Literacy: Beyond just Books
February 2015
Pediatric Continuity Clinic Curriculum
Created by: Rebekah Soto
Objectives
• Review benefits of early introduction to reading for
infants and toddlers
• Understand how reading and looking at books together
can be used to help encourage developmental
milestone progression
• Discuss ways to encourage families to read together
• Learn practical techniques to include reading
recommendations in your well child checks while
addressing parental concerns
• Evaluate parental concerns regarding learning or
reading skills
Case #1
You are seeing a 2 month old healthy infant for
WCC. When you ask how the family is adjusting to
the new baby, MOC states they are doing well
except for the older 4 year old sibling who is
struggling to adjust to having a new baby at home
and starting into pre-K (which is his first school
experience away from mom).
Mom reports she plans to keep this baby at home
for now, but “doesn’t want to make the same
mistakes again” because she feels her older child
was not prepared to start school this year.
Case #1 Discussion Questions
• What advice could you provide this mother
with regard to “school preparation” for her
new infant?
• How could books be used as a helpful tool for
this family?
• What does the AAP recommend with regard
to reading with young children?
What advice could you provide this mother with
regard to “school preparation” for her new infant?
• It’s never too early to start reading books with your
little one.
• Reading books aloud with your baby has been shown
to have a positive effect on parent-child bonding, early
language skills, and literacy development.
• Children who are read to as infants and toddlers have
better language skills and interest in reading when they
start school.
• Building positive associations with reading as a young
child helps foster a lifelong love for reading and
learning.
How could books be used as a helpful
tool for this family?
• Reading books together can be a fun activity to bring the
whole family together and create lifelong memories.
• A special reading time or library trip with just the older
sibling can help him to maintain a bond with his parents
and prevent him from feeling like he is competing with the
new baby for attention.
• Reading books about a new baby, bedtime routines, and
going to school can help this child understand some of the
new changes in his life.
• Allowing him to pick out books and read to his younger
sibling is a good way to build sibling relationships and build
confidence as big brother “helps” mom and dad with caring
for the baby in a safe and age appropriate way.
What does the AAP recommend with
regard to reading with young children?
Pediatric providers promote early literacy development for children beginning
in infancy and continuing at least until the age of kindergarten entry by
• (1) advising all parents that reading aloud with young children can
enhance parent-child relationships and prepare young minds to learn
language and early literacy skills;
• (2) counseling all parents about developmentally appropriate sharedreading activities that are enjoyable for children and their parents and
offer language-rich exposure to books, pictures, and the written word;
• (3) providing developmentally appropriate books given at health
supervision visits for all high-risk, low-income young children;
• (4) using a robust spectrum of options to support and promote these
efforts; and
• (5) partnering with other child advocates to influence national messaging
and policies that support and promote these key early shared-reading
experiences.
Case #2
• A 12 month old presents for his 1 year WCC.
While he appears to be developing well in
other areas, his mother is concerned that he is
not as vocal as his older sister was at this age.
– What are normal communication skills for a child
this age?
– How do you answer mom’s questions about “why
he doesn’t talk as much as his sister?”
– What can mother do to help encourage his
vocalizations?
What are expected communication skills
for a 1 year old child?
• 1 year olds can generally say “mama,” “dada,”
and possibly a few other favorite words.
• May point to something they want (protoimperative pointing).
• May use gestures with vocalizations (i.e. reaching
or waving at something).
• Can generally follow a one step command
provided with a gesture.
• May recognize an object when it is named and
look toward that object.
“Why doesn’t he talk as much as his sister?”
• Remind mom that each child has their own pace of
development and personality traits.
• Let her know you will evaluate all domains of his
development to ensure he is developing appropriately
in other areas. Reassure her if these are all appropriate
for age.
• Don’t forget to assess for hearing concerns or failure to
respond to sounds appropriately, as these may present
with speech delay.
• Review birth history and family history for any risk for
hearing loss and ensure he passed his newborn hearing
test. *
What can mother do to help
encourage his vocalizations?
• This mother is motivated to do something to help
her child with speech so take the opportunity to
advise her on the lifelong benefits of reading!
• By reading stories and looking at books together
daily, he will hear words and sounds and begin to
mimic them.
• Incorporate singing, rhyming, and “having
conversations” within the daily routine to encourage
his vocalizations.
• Responding to his sounds and gestures with eye
contact and talking back provides feedback and
attention that he craves to keep attempting sounds.
Don’t forget!
• The local library is a great FREE resource for finding
age appropriate books and other family oriented
activities allowing children to interact with their
community in a safe, supportive environment.
• There are books available on a number of topics that
you would never expect. Encourage families to look
into topics that they express concern about (ie dealing
with bullying, death of a loved one, non-traditional
families, suicide, potty training, children with
disabilities, etc).
• Families can look up Alachua County Library District
online to find the library location closest to them and
fun events taking place as well as look up
books/movies/etc in the online catalog. Check it out at
www.aclib.us!
Case # 3
7 year old male presents for a urgent visit with his
mother due to “school concerns” because his grades at
school are dropping. His teachers report he is doing
well with basic math and answers questions verbally
during class time, but struggles with finishing
assignments at school.
His mother is concerned that he has always been a
“slow reader” and now seems to have increasing
difficulty and frustration with completing homework at
home. Furthermore, the teacher has noticed he will
sometimes “act out” or “become a class clown” during
group reading activities. He is an otherwise well
behaved and articulate child.
Case # 3 Discussion
• What additional history should you obtain at
this visit?
• Mom asks you, “do you think he has a learning
disability?”
• What guidance can you provide this
concerned mother regarding her child’s future
school performance?
• What interventions or work-up should be
initiated today?
What additional history should you
obtain at this visit?
• Because learning impairments or disability can be attributable to a
number of factors, a thorough history is necessary to help determine
the cause of learning problems:
– Current and past school history (including current interventions or
individualized education plans/504 and if the learning or behavior
issues are limited to a certain class, teacher, or time of day)
– Prenatal/birth history (in utero exposures/infections)
– Developmental milestones attainment or delays (was the child
ever evaluated for delay or receiving any therapies?)
– Social history
– Past medical history (including consideration of vision or hearing
issues which may impact learning)
– Family history of learning disability or intellectual disability
(including history of family member who dropped out of school or
had difficulty obtaining and maintaining a job)
“Do you think that he has a learning problem?”
• Around 3 million children 6-11 years old are affected by learning
disability. Disability can be in mathematics, written expression, or most
commonly in reading disability or dyslexia.
• Reading disability accounts for 80% of learning disability cases and affects
5-10% of the general pediatric population.
• Males are more commonly affected than females and the degree of
disability varies from child to child.
• Children may be able to cope with or overcome their disability for a period
of time, but tend to struggle during the transition from “learning to read”
to “reading to learn” when reading comprehension becomes necessary
for building skills.
• Children may “act out” or clown around in class to distract from their
embarrassment with their inability to complete work. They may also be at
higher risk for suspension, poor self-esteem, or getting into fights at
school due to bullying, and ultimately at higher risk for being held back
grades and dropping out of school.
What guidance can you provide this concerned mother
regarding her child’s future school performance?
• Reading proficiency by 3rd grade is the most
significant predictor of high school graduation and
career success, yet 2/3 of U.S. 3rd graders lack
competent reading skills.
• Many children with disabilities can excel in school
(and in adult life) with the proper interventions to
support learning.
• Because of the high morbidity of untreated learning
disability and the lifelong detrimental effects, it is
essential to begin addressing problems immediately.
What interventions or work-up
should be initiated today?
• Work up should be guided by the history & physical
• As the PCP, rule out/consider other causes of learning
problems (see notes)
• Interventions at school to promote achievement can be
put into place prior to “having a diagnosis” and should be
initiated ASAP to prevent child from falling further behind.
• Children with suspected learning disability should undergo
psychoeducational testing (through school or private
psychologist) to determine disability and most appropriate
interventions to facilitate learning.
• The medical home should advocate for appropriate
educational interventions (IEP/504 plan) and referrals for
subspecialty evaluation or therapies as needed.
PREP Question
PREP Question
• Answer: C. 24 Months
• The child described in the vignette exhibits
normal cognitive/behavioral milestones for a
24 month old: combines words into 2-3 word
phrases, points to pictures named, uses
vocabulary of 50+ words and uses “I” “me”
and “mine” in speech.
PREP Question
PREP Question
• Answer: D. Learning Disability
• The girl described in the vignette has evidence of a learning disability
with difficulty in reading.
• In order for a learning disability to be diagnosed, there must be a
significant discrepancy between the child’s achievement scores in
reading, writing, or math and the child’s cognitive ability (IQ). The
discrepancy must impact the child’s educational success.
• To confirm the diagnosis of a learning disability, a psychoeducational
evaluation is performed that includes cognitive and academic testing.
A comprehensive speech and language evaluation and audiologic
examination will help clarify if there is an underlying language disorder
or hearing deficit. When there is a concern that a student may have a
learning disability, public law requires a psychological and educational
evaluation.
PREP Question
PREP Question
• Answer: A. Learning Disability.
• The infant in the vignette has congenital hearing loss due to connexin gene
mutation.
• These infants are at increased risk for learning disabilities and a low
reading level. Even children with mild or unilateral hearing loss will have
more difficulty listening when there is background noise, as is often the
case in a school classroom.
• The child in this vignette has an isolated hearing loss and is therefore not
likely to have a significant intellectual disability (ID). However, children
who have hearing loss due to prenatal infections are at increased risk for
ID and neurodevelopmental delays, including learning or language
difficulties, inattention, or behavioral disturbances.
• Congenital or acquired hearing loss has been linked to lifelong deficits in
speech and language acquisition, poor academic performance, personalsocial maladjustments, and emotional difficulties.
Resources
• Literacy Promotion: An essential component of primary
care pediatric practice (2014 AAP Policy Statement)
• Parents who read to their children nurture more than
literacy skills- AAP News June 2014
• Reach Out and Read Website
• Reading is Fundamental Website
• Alachua Country Library District Website
• Hearing Loss in Children-Peds in Review
• Learning Disability and School Failure-Peds in Review