Promoting Social Emotional Development Through Reach Out and Read

Reach Out and Read


Date Submitted: 09/08/2021


Contact Information:

Lori Lake Executive Director, Reach Out and Read OK

615-948-6481

Lori.lake@reachoutandread.org

Reach Out and Read

1000 NW 39th Street, Oklahoma City, OK 73118


Rating Category: Well-Supported by Research

Focus Area: Social Emotional Learning


Focus Population: Children, Caregivers, Guardians, Medical providers, Parents


Goals and Outcomes:

The goal of this project is to ensure the healthy development and social emotional well-being of young children ages 5 and below throughout Oklahoma through the promotion of the Reach Out and Read (ROR) intervention, designed to foster intentional skill-building in parents, resilience in families, and positive bonding between children and families, integrated into pediatric primary care.


The outcomes are as follows:

  1. Through partnership with Reach Out and Read, pediatric primary care providers gain a framework for integrating promotion of early literacy and relational health into pediatric care, awareness of the developmental importance of reading and relationships, clinical skills to engage with diverse families, and systems that support comprehensive care.

  2. Parents/caregivers are motivated to prioritize reading and other language-rich interactions with their young children as part of their daily routines starting from birth, knowledge of developmentally appropriate and accessible ways to engage with their child, and access to diverse, high-quality books.

  3. As a result of increased engagement with their parents/caregivers, children experience nurturing foundational relationships that support improved early childhood social emotional development and long-term health and well-being.

  4. Expansion of the Reach Out and Read intervention provides families throughout Oklahoma with protective factors to mitigate the effects of adverse childhood experiences (ACEs).


Brief Summary of target population and issues/challenges:

According to America's Health Rankings analysis, Oklahoma is the least-healthy state for ACEs, which include economic hardship, parental separation, living with an alcoholic, living with someone who is mentally ill, neighborhood and domestic violence, death of parent, and being treated unfairly due to race. Early experiences have a broad and profound impact on an individual’s development and subsequent emotional, cognitive, social, and biological functioning, and consequently, ACEs result in poor student achievement, discipline issues, and lower high school graduation rates.


But the presence of protective factors, especially safe, stable, and nurturing relationships, helps mitigate the consequences of ACEs. Families influence the promotion of protective factors, and our ROR providers teach parents/caregivers about how close, loving relationships support their child’s ability to thrive. Reading, singing, and spending time together is a way to foster fun, purpose, social connection, and the development of individual competencies (problem solving skills, self–regulation, agency). Protective factors help a child feel safe more quickly after experiencing the toxic stress of ACEs and help to neutralize the physical changes that naturally occur during and after trauma. If the child’s protective networks are in good working order, development is strong even in the face of severe adversity.


ROR has unparalleled access to young children from birth through age 5 through its integration into pediatric primary care. In Oklahoma, we serve more than 64,000 children. Most of the children we serve come from low-income families, with 70% relying on public health insurance or uninsured.


Building upon the unique relationship between parents and doctors, we employ a 3-part model to promote early literacy, empathy, and parental engagement during regular pediatric visits:

  • During well-child visits, medical providers prescribe reading by modeling read aloud strategies while teaching and training the parent about how to share books and why it is important, emphasizing how reading brings families together, assists in building healthy bonds, and establishes routines.

  • Starting at infancy and continuing through the 5-year visit, medical providers give children new developmentally appropriate books.

  • Following their medical provider’s advice, parents read aloud with their children more often and engage them in literacy-rich activities, far extending our program's impact.


Rated by another Clearinghouse: No


Conducted Research:

ROR is built on and backed by science. Research supporting the importance of positive childhood experiences (PCEs) in healthy childhood development underpins our model of promotion of shared reading and other language-rich interactions with infants, toddlers, and preschoolers. Then, the effectiveness of our model is supported by a significant body of peer-reviewed publications in prestigious medical and scientific journals.


In August 2021, the American Academy of Pediatrics released a policy statement “Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health,” published in Pediatrics. The statement outlines recent evidence demonstrating that the trajectory of a young child’s life is shaped by exposure to positive childhood experiences. It moves away from a problem-based model that focuses on a child’s past adverse experiences and instead presents a positive, strengths-based approach that fosters solutions at the family, community, and societal levels.


The statement recommends a public health framework built on the universal promotion of safe, stable, and nurturing relationships that includes support of positive parenting styles, developmentally appropriate play, and shared reading, with ROR specifically named. It presents a broad overview of research demonstrating that positive childhood experiences promote the healthy cognitive and social emotional development of young children.


ROR integrates books and reading into pediatric primary care throughout the U.S. and at 88 clinics in Oklahoma. We provide the training and resources that pediatric care clinicians need to deliver our evidence-based model, making books, shared reading, and meaningful moments of parent and family interactions accessible to every child we serve. Our leadership, many of whom are Fellows of the American Academy of Pediatrics, commits to continuing to strengthen the impact of our model and supporting the broader implementation of this science-backed policy.


ROR’s effectiveness is consistently supported by more than 20 independent, peer-reviewed publications that speak to the impact of Reach Out and Read on parental behavior and attitudes towards reading aloud; on early language development; and on clinic culture and clinician morale. A range of studies have been documented in ethnically and economically diverse families throughout the nation.


Restricting the description of our research to studies that support the submission of this proposal, namely evidence that implementation of ROR improves social emotional development in early childhood, we present logic model in the supporting documents. (Please refer to it at this time.)


For phase 1 of the evidence, a substantial body of peer-reviewed publications confirms that implementation of the 2-generational ROR intervention including anticipatory guidance delivered through pediatric healthcare and the gift of a new developmentally and culturally appropriate book, results in increased parent/caregiver-child engagement with their young children through sharing books. Together, these show that families exposed to ROR are 2.5x more likely to read to their children, 2x more likely to read to their children 3 or more times a week, and 2.5x more likely to enjoy reading together.


The most significant of these studies are listed below, and a full listing can be found on the Reach Out and Read website.


Canfield et al Early Childhood Research Quarterly, 2020

Parents who received both a book and guidance through ROR about the importance of reading were more likely to engage in literacy activities with their children through book sharing at home.


High et al, Archives of Pediatrics and Adolescent Medicine, 1998

Parents whose children (< 3 years) had received books and educational materials during well-child visits, were more likely than parents in a control group to report that they shared books with their children, and to cite sharing books as a favorite activity or a child’s favorite activity.

Needlman et al, Ambulatory Pediatrics, 2005

In a multicenter study, families exposed to ROR were more likely to report reading aloud at bedtime, to read aloud 3 or more days per week, mention reading aloud as a favorite parenting activity, and own 10 or more children’s books.


Our most recent research study, not yet published (manuscript in preparation), is our strongest evidence to date that implementation of ROR has a significant impact on both the frequency of shared reading and the engagement of parents/caregivers with their young children through sharing books. A 2021 analysis of parent survey data collected from 2014 – 2019 (100,656 surveys) showed that parents who had previously been exposed to ROR were 27% more likely to read with their young children than those who had not experienced ROR before. They were also significantly more likely to use a variety of reading strategies that promote positive parent child interactions.


Phase 2 of the evidence base is supported by a 2018 study by Yamaoka and Bard demonstrating that positive parenting practices that included engaging with young children through sharing books four or more times a week resulted in a 33% reduction in the probability of social emotional deficit and developmental delay.


Taken together, the research outlined above provides strong evidence that implementation of ROR supports improvement of early social emotional development.


Relevant Published Articles with brief summary:

The description of the research that has been conducted to support this submission described above was all conducted in early childhood settings. The three most relevant articles listed here are:

Canfield et al Early Childhood Research Quarterly, 2020


In this quasi RCT, data about home literacy behavior related to exposure to Reach Out and Read and/or literacy activities at the public library were gathered by interview of 98 parents/ caregivers through the City’s First Readers initiative in New York City. Results showed that exposure to ROR enhances home literacy behavior, such as parents reading with their children at home more often, reading a wider variety of books, and having higher quality interactions through book sharing. It also provides critical evidence that simple provision of literacy materials is not sufficient to change parent behavior, but requires the anticipatory guidance and modeling delivered by the pediatric care professional.


Yamaoka and Bard American Journal of Preventive Medicine, 2018

An analysis of data on all children aged 0–5 years (n=29,997) from the National Survey of Children's Health 2011/2012 demonstrated that before the age of 6 years and as early as 4 months, accumulated Adverse Childhood Experiences (ACEs) already manifest signs of negative impact on social-emotional skills and general development. Positive Parenting Practices (PPPs), including engaging through book reading (≥ 4 days a week), storytelling/ singing (≥ 4 days a week), playing with a peer (≥ 4 days a week), family outing (≥ 4 days a week), family meal (≥ 4 days a week), TV-watching (≤ 2 hours a day) appear to mitigate the negative effects of adversities on these same outcomes and over this same period of early development.


The study additionally showed that the absence of PPPs can be viewed, itself, as another adversity that at the extremes is equivalent to the addition of four or more ACE score units. The study authors recommended that to promote PPPs, policies that strengthen and fund evidence based parent training (e.g., home-visiting) and parent resource programs (e.g., Reach Out and Read) ought to remain at the forefront of early childhood efforts.


Needlman et al, Ambulatory Pediatrics, 2005

A multi-center prospective study of two groups, one pre- and one post-ROR implementation capturing parent-report data of 1647 children 6 months to 6 years old. Families exposed to Reach Out and Read were:

  • 1.6x more likely to enjoy reading together with their children

  • 1.8x more likely to read together with their children 3 or more times a week

  • 1.6x more likely to own 10 or more picture books


Promote equity, diversity, inclusion, and belonging:

Children’s books help shape what children think about themselves, their peers, and the world around them. What children see – and do not see – in books can have a lasting impression on their values, attitudes, and actions. At Reach Out and Read, we believe that books have the power to be a catalyst for discussing race and racism and promoting equality and inclusion with young children. We are committed to having diversity in our books to reflect the population we serve.


Within the well-child visit, the medical provider uses a book as a clinical tool to do developmental surveillance. However, the books also serve another valuable purpose. Books, like mirrors, help reflect what we observe and know about the world we live in. It is powerful to read or listen to a story about someone like you. Books also allow us to view and understand lives that are different from our own, like a window onto other experiences. But to succeed as mirrors and windows, books must tell a wide range of stories—and they must include a diversity of people and worlds. It is never too soon to start reading diverse and culturally responsive books to young children. Children become aware of race-based differences starting in infancy and can express racial bias by the time they are in preschool. Through this project, we are committed to having children see themselves in books.


We are also committed to serving families in their primary language, as well as families that may include parents who are not comfortable with reading. When parents engage with their children in the language they speak best, they provide the foundation by which early language and literacy develop. Loving a child in any language stimulates cognitive growth and the more experience a child has with their family's native language, the easier it will be for them to learn English when they arrive at school. For those parents who struggle with literacy themselves, our clinicians guide them in creating stories based upon the pictures rather than the written text. We strive to show all families that reading together is an engaging and enjoyable experience that builds better brains, bonds, and memories that last forever.


Implementation:

Reach Out and Read is an intervention designed for implementation in early childhood. In Oklahoma, the program is currently implemented in 88 clinics, serving 64,000 children and their families. At each clinic, Reach Out and Read’s 3-part model is delivered during regular pediatric visits from birth through age five to promote early literacy, empathy, and parental engagement during regular pediatric visits:

  • Medical providers prescribe reading by modeling read aloud strategies while teaching and training the parent about how to share books and why it is important. Parents are engaged in the conversation as the provider offers anticipatory guidance and emphasizes how reading brings families together, assists in building healthy bonds, and establishes routines.

  • Starting at infancy and continuing through the 5-year visit, medical providers give children new developmentally appropriate books.

  • Following their medical provider’s advice, parents read aloud with their children more often and engage them in literacy-rich activities, far extending our program's impact.


Evaluation Plan:

Research and a robust evidence base indicate that Reach Out and Read delivers results for families when it is implemented in accordance with our model. This is ensured by a networked infrastructure of local offices that engage with and provide technical assistance for clinics and clinicians. The Reach Out and Read office in OK is staffed by an Executive Director and a Program Specialist who are committed to regular program evaluation so that we can target areas for improvement to enhance program quality. They utilize three standard tools to assess the quality of program delivery at individual sites: our biannual Progress Report; annual Medical Provider Survey; and the biannual Site Quality Classification. These measures collect both qualitative and quantitative data on each clinic’s Reach Out and Read program. The data and anecdotal information obtained provide a solid base to monitor quality of the intervention children are receiving, collaboratively create an action plan with specific performance goals as needed and extend the necessary technical assistance and programmatic support to ensure that each site is operating at its highest level.



Supports:

Support for high quality delivery of the Reach Out and Read intervention is provided through a networked infrastructure of a national headquarters and local affiliates that regularly engages with and provides technical assistance for clinics and clinicians. The Reach Out and Read office in OK is staffed by an Executive Director and a Program Specialist. All clinics delivering Reach Out and Read in OK are offered training through an online comprehensive Continuing Medical Education-accredited training program for medical providers and staff that covers the research on the biological and environmental factors that contribute to healthy child development. The Oklahoma affiliate also offers quarterly webinars for providers and staff on topics such as developmental surveillance, Early Relational Health, ACEs, positive parenting practices, and incorporating Reach Out and with infant’s right from birth. Opportunities to participate in ROR initiatives such as “Reach Out and Read Counts”, Birth-Five Months Expansion, and “Books Build Better Bites” are made available to sites as appropriate. Ongoing technical assistance and programmatic support are provided by ROR Oklahoma program staff to personnel at all clinics to assist each site in achieving its performance goals. Finally, clinics receive brand new books to be given to the young ones in well-child visits, as well as resources for parents, as funding allows.


Standards/Guidelines, Models, outcomes, programs:

As described above, the recommendation for implementation of the Reach Out and Read program in Oklahoma is backed by science and our extensive evidence base of over 20 peer-reviewed studies for ROR. The evidence is clear – Reach Out and Read works. More than 20 published studies demonstrate the impact, scale, reach, and effectiveness of our program. Key findings show that, because of our intervention, parents are two and one-half times more likely to read to their children, and their children’s language development is improved by three to six months (relative to non-ROR peers) by the time they reach kindergarten. Research also links our model to improvements in the socio-emotional development of children and decreases parent stress. The American Academy of Pediatrics endorses the Reach Out and Read model as an essential component of pediatric care.

In particular, a study published from Oklahoma data (Dunlap et al. J Investig Med 2021) (https:// reachoutandread.org/wp-content/uploads/2021/01/Dunlap-2021-HSI-in-OK.pdf) was used to inform our plan. The study showed that ROR clinics in Oklahoma had significantly higher rates of both developmental screening and well-child visits adherence than non-ROR clinics. This evidence highlights how ROR can be used as an important strategy to reach more children in a medical home that focuses on the needed tools for assessing children’s social emotional health through methods such as developmental screening and increasing the number of children receiving well-child visits. Implementation of Reach Out and Read transforms the well-child visit experience for both provider and parent. As a result, providers report greater satisfaction with their work, and families show greater compliance with well-child attendance, ensuring that children receive critical preventive health care.


Training materials and manuals:

Reach Out and Read has a comprehensive, standardized online training that all clinicians are required to take. In addition, ROR offers supplemental trainings on topics such as early math or birth to five months. These trainings are regularly updated and vetted by a committee of professionals and pediatricians. Our Continuing Medical Education-accredited training is available online to approved providers at no cost to the clinician. The hard copy of the online training is enclosed with this submission.


Implementation cost:

The average cost of Reach Out and Read implemented from 6 months through 5 years is $20 per child annually including programmatic support/technical assistance for clinics and clinicians from the local ROR OK affiliate and a brand new, developmentally, and culturally appropriate book for the child to take home from each well-child visit. This economical pricing is a consequence of operating through the established pediatric healthcare system and acquisition of books at discount prices through partnerships with book publishers and distributors.


Additional Information:

Reach Out and Read is the only national literacy program delivered through pediatric care providers endorsed by the American Academy of Pediatrics. More than 90% of children under age six, have visited a medical provider for a checkup in the last year, and medical providers are highly trusted by parents. With a network of 455 providers and 88 clinical sites throughout Oklahoma, Reach Out and Read provides more than 64,000 children and their families with strategies for parental engagement that build bonds and promotes healthy social emotional well-being, tips for establishing regular routines, new books, and guidance for reading aloud together.


The relationships that we have in very early childhood shape the trajectory of our lives, and those who love and nurture us provide the foundation for a healthy and fulfilling life in which we contribute to our community and to society. Early positive childhood experiences through safe, stable, nurturing relationships can buffer the effects of ACES. Studies show that positive childhood experiences, including reading aloud together, singing, and telling stories, playing with peers, and family meals, mitigate the effects of ACES on social-emotional deficits and the risk of developmental delay. Reach Out and Read is an ideal strategy for pediatric clinicians to promote the positive, language-rich parent- and caregiver-child interactions that promote attachment, build bonds, and help to provide the resilience needed to buffer the impact of ACEs.


The more at Reach Out and Read that we learn about the importance of the early months for fostering healthy brain development, the more convinced we are of the importance of pediatric primary care for its unparalleled access to and influence on families and children during this critical developmental window. The positive relationships between caregiver and child that we support and help nurture are not only foundational for healthy child development but improve family resilience, support child perseverance through adversity, and help families to flourish. Among adults who had experienced similar levels of adversity during childhood, those with more positive experiences, such as shared reading, were less likely to report depression or poor mental health as adults.


With the proper funding, Reach Out and Read is uniquely scalable. Since the program began in Oklahoma in 1996 at one site, we have expanded rapidly. Since 2013 when our state affiliate received new leadership, the number of active, partnering clinics increased by more than 200% resulting in 88 at this time. Prospective Reach Out and Read programs complete an online application and training course in early child development. Our program is delivered through the existing medical infrastructure, with the volunteer efforts of medical providers who choose to incorporate the model into children’s checkups. As a result, Reach Out and Read offers a low-cost, impactful solution to the low social emotional development currently experienced by Oklahoma’s youngest children.