Reach Out and Read: Literacy Promotion in Pediatric Primary Care

Anyone who works with children, and especially with child development, balances the quantifiable and the ineffable. When one looks at social–emotional development, and specifically at infant attachment and parent–child interactions, one must take into account the carefully argued theories of mental and social development that define the history of developmental psychology, a vast literature of observation and experimentation, the variations described by cultural anthropologists, and the clashes of the nature–nurture debate. But it would be naive to think that any of these intellectual endeavors fully captures what goes on between a parent and a child. To round out the picture, or gallery, one must include fiction, poetry, memoir, art, music, and all the complexities of emotion they evoke. Even if it does not have any clear place in scientific inquiry or evidence-based medicine, when one considers child development, one must make room for elements of spirit, serendipity, and occasionally magic. This is also true when one thinks about how children learn, how children read, and how children learn to read. On one hand, the mechanics of teaching and learning the technical skills of reading can be studied and quantified and can engender passionate debate among different schools of educational thought. Yet, on the other hand, the relationships between children and books, both before and after literacy acquisition, can go far beyond quantification. What books can mean in a child’s life—what a specific book can mean to a specific child—is not something that can be broken down into components easily, or understood by formula. The explanation of why that specific book means so much to that specific child defies analysis and quantification, as does the phenomenon of mass appeal. Just watch the publishing companies flail as they search for another Harry Potter. Reach Out and Read (ROR) is an evidence-based national pediatric literacy program through which medical providers, as part of routine primary care for young children, are trained to offer parents anticipatory guidance about the importance of reading aloud. The program model focuses on children from 6 months to 5 years of age, and at each health supervision visit during that period, each child receives a new book to take home and keep. The book is chosen carefully to be developmentally appropriate. The family leaves the health supervision visit with the parents understanding the importance of reading aloud and primed with age-appropriate techniques to make it work (Fig. 1). This article reviews the history and development of the ROR program, the ROR model, and the recommended strategies for literacy promotion in the examination room, along with the evidence that the model is effective and the current structure that exists to support clinics that incorporate the model into daily practice. The article considers what books can mean in the lives of children, in both quantifiable and unquantifiable ways. Fig. 1 The Reach Out and Read program is incorporated into routine primary care visits for young children. (Courtesy of the Reach Out and Read National Center.) ROR is designed to promote books and reading aloud in the preschool years. The program’s mission is to help children grow up with books and a love of reading. Although that mission does not mention the process of learning to read explicitly, one major goal of preschool literacy activities is to provide children with some of the cognitive skills they need for successfully learning to read once they get to school. Early exposure to books and reading aloud contributes to a child’s readiness to read and learn at school entry, as does more general language exposure [1,2]. Successfully learning to read on time and on grade level is an essential key to overall school success [3]. Children who require remedial reading help in the first grade are statistically at increased risk to remain in remedial reading groups [4]. Children who go through school reading below grade level are at risk in their other subjects, especially once they get beyond the third grade, because school assignments and tests rely increasingly on printed texts and the fluency, efficiency, and accuracy with which the child can interpret, manipulate, and respond to text. To go from printed words to meaning is an essential part of the intellectual journey of education, including early education. The child who struggles with the mechanics of decoding print is a child who may struggle with a whole range of aspects of school achievement and school function. For children too young to read, picture books offer an attractive introduction to the mechanics of book handling and story structure (Fig. 2). They offer occasions for language exposure and language practice, both expressive and receptive, for naming and for dialogue and discussion as the child’s verbal ability grows. “Dialogic reading” techniques, as elaborated by White-hurst and the Stony Brook Reading Project [5], enhance the back-and-forth between adult reader and read-to child, which promotes pleasure and learning as the child becomes the teller of the story. Books and the routine of reading aloud also form links between child and parent/caretaker, because reading aloud to young children provides them with opportunities for close contact and concentrated parental attention. The stories and pictures that constitute the content of children’s books can enrich and enlarge a young child’s world with everything from animals (real, extinct, imaginary) to silly rhymes [6]. Books should serve young children as both mirrors and windows, reflecting back aspects of their own family’s life and also offering a vision of the great wide world and all of its possibilities [7]. Given the current dominance of television and electronic media, reading aloud may be more important than ever. A growing body of evidence has documented the degree to which television exposure is associated with reduced reading, teaching and verbal interactions, reduced early learning, and reduced later achievement in school [8–11]. Fig. 2 Developmental milestones of early literacy. (Courtesy of the Reach Out and Read National Center.) The authors will state their prejudice at the outset, that storybooks and picture books for young children teach their many, varied, valuable, and somewhat unpredictable lessons best when they are not explicitly educational. Children have an excellent eye for a message and a moral, and they seem to know immediately when a book has been concocted to improve them, rather than confected to engross and excite them. Real books, whether classics that have been calling out to children successfully for decades, or new flashes of mysterious picture book genius, cannot be replaced by carefully weighed and measured doses of approved vocabulary and character-building message. Anyone who has lived with a young child also knows that sometimes all the time-tested childhood classics, along with this year’s expensively produced and stunning award-winning works of art, fade for an individual child compared with some particular inexplicable (and often highly tedious) work that becomes that particular child’s particular obsession for some period of time. Parents of a 2-year old boy, for example, found it tedious to read Bernie Drives a Truck night after night, for some number of weeks (actually, it felt like months, if not years), but the boy was satisfied with nothing else. This must be considered a triumphant demonstration of the individuality and personality of the developing brain and the tenacity and determination of the 2-year-old will. Books and stories and pictures enlarge a child’s world and a child’s vocabulary. Reading aloud to a young child fosters attachment to books and also promotes the language-rich attachment between parent and child. Part of the curriculum of ROR, included in the section describing techniques for literacy promotion in primary care, involves using books in the examination room to reinforce other important behavioral and developmental messages, including dialogic language with young children and building routines and rituals into toddlers’ days. Books and literacy promotion in the examination room can offer providers avenues for anticipatory guidance and intervention that support families with young children on a level that is practical, pleasurable, and rewarding for the provider, parent, and child.