientific journals:

S T U D Y N * M A I N F I N D I N G S

Needlman 79 Among parents in a primary care waiting room, those who had been given books and guidance were 19911 four times more likely to report reading aloud or doing it in the last 24 hours.Boston, MA

High 151 Comparing parents in clinic before ROR was instituted, versus after, there was approximately four19982 times increase in literacy orientation (reading aloud as a favorite activity, or as a regular bedtimeProvidence, RI activity, or reading aloud more than 3x/week) in the “after” group.

Golova 135 In this study, families were randomly chosen to receive books and guidance, or usual care. After 1019983 weeks, parents were surveyed. There was a ten times increase in parents reading aloud 3 nights/week,Providence, RI and large, statistically-significant increases in “favorite activity” and other measures.

High 205 A group of parents randomly chosen to get ROR guidance and books had significantly higher20004 literacy orientation (as defined above), compared to a control group that got usual care. Among Providence, RI children 18 months and older, there were also significant increases in language scores using a

modified standard language assessment, both for speaking and understanding. Language development is crucial for successful reading acquisition.

Sanders 122 Among Spanish speaking, immigrant families, those who had been exposed to ROR reported a 20005 doubling in the rate of frequent book sharing, defined as reading aloud 3 or more days per week.Palo Alto, CA

Jones 352 Parents given books and guidance were twice as likely to report reading aloud as a favorite activity,20006 and rated the pediatrician as significantly more "helpful" than did a comparison group of parents.Louisville

Mendelsohn 122 One urban clinic had ROR for three years; another which was similar in all other respects, did not20017 have ROR in place. Reading aloud by parents, and children’s book ownership were significantlyNYC higher in the ROR clinic. What’s more, scores on standardized vocabulary test were significantly

higher in the ROR clinic — 8.6 points higher for receptive language (understanding words) and 4.3 points higher for expressive (picture naming), both large, meaningful effects.

Sharif 200 Comparison between two similar clinics in the South Bronx, one with ROR for 3 years, one with ROR20028 for 3 months; otherwise, very similar. Receptive vocabulary (One-Word Picture Vocabulary Tests) NYC was higher (average 81.5 versus 74.3) at the ROR site; parents scored higher on the STIQ reading

section (more frequent reading aloud, more book ownership) and on the Literacy Orientation questions (book as favorite activity, and bedtime activity).

Silverstein 180 This study sought to determine ROR’s effectiveness among non-English speaking families in a Seattle20029 pediatrics clinic, with patient families of East African and Southeast Asian origin. Using a pre-/post- Seattle, WA design, the study showed improved self-reports of home reading attitudes and practices among both

English and non-English speaking families given English language books as part of ROR.

Weitzman 137 Families with children 18-30 months were studied with waiting room interviews and home visits to 200410 determine the effect of ROR on a Child Home Literacy Index and on the HOME measure of the home New Haven, CT environment; after adjusting for multiple confounders, ROR was found to contribute positively to a child's

home literacy environment; more frequent ROR encounters had a greater impact.

Needlman 1647 In a national sample of parents of children age 6-72 months, implementation of ROR programs 200511 was associated with increased parental support for reading aloud. The study provides multi-site evidence,Cleveland, OH from 19 clinical sites in 10 states, of the effectiveness of a primary care intervention strategy to promote

reading aloud to young children.

*N= number of subjects enrolled (over, for references)

Efficacy of Pediatric Office-Based Interventions to Support Literacy DevelopmentResearch shows that when pediatricians promote literacy according to the Reach Out andRead (ROR) model, there is a significant effect on parental behavior, beliefs, and attitudestowards reading aloud, as well as improvements in the language scores of young childrenreceiving the intervention.

For more information, contact the Reach Out and Read National Center by phone at 617-455-0600, email at info@reachoutandread.org, or by writing to us at 56 Roland Street, Suite 100D, Boston, MA 02129.

Visit our web site: www.reachoutandread.org

References Cited:

1. Needlman, R., et al., Clinic-based intervention to promote literacy. American Journal of Diseases ofChildren, 1991. 145: p. 881-884.

2. High, P., et al., Evaluation of a clinic-based program to promote book sharing and bedtime routines amonglow-income urban families with young children. Archives of Pediatrics and Adolescent Medicine, 1998. 152:p. 459-465.

3. Golova, N., et al., Literacy promotion for Hispanic families in a primary care setting: a randomized,controlled trial. Pediatrics, 1999. 103: p. 993-997.

4. High, P., et al., Literacy promotion in primary care pediatrics: can we make a difference? Pediatrics, 2000.104: p. 927-34.

5. Sanders, L.M., et al., Prescribing books for immigrant children. Archives of Pediatrics and AdolescentMedicine, 2000. 154: p. 771-777.

6. Jones, V.F., et al., The value of book distribution in a clinic-based literacy intervention program. ClinicalPediatrics (Phila), 2000. 39: p. 535-541.

7. Mendelsohn, A., et al., The impact of a clinic-based literacy intervention on language development in inner-city preschool children. Pediatrics, 2001. 107: p. 130-134.

8. Sharif, I., S. Reiber, and P.O. Ozuah, Exposure to Reach Out and Read and vocabulary outcomes in innercity preschoolers. Journal of the National Medical Association, 2002. 94: p. 171-177

9. Silverstein, M., et al. An English-language clinic-based literacy program is effective for a multilingualpopulation. Pediatrics, 2002. 109 e76.

10. Weitzman, C.C., et al., More Evidence for Reach Out and Read: A Home-Based Study. Pediatrics, 2004.113: p. 1248 - 1253.

11. Needlman, R., et al., Effectiveness of a Primary Care Intervention to Support Reading Aloud: A Multicenter Evaluation. Ambulatory Pediatrics, 2005. 5:209-215.