Pediatricians

The American Academy of Pediatrics policy statement on literacy promotion urges pediatricians to encourage families and caregivers to read to their children, early and often. When caregivers read to their children, significant social-emotional, developmental, and academic benefits flourish.

Oral language is strengthened when the reader engages in conversation or questioning during or after the reading.  Research shows that conversations between adults and children, about books or otherwise, are critical for language development. Researchers have highlighted the strong connection between early conversational turn-taking and later cognitive outcomes, including IQ (see Romeo et al., 2018). They found that the number of back-and-forth exchanges between children and adults was associated with increased activation in Broca’s area, stronger white matter connectivity in language-related brain regions, and higher verbal IQ scores. Similarly, Zimmerman et al. (2009) demonstrated that adult-child conversations were more predictive of language development than word count alone. Gilkerson et al. (2018) further showed that the frequency of conversational turns between 18 and 24 months predicted verbal comprehension, vocabulary, and IQ in late childhood, even after controlling for socioeconomic status. These findings underscore the critical role of responsive, interactive language experiences in early brain and language development. It is important to note that language development in a child’s home language is recommended even if it is not their language of instruction. 

Pediatricians are encouraged to continue stressing the importance of parents and caregivers reading to their children and engaging in back-and-forth conversations with them. This is particularly important in light of the increased use of screens and technology (both among children and caregivers), where opportunities for back-and-forth conversation all but disappear.

ACTION STEP: During visits, stress the importance of language development over screen time. This is a good opportunity to point caregivers to The Reading League’s conversation starters, which were previously mentioned in the introduction.

COMING SOON: The Reading League’s Conversation Starters

Additionally, pediatricians can work with reputable organizations supporting language development and book access. These resources provide guidance on the importance of language comprehension and shared book reading:

In recent years, the field of education has recognized the importance of research findings on language development, and the equally critical role of decoding skills in learning to read. The podcast Sold a Story highlights the concerns that students were not learning to read in school because an ineffective method of teaching reading had become pervasive in teacher training programs and the instructional materials used to teach young children to read. This flawed method, called three-cueing, asked children to learn to read by using pictures, context clues, and the first letter of a word to guess unknown words. This method does not allow students to develop the neural pathways necessary to turn printed words into meaningful language. 

Instead, students must learn that letters represent speech sounds (phonemes) and that blending and segmenting these sounds will help them learn to read and write words, which carry meaning. 

Skilled literacy is the most important component of academic success, which has implications for children’s mental health and future success. Because all children cycle through a pediatrician’s busy office, there is an excellent opportunity for their parents or caregivers to receive information on how skilled literacy develops, how their child is progressing, tools to support their development, and resources to understand if their schools are teaching in a manner that aligns with decades of cognitive science.

Many schools use a model in which they wait for students to show a lack of progress before determining their need for intervention. This is sometimes known colloquially as the “wait to fail” model. Instead, research points to early intervention’s efficacy in preventing many reading difficulties from occurring by leveraging data from literacy screeners as a resource to inform evidence-aligned instruction.

ACTION ITEM: Pediatricians can provide families with information on this research so they may be equipped with knowledge to bring to their schools if their children are struggling and are told to “wait and see” how they perform in later grades.

Learning to read is complicated. Children need two main contributing skills to learn to read: They need to know how to turn printed words into language and understand the language of what they are reading. Children can struggle with these skills either because they have not received adequate evidence-aligned instruction or because they need additional support in these areas. 

If a child needs additional support and multiple repetitions to learn the words on the page, they may have characteristics of dyslexia.

If a child struggles to understand and/or express language, they may have characteristics of developmental language disorder (DLD).

The Quadrant Model is a helpful way to understand the academic implications of dyslexia and DLD.

There are some signs of dyslexia and DLD that can be pre-screened. These include the following characteristics:

• Family History: A known family history of dyslexia or DLD, language delays, or other reading disabilities.
• Delayed Language Development: Early signs include limited babbling, late talking, limited vocabulary, or difficulty with grammar.
• Difficulty Remembering Sequences: Trouble with remembering steps in sequences or routines, which can correlate with difficulty in tracking words or understanding story order.

Language is the foundation of early literacy. When discussing language milestones with parents, pediatricians can refer to the following linked documents from the U.S. Centers for Disease Control and Prevention (CDC) and the American Speech-Language and Hearing Association (ASHA). A referral to a speech-language pathologist is warranted in cases of late talking or concerns about a speech/language delay.

Pediatricians can use the following literacy milestones to help parents understand if their children are meeting the expected benchmarks. If they are not, families and caregivers can work on targeted skills at home with their children and can follow up with their child’s school and/or Early Intervention Services if they do not make adequate progress.

Aside from these broad understandings, pediatricians and health professionals will benefit by understanding key expected milestones of language and literacy, look-fors, and questions to ask, as well as resources for families for each age range.

Language Development:

Literacy Development:

• Responds to your voice during shared book reading (e.g., by smiling, cooing, or turning their head)
• Looks at or shows interest in pictures or books
• Enjoys read-aloud and singing time with caregivers 
• Makes sounds or facial expressions during book time

Language Development:

Literacy Development:

• Points to pictures in a book when you name them
• Attempts to say familiar words from favorite books
• Brings books to you to read
• Tries to turn pages in a board book (even if several at a time)

Language Development:

Literacy Development:

• Names pictures or objects in books without prompting
• Finishes familiar phrases in books that have been read multiple times
• Pretends to read or tell a story
• Recognizes familiar signs or logos (e.g., stop sign, store logo, restaurant logo)

Language Development:

Literacy Development:

• Sits and listens to a short story from a picture book
• Shows interest in letters, especially those in their name
• Recognizes words that rhyme (e.g., cat, hat, bat)
• Knows how to open a book and turn pages one at a time and knows where on the page to start reading
• Remembers some letter names and their sounds once they have been taught

Language Development:

Literacy Development:

• Understands that written words have meaning and that we read from left to right
• Recognizes and names several letters of the alphabet and the sounds they represent
• Tells you the beginning and ending sounds of words when prompted
• Attempts to write their name or other familiar words
• Answers simple questions about a story read aloud (e.g., “What happened at the end?”)

Language Development:

Literacy Development:

• Breaks down words into individual sounds, or phonemes (example: breaks “sat” into the sounds s-a-t), and blends sounds together to make words (example: blends s-a-t to make the word “sat”)
• Consistently applies the correct sounds to letters when prompted
• Sounds out unfamiliar words when reading instead of using context and picture cues to guess at words  
• Spells and reads words accurately after instruction and practice 
• Reads aloud and participates in reading activities without reluctance
• Retells a story in order (beginning, middle, and end)

Literacy Development:

• Reads with accuracy and with expression
• Spells most words correctly
• Writes well-structured sentences and organized paragraphs
• Summarizes a story and explains what characters feel or why events happened
• Reads longer and more complex words fluently 
• Does not avoid reading or have low self-confidence in literacy tasks

Literacy Development:

• Exhibits the ability to read unfamiliar or complex words accurately and automatically
• Spells accurately most of the time, particularly when spelling common words
• Writes a paragraph and/or essay with well-organized writing and accurate sentence structure 
• Understands complex information, draws inferences, and analyzes texts
• Knows and correctly uses a variety of vocabulary words

Sharing these milestones with parents helps to build awareness about the knowledge students need in order to become skilled readers. The following resources will provide additional information for families with readers who need extra support:

Pediatricians can ask targeted questions to gauge whether a child receives literacy instruction that is aligned with the decades of research on how children learn to read, or they can equip parents to ask them at school. These questions help identify whether the instructional approaches align with the science of reading, focusing on skills like phonemic awareness, phonics, fluency, vocabulary, and comprehension.

1. Letter and Sound Awareness: “Is your child learning letter names and the sounds they make? Are they practiced until your child knows them automatically?”
2. Reading Approach: “Have the teachers talked about how they teach reading? Do they focus on sounding out words, or is it more about guessing based on pictures or context?”
3. Instructional Consistency: “Is your child’s reading program explicit and systematic, focusing on building foundational skills day by day?”
4. Language: “Is your child taught a variety of vocabulary words? Do they have enough time to talk about what they are learning with one another and with the teacher?”

1. Phonics and Decoding Skills: “Does your child learn to break down words into individual speech sounds and also blend speech sounds to read words?”
2. Practice Reading: “Is your child given practice opportunities to  and also read aloud to a teacher with guidance to improve accuracy and fluency?”
3. Spelling and Writing Instruction: “How does the school teach spelling and writing? Do they emphasize understanding letter-sound relationships and word parts, like prefixes and suffixes, or is it more about memorizing words?”
4. Reading Comprehension: “During and after reading, do students discuss what they read to make sure they understand the meaning? Are they encouraged to ask questions about the story or explain it in their own words?”
5. Reading Fluency and Comprehension: “Does your school measure your child’s reading fluency? Do they determine if they read words accurately? Do they teach your child to read with expression so it sounds like how they speak?”

1. Vocabulary and Language Development: “Does the school help expand your child’s vocabulary and understanding of more complex grammar? Are they encouraged to read a variety of texts to build their knowledge?”
2. Reading Fluency and Comprehension: “If your child is not reading on grade level, does your school measure their reading fluency? Do they determine if they read words accurately? Do they teach your child to read with expression so it sounds like how they speak?”
3. Support for Difficulties: “If your child has had trouble with reading, what steps has the school taken to help? Do they use specific, targeted interventions for reading challenges, like one-on-one support or additional small group instruction?”

1. Reading Comfort and Enjoyment: “Do you like reading in class? What’s the hardest part of reading for you?”
2. Sounding Out Words: “When you come to a word you don’t know, do your teachers show you how to sound it out (recommended), or do they tell you to look at the pictures or guess (not recommended)?”
3. Understanding Stories: “When you read a story, do you talk about it in class, like what it’s about or why things happen?”

Reading difficulties in children and adolescents are closely linked to a range of mental health challenges, including both internalizing and externalizing behaviors. Internally, struggling readers often experience heightened anxiety, depression, and low self-esteem due to repeated academic failure and negative social comparisons (Mugnaini et al., 2009; Undheim, 2003). At the same time, research also shows an increased risk for externalizing behaviors such as aggression, defiance, and hyperactivity, particularly among boys with reading problems (Trzesniewski et al., 2006; Morgan et al., 2008). These behaviors may emerge as coping mechanisms for frustration or as attempts to divert attention from academic struggles. Moreover, combining academic difficulties and behavioral problems can contribute to a cycle of negative feedback from teachers and peers, further reinforcing both emotional and behavioral challenges (Alexander-Passe, 2006). Early, holistic interventions that address both literacy skills and emotional well-being are essential to interrupt this cycle and support healthy development.

The Rapid Online Assessment of Reading, or ROAR, consists of a suite of completely automated, lightly gamified assessments developed by Stanford University researchers. ROAR can be used to screen for reading difficulties (and is an approved screener in the state of California) and also provides parent-facing score reports with detailed information on strengths and weaknesses. Roar@Home provides a portal for families to access ROAR assessments and score reports, which can be shared with a clinician for additional support. Pediatricians can raise awareness of this resource and review scores with families and caregivers.