One day in clinic I gave a three-year-old patient a book at the beginning of her well child visit. The book came to me through Reach Out and Read, a national program where clinicians give books to children during each of their well child visits from ages six months to five years. My patient smiled a toothy grin, took the book, and said “Wheels on the Bus!” Her mother smiled and watched as the girl opened the book and started to sing.

The wheels on the bus go round and round, round and round, round and round.

To the lovely background music the mother and I talked about her daughter’s development, eating habits, and concerns. I performed a physical exam. The girl was growing well, and the exam was normal.

The people on the bus go up and down, up and down, up and down.

The mother and I discussed child care, how to keep her daughter safe and healthy in the summer, and ways to channel her blossoming personality. The girl was cheerful throughout the visit.

The mothers on the bus say, “I love you, I love you, I love you.”

On their way out the door, when the mother told her daughter to thank me for the book, the girl tucked her chin into her chest, looked up, and thanked me with an impish smile. In many ways, the visit could not have gone better.

Except that the book I had given her was “Brown Bear, Brown Bear” and not “Wheels on the Bus.” I had given her “Wheels on the Bus” at the last visit. I am sure the patient didn’t know this and I am guessing her mother didn’t either. My guess is that “Wheels” was one of the few books she owned so any book, in her mind, was probably “Wheels.”

Reach Out And Read

Reach Out and Read, begun in 1989, is an early literacy program where, at each well child care visit between six months and five years, pediatric clinicians give an age-appropriate new book to the child and counsel parents on the importance of and tips on how best to read with young children.

I first heard about Reach Out and Read at a professional development meeting. A pediatrician described how giving books to kids in well child visits was great for promoting literacy in children. She also described how the book would make the visit better for the clinician because you walked into the exam room with a gift and then were able to do much of the developmental exam by watching what the child did with the book.

I was sold. I applied to Reach Out and Read for training and to the hospital in Baltimore where I worked for funds to buy books. Today over 4,000 primary care offices give over 5.7 million new books to over 3.5 million families across the US. Reach Out and Read is funded through public and private grants and has received bipartisan support in Congress.

Reach Out and Read evaluations have shown that among families living in poverty and with low education levels, preschool children who participated in the program were read to more often; children’s language skills improved more than their peers who were not exposed to Reach Out and Read — they both understood more words and spoke more words; and their literacy skills after kindergarten were better than their non-participating peers. The more interaction a family had with Reach Out and Read, the more likely parents were to read to their child and report that they liked reading with their child.

This is amazing. But such progress may be tempered by adult literacy. To be most effective, an intervention to improve a child’s reading may need to take into consideration opportunities for adults to improve their own literacy. But this is hard. In a study my colleagues and I did in that same clinic, the family medicine residents—doctors who are training to take care of both adults and children—rarely asked about adult literacy and were far more comfortable asking about illicit drug use during pregnancy than about adult comfort in reading.

The Literacy Health Connection

In the US, about 14 percent of English-speaking adults read at a fifth grade level or below. An additional 30 percent of adults read at an eighth grade level or below. Almost half of these adults—and therefore their children—live in poverty. Poverty and literacy exist in a vicious cycle — adults with low-literacy have fewer employment opportunities and children living in poverty are less likely to start kindergarten ready to learn to read.

Health and poverty also exist in a vicious cycle. Health care costs are the primary cause of personal bankruptcy and both children and adults living in poverty have poor health outcomes. And health and literacy live in a vicious cycle as well. Youth who are struggling with school are more likely to engage in high risk teenage behavior—like drinking alcohol and engaging in unprotected sex—which sets them up for greater school failure.

But it’s not just the individual who experiences the vicious cycle. Low-literacy, poverty, and suboptimal health are contagious within a family. Embedded in the socio-economic etiologies of the issues, the transmission of low-literacy, poverty, and sub-optimal health from generation to generation are problems that continue to vex traditional solutions.

Toxic stress, increased activation of the stress response system, is a prime example. It occurs when a child experiences frequent or prolonged adversity—such as child abuse or exposure to neighborhood violence—without the long-term buffering of a caring, responsive adult. Toxic stress leads to developmental, physical, and mental disabilities in childhood and adulthood. Of course, if a parent experienced toxic stress as a child, she is much less likely to have the tools to be the caring, responsive adult her child needs, and the cycle continues.

Thankfully, there are some successes in interrupting these vicious cycles in what are called two-generational or multi-generational solutions. In the Baltimore clinic where I worked as a pediatrician, we served many families living in poverty and this mother-child dyad was no exception. The mother I saw may have been able to read “Wheels on the Bus” to her daughter but it might not have been an enjoyable activity for her so she didn’t do it. Or she might have read and sang “Wheels on the Bus” with her daughter but she did not have other books in their home.

Children living in homes with parents who don’t read well have fewer books in their home. If children don’t see people modeling reading, they are less likely to do it. Children living in poverty in the first few years of life hear fewer words so they learn fewer words. They show up for kindergarten without knowing how to listen to a story and with limited language skills — both of which set them up to have problems learning to read.

The Two-Generation Approach

The concept of the two-generation approach as described by Ascend at the Aspen Institute and the Annie E. Casey Foundation includes interventions that target adults and children so they not only improve their lives in parallel, but they provide constant positive feedback to each other.

Imagine if my patient’s mother held the book “Brown Bear, Brown Bear” with her child and knew she had the opportunity to work on her own reading while reading to her child.

Two-generation approaches have been around for decades. They include home visiting programs that attend to maternal mental health and child development. They include Head Start preschool programs that provide high quality child care and require parental involvement — as the teachers educate and facilitate healthy development in the children, they provide parents with the tools to best educate and facilitate their whole family’s healthy development.

They include supportive housing programs that offer child care for children and job training in meaningful work for the parents. And they include a home child care quality improvement program that professionalizes home child care providers so they improve their own practice and business, improve the quality of child care that children receive, and provide parents with the ability to work outside the home, knowing their young children are being nurtured.

Many of these programs require new training (preschool teachers need to learn to teach parents) and new partnerships (supportive housing advocates need to work with child care providers and GED teachers) which may be why the medical world has not jumped on the two-generation bandwagon.

But we should.

With the increasing evidence regarding the ill effects of toxic stress, it’s clear that two-generation solutions are needed and that people across the spectrum of social and medical professions need to work together.

While there are some exceptions, most of health care remains siloed. Most primary care is provided by those who specialize in pediatrics, adult medicine, or OB/GYN. For family medicine clinicians, there is less siloing in physical health but many mental health clinicians treat children or adults but not both. While restructuring the health care system to provide more multi-generational care seems onerous, another option includes opening up our silos just enough that we learn to work across disciplines.

For example, the American Academy of Pediatrics Bright Futures Guidelines state that pediatric clinicians should counsel about parental smoking and maternal mental health — topics that have multi-generational impact but involve counseling adults about their behavior. Yet fewer than half of pediatricians counsel about parental smoking or maternal mental health.

Even though 82 percent of pediatricians in one study believed they should help parents quit smoking, 69 percent reported they didn’t have enough time, 79 percent reported they didn’t know how to do it, and 89 percent reported they didn’t know the resources available for parents. Similarly, 75 percent of pediatricians reported they didn’t know how to counsel about maternal mental health, and 64 percent reported they didn’t have enough time to counsel.

The Affordable Care Act (ACA) may offer some assistance to the key barriers in two-generation solutions. For example, the ACA provides funding opportunities for maternal depression screening in pediatrics offices and for community health workers to help parents navigate their mental health or smoking cessation treatment. This funding could remove key barriers to two-generation interventions. Training and funding for patient-centered medical homes will hopefully remove more of the barriers.

A few two-generation approaches are already making a small impact in health care. One is pediatric group health maintenance appointments. In the group model we have been using at the Primary Care Center at Yale-New Haven Hospital for the past six years, adapted from decades of others’ work, we run groups of five to seven families who each have a child within three weeks of each other’s age. By meeting as a group of families and providers at all of the regular check-up visits during the baby’s first year of life, not only do we weigh, measure, examine, and vaccinate at each visit, we also have time to talk about child development and maternal mental health.

While we play with children on a playmat, we discuss responsive parenting, that is, when a parent takes care of their own needs, they are better able to respond to their child’s needs, and that a child who knows their needs will be met is better able to learn and thrive. When we hand out books, we draw attention to the parents who are modeling reading.

It’s a small program but at our clinic we have better attendance than we do at our traditional well child care — perhaps because the parents understand that we are practicing two-generation pediatrics, and they are voting with their feet. Group well child care is cost-neutral. We are providing all of a child’s well child needs so we can fund it through the child’s SCHIP or Medicaid health insurance.

When First Steps Are Not Enough

When my older daughter was five-years-old, she started taking Kuchipudi, a form of dance popular in India. My deceased husband’s family is from India, and I am Ashkenazi Jewish. The nearest connection I had to the dance classes were my childhood ballet lessons. I wasn’t trying to nurture a professional dancer, but give her a cultural lesson in her heritage that I could not give her.

The dance teacher made it clear that she expected children to practice daily at home. It seemed that the other children did. But in our home, I had no reference for the intricate hand positions. I could not spread my feet and then get on my toes. I did not know the music, and I didn’t understand the Hindi lyrics.

I felt ostracized in the class. The teacher saved the last few minutes of class for the mothers to get up and dance. We were to learn the steps so we could encourage our daughters to practice. I was the only one who had no idea what she was doing. Most of the mothers were encouraging. One asked me why I was there—she wasn’t being mean, just curious—but, for me, it highlighted what I could not do. So perhaps it was no surprise that my daughter’s home practice was limited, her skills were less than the other girls, and she eventually wanted to quit.

I let her quit. I didn’t have it in me to learn on my own, and I didn’t feel like there was an opportunity to learn from the teacher. I was not judging the teacher. It was just that we were all there for our children’s education, not ours.

Dance lessons for me are not the same as, for those who need them, literacy classes, job training, supportive housing, and classes where parents learn how to best be responsive to their child. Society does not need me to be a skilled enough Kuchipudi dancer to model it for my daughter as much as we need to support parents. But the parallels are there.

My daughter wanted to quit dance—lots of kids want to quit dance—but I let her quit, in part, because it made me feel inadequate. I didn’t have the tools to transcend my feelings. And the norm where we lived didn’t include learning Indian dance. I would have had to step out of my comfort zone and out of my community norms to learn the dance. It didn’t happen.

On some days, giving a book to a child in her well child care appointment or talking to a child about her behavior feels like signing my daughter up for Indian dance lessons. It’s a step in the right direction but if not coupled with talking to the mother about her needs then helping her access the right programming, it’s not enough.