School readiness and educational success is strongly mediated by early literacy skills. In both exam-room and community-based settings, child-health providers can affect the trajectory of early literacy by implementing evidence-based, culturally appropriate interventions that support child development, parenting skills, and child-caregiver interaction. Despite limited research on the subject, these interventions should also attend to the evolving role of digital-media exposure (both positive and negative) on the developmental health of children.
Key points
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School readiness and educational success is strongly determined by early exposure to print and socioeconomic milieu.
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Early literacy promotion is a key avenue for clinicians to positively influence child development, parenting interactions, and intentional skill building in both child and caregiver.
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Quality children’s literature, dialogic reading, and careful support of nurturing relationships in a child’s environment are key elements to success.
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Digital media remains an increasingly popular yet not-well-researched exposure starting at younger and younger ages, with a lack of consensus as to how best to advise parents.
The better index of disadvantage for a child is not family income, but how often the child is read to.
The nation’s leading health researchers and public health agencies, not to mention national leaders in economics and national security, have reached consensus on the most cost-effective social factor promoting the nation’s health and economic vitality: the quality of early childhood environments before school entry. Profound health effects across the life course are strongly and independently associated with home-based exposures during infancy and early childhood, both the negative effects of toxic stress and adverse childhood events as well as the positive and moderating effects of prosocial environments. For pediatric primary care, however, important questions remain. What can the general pediatrician do? What does the pediatrician need to know about these early childhood exposures? What can the pediatrician do to influence those determinants? What are the implications in the context of expanding income inequality and increasingly early exposure to digital media?
The topic of emergent literacy skills in children has evolved significantly in recent years and has become recognized as not only a vital component of a child’s development and early learning but also a marker for other environmental influences, including parent-child engagement. However, that same period has also brought many new questions and challenges with it. How does one ensure that young children living in poverty build literacy skills appropriately so they begin school with skill sets comparable with other children? Across all income groups, how can one advise families well about other forms of media, including interactive digital experiences?
Early literacy as a social determinant of health
In the United States, more than 1 in 4 children enter kindergarten with poor early literacy skills. These children are not only more likely to live in resource-poor households but also more likely to live in literacy-poor households, among the 17% of children who are not read to on a regular basis. Such disparities in early educational exposures are strongly linked to another dismal fact that has persisted over the past half century: 1 in 4 US children lives in poverty. The American Academy of Pediatrics (AAP) has begun to address child poverty as a key and trenchant determinant of child health. School readiness is strongly associated with the socioeconomic gradient. The language milieu children in lower socioeconomic circumstances inhabit is poorer, with a nearly 30-million-word gap between children being raised in poverty and their more affluent peers ( Table 1 ).
| 1 by Age 3 y | Welfare | Professionals |
|---|---|---|
| Vocabulary size | 525 words | 1100 words |
| IQ | 79 | 117 |
| Utterances | 178/h | 487/h |
| Encouragements | 75,000 | 500,000 |
| Discouragements | 200,000 | 80,000 |
Early childhood literacy is one of the proposed mechanisms by which poverty acts as a profound social determinant of child health outcomes, not only to the development of physical health but also to that of cognitive, behavioral, and emotional health. During infancy and early childhood, the physiology of a child in poverty faces toxic stress, defined as prolonged, unremitting stress with limited presence of socioemotional buffering relationships, mediated by disordered cortisol responses. This type of stress is much higher than the typical, normative stress experienced by children in more affluent families. As a result of this toxic stress and associated adverse childhood events, children in poverty are more susceptible to illness and less able to perform adequately in educational settings, where they are more often affected by poor executive functioning, poor short-term memory, anxiety, and other behavioral health conditions. Fig. 1 shows the sizable difference in reading scores in schools that have a higher percentage of children living in poverty.
Poor early reading skills carry lifelong health consequences, reflected by the continuum from poor emergent literacy during early childhood to poor literacy skills during adolescence and adulthood. The children who enter kindergarten with suboptimal reading skills are at significantly higher risk to be among the children who enter middle school and high school with reading and math skills less than grade level and to be among those who fail to complete high school. Children reading less than grade level are at significantly increased risk for serious behavioral and mental health problems. As adults, they are likely to be among the 1 in 3 with limited health literacy, defined as an individual’s “capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.” Adults with low literacy or low health literacy are at substantially increased risk for poor health outcomes, including poor chronic-illness outcomes, poor physical and mental health status, and increased use of acute health services. In turn, the children of adults with limited literacy are at increased risk for poor child health outcomes, including poor child health access and poor health behaviors. Completing the downward cycle of low literacy, children of adults with limited literacy are also at increased risk themselves for poor emergent literacy.
Early literacy as a social determinant of health
In the United States, more than 1 in 4 children enter kindergarten with poor early literacy skills. These children are not only more likely to live in resource-poor households but also more likely to live in literacy-poor households, among the 17% of children who are not read to on a regular basis. Such disparities in early educational exposures are strongly linked to another dismal fact that has persisted over the past half century: 1 in 4 US children lives in poverty. The American Academy of Pediatrics (AAP) has begun to address child poverty as a key and trenchant determinant of child health. School readiness is strongly associated with the socioeconomic gradient. The language milieu children in lower socioeconomic circumstances inhabit is poorer, with a nearly 30-million-word gap between children being raised in poverty and their more affluent peers ( Table 1 ).
| 1 by Age 3 y | Welfare | Professionals |
|---|---|---|
| Vocabulary size | 525 words | 1100 words |
| IQ | 79 | 117 |
| Utterances | 178/h | 487/h |
| Encouragements | 75,000 | 500,000 |
| Discouragements | 200,000 | 80,000 |
Early childhood literacy is one of the proposed mechanisms by which poverty acts as a profound social determinant of child health outcomes, not only to the development of physical health but also to that of cognitive, behavioral, and emotional health. During infancy and early childhood, the physiology of a child in poverty faces toxic stress, defined as prolonged, unremitting stress with limited presence of socioemotional buffering relationships, mediated by disordered cortisol responses. This type of stress is much higher than the typical, normative stress experienced by children in more affluent families. As a result of this toxic stress and associated adverse childhood events, children in poverty are more susceptible to illness and less able to perform adequately in educational settings, where they are more often affected by poor executive functioning, poor short-term memory, anxiety, and other behavioral health conditions. Fig. 1 shows the sizable difference in reading scores in schools that have a higher percentage of children living in poverty.
Poor early reading skills carry lifelong health consequences, reflected by the continuum from poor emergent literacy during early childhood to poor literacy skills during adolescence and adulthood. The children who enter kindergarten with suboptimal reading skills are at significantly higher risk to be among the children who enter middle school and high school with reading and math skills less than grade level and to be among those who fail to complete high school. Children reading less than grade level are at significantly increased risk for serious behavioral and mental health problems. As adults, they are likely to be among the 1 in 3 with limited health literacy, defined as an individual’s “capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.” Adults with low literacy or low health literacy are at substantially increased risk for poor health outcomes, including poor chronic-illness outcomes, poor physical and mental health status, and increased use of acute health services. In turn, the children of adults with limited literacy are at increased risk for poor child health outcomes, including poor child health access and poor health behaviors. Completing the downward cycle of low literacy, children of adults with limited literacy are also at increased risk themselves for poor emergent literacy.
Digital media exposure during early childhood
During the past decade, early childhood exposure to screen time has rapidly expanded, with disparately greater exposure in low-income, ethnic-minority communities, in which risk for impaired early literacy skills is the greatest. The implications for child health are as of yet incompletely understood, but through some studies, a portrait is beginning to emerge. Young children exposed to greater amounts of unmonitored or unregulated screen time are at increased risk of sleep disturbance and behavioral problems, including attention-deficit hyperactivity disorder, during the school-aged years. Although some limited evidence suggests the possibility of e-books and digital tools to support other early-learning interventions, digital tools alone are unlikely to replace brain’s evolutionary reliance on human interaction to develop the full range of early literacy skills. Most digital media does not require or prompt the serve and return adult-child interaction necessary to stimulate brain development. By contrast, well-meaning parents and adult caregivers often use digital media devices as a convenient child sedative or as a timely distractor that allows the adult to disengage from the child without immediate consequences (eg, crying or other demands for attention). Based on prior research regarding the essential nature of adult-child verbal, visual, and tactile interaction during the early years, some are concerned that digital media may be displacing this essential activity and unintentionally impairing normal child development.
Despite the above-mentioned concern, digital media use during infancy has become an increasingly common phenomenon in the last few years and shows no signs of abating. Much of it consists of educational videos, apps, and specialized devices marketed to parents as giving their child a significant edge in learning, despite an almost complete lack of evidence supporting such assertions. When it comes to traditional one-way media (eg, television, DVDs), it is fairly clear that there is little value. Developmentally, children seem not to learn from screens until at least 18 months of age (and some as late as 30 months). Most media aimed at young children rely on a steady diet of quick scene changes and other stimuli that exploit the orienting reflex to keep a child engaged and give the parent the perception that their child is learning.
However, when it comes to interactive media (such as tablet apps and custom devices), there seems to be no evidence in either direction. Although traditional screen media has no educational value and also displaces human interaction and child-directed language, interactive media may or may not have benefit. If interaction with other humans is central to driving development, other forms of interaction may have similar benefits, even if the exchange is not as finely attuned. Nevertheless, no clear evidence exists to support this. Even if such studies emerge, they may be highly specific to particular products and not necessarily generizable to even subclasses of apps or devices.
Parents and adult caregivers: the gatekeepers to emergent literacy
Promotion of emergent literacy skills, before school entry, is key to supporting the health and development of any child. Literacy is conventionally defined as “the ability to read and write.” The subcomponents of literacy include text recognition, text decoding and comprehension, oral language fluency, and numeracy. The educational system is built in large part on an attempt to build these fundamental literacy skills, on which one can build future skills and seek new knowledge.
Emergent literacy, by contrast, is defined as “the skills, knowledge, and attitudes that are presumed to be developmental precursors to conventional forms of reading and writing and the environments that support these developments.” The development of literacy skills is not the same as many other aspects of child development. A typical child, if appropriately nurtured, progresses through the stages of gross motor, fine motor, speech, social, and problem-solving domains; in a sense, one can consider these to be mostly hard-wired and primed to develop if given the appropriate scaffolding. Early reading skills, however, are not encoded into a single area of the brain and requires the repurposing and inclusion of other circuits and skills to allow for the process of text decoding that is called reading. Ultimately, it is an amalgamation of oral language, vision, fine-motor skills, memory, and more. Central to this notion of early literacy is a key developmental leap that children make around the concept of print awareness. Before about 3 years of age, most children do not understand that printed text conveys information; after age 3 years, children who have been exposed to print generally understand that print carries meaning to be decoded, even if letter recognition is nil.
Positive home environments, rich in the quantity and quality of verbal interactions between adult and child, do have a greater ability, however, to buffer the negative effects of poverty on child health. Decades of research have confirmed the strong independent relationship between a child’s emergent literacy skills and a literacy-rich home environment, including accessibility of reading materials in every room of the home, adults’ modeling reading by themselves, and dialogic reading. A literacy-rich home environment can moderate social and ethnic disparities in child literacy outcomes.
Adult caregivers are responsible for a key determinant of emergent literacy: child exposure to both print and oral language. Adult-child interaction, which helps children to contextualize words and pictures on a page, is essential to child brain development. An adult who engages in dialogic reading helps the child take on a new role, not merely as a passive recipient of reading, but as a participant, author, and teller of the story. In one study of 382 preschool children, families in which dialogic reading was uncommon were almost twice as likely to have a child with delays.
Adult mediation of emergent literacy also allows for sociocultural diversity in styles of reading, which enhance early child brain development. For example, one study showed that middle-class parents tended to use a more interactive, dialogic style when reading to their children. As the child grew older, they were encouraged to ask questions at appropriate junctures. This situation was in contrast to working-class nonwhite parents, whose style was more centered on drills and skills, naming pictures, counting, and identifying letters but less around narrative and interaction. Children exposed to dialogic reading have higher expressive language scores, have longer and more frequent utterances, and combine words more frequently than their peers whose parents did not use dialogic reading. The use of what is termed nonimmediate talk (conversation that goes beyond the immediate context of the book or story and instead refers the broader world or prior experiences) strongly benefited children. Active engagement with a child via shared book reading was much more beneficial than simply reading at the child. The British Millennium Cohort Study, which followed 12,500 children from birth to age 5 years, observed that early exposure to adults’ reading aloud may moderate some of the powerful effect of family income on child reading skills. Although 5-year-old children in the lowest-income homes had expressive vocabularies comparable to 4-year-old children in the most affluent homes, daily reading aloud could reduce that gap by several months.
Adult role modeling is also an evidence-based component of emergent-literacy promotion. A child who observes adults around them reading, writing, and interacting with text on a regular basis are more likely to mimic and adopt those behaviors as they develop and grow. Observational studies in homes of children with advanced early literacy skills commented on the diverse range of adult reading materials found on the floors of bedrooms, kitchens, and bathrooms: from novels to newspapers, from checkbooks to magazines.
Despite this evidence, literacy-rich home environments and adult-child interaction around books remain far from universal during early childhood, particularly in low-income communities. In 2011, the percentage of children aged 1 to 5 years whose family members read to them fewer than 3 days per week was 14%. When examining children ages 3 to 5 years for daily reading, the percentages vary between 35% and 68% ( Fig. 2 ). Significant modifiers of reading-aloud frequency are maternal education level (daily reading in 74% of children with college-educated mothers vs only 31% with mothers who had not completed high school) and family income (daily reading in 64% of families living at >200% of the Federal Poverty Line but only 40% in those living under the poverty line) ( Figs. 3 and 4 ).
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