CLINICAL CARE FOR CHILDREN Literacy Promotion in Primary Care Pediatrics: Can We Make a Difference?

Background. Reading skills are critical to children’s success in school and the increasingly technologic workforce. Children from low-income families are at risk for home environments that fail to promote emergent literacy and for reading failure. A home environment that encourages learning and parents who are involved in their children’s education are important factors in school achievement. Objective. To evaluate the effects of a literacy promoting intervention delivered by pediatric providers as part of well-child care on parent attitudes and behaviors and on child language. Design/Methods. A multicultural group of 205 lowincome families with 5to 11-month-olds were prospectively enrolled, interviewed, and randomized to intervention (n 5 106) or control (n 5 99) groups. Families in the intervention group received developmentally appropriate children’s books and educational materials and advice about sharing books with children, while those in the control group received no books or materials relevant to literacy. After an average of 3.4 well-child visits in both groups, 153 (75%) were reinterviewed and the children’s receptive and expressive vocabulary was tested using a modified version of the MacArthur Communication and Development Inventory (Short Form). Parents were asked if their child understood (receptive vocabulary) or said (expressive vocabulary) each of 100 words, half of which were in the books given. Families were found to have a Child-Centered Literacy Orientation if they mentioned reading aloud as one of their child’s favorite activities or as one of their own favorite joint activities or if they usually read together at bedtime. At follow-up toddlers were 18.4 months old on average. Results. Intervention and control groups had similar literacy related characteristics at baseline. There was a 40% increase in Child-Centered Literacy Orientation among intervention families compared with 16% among controls. Intervention families read more with their toddlers (4.3 vs 3.8 days/week). Both receptive and expressive vocabulary scores were higher in older intervention toddlers (18–25 months old; n 5 88), but not in younger intervention toddlers (13–17 months old; n 5 62). This significant effect of the intervention on vocabulary scores in older toddlers was found for both the 50 words in the books and those not in the books. After parent education, foreign birth and language proficiency, and child age were statistically controlled, the intervention remained significantly associated with higher language outcomes in older toddlers. However, when reading aloud was added to the multivariate analysis, the influence of the intervention was no longer evident, suggesting the intervention’s effect on child language was mediated through increased shared reading with these toddlers. Conclusion. This simple and inexpensive intervention, delivered as part of well-child care, changed parent attitudes toward the importance of reading with their infants and toddlers. These intervention parents and their children read more together and this was associated with enhanced language development in older toddlers in this diverse group of low-income families. Pediatrics 2000;105:927–934; literacy, reading promotion, child, books, anticipatory guidance, multicultural, underserved populations, language development, receptive vocabulary, expressive vocabulary. ABBREVIATION. CCLO, Child-Centered Literary Orientation. Success as an adult depends in part on the learning and development that occur in infancy and early childhood. Infants raised in safe and stimulating environments are better learners later in life than those raised in less secure and attentive settings.1 Because many children from socially and economically disadvantaged backgrounds lack environments that promote language and literacy growth, they are at risk for failing to develop essential literacy skills. The National Assessment of Educational Process 1998 Reading Report Card for the Nation found that children in the United States who live near or below the poverty line have lower average reading scores than their peers.2 Of adults living in poverty, almost half read and write at the lowest literacy level.3 This lack of basic literacy skills is linked to decreased productivity, increased rates of teenage pregnancy, and increased welfare dependence.3,4 Low literacy levels contribute to the propagation of the cycle of poverty.5 Several studies have evaluated the efficacy of literacy promoting anticipatory guidance delivered From the *Department of Pediatrics, Rhode Island Hospital; ‡Brown University School of Medicine; and §Women and Infants Hospital, Providence, Rhode Island. Portions of these data were presented at the Pediatric Academic Societies Meeting, May 2, 1999, San Francisco, CA; and at the Society for Developmental and Behavioral Pediatrics Meeting, September 28, 1999, Seat-