Early Literacy Developmental Activities and Pre-Kindergarten Learning Skills in the Context of Childhood Adversity

Abstract

OBJECTIVE:

School readiness (SR) encompasses a wide range of skills that affect children’s ability to succeed in school and later in life. Shared reading is an important strategy that assists children in gaining SR skills, whereas adverse childhood experiences (ACEs) negatively affect a child’s SR. This study assessed if early literacy developmental activities (shared reading, singing, or storytelling) were associated with improved SR among children with and without ACEs.

METHODS:

2020–2021 National Survey of Children’s Health data were used for analysis. We identified children aged 3–5 years to assess their exposure to ACEs, participation in reading/storytelling/singing, and overall SR.

RESULTS:

In a sample of 17,545 children, 29% of children were exposed to one or more ACEs. Seventy-seven percent of children with no ACEs received daily early literacy developmental activities compared to 23% of children who experienced any ACE. On ordinal logistic regression, daily early literacy developmental activities were associated with 56% greater odds of higher SR among children not exposed to ACEs (OR: 1.56; 95% CI: 1.29, 1.88; P < .01). Among children exposed to ACEs, daily early literacy developmental activities were also associated with higher SR (OR: 1.50; 95% CI: 1.06, 2.13; P = .02).

CONCLUSIONS:

Shared reading, storytelling, and singing are associated with improved SR in both children who have and have not been exposed to ACEs. However, children exposed to ACEs had fewer experiences with early literacy developmental activities. Future efforts should address the barriers that limit shared reading, singing, or storytelling for children exposed to ACEs.

School readiness (SR) encompasses a wide range of skills that impact children’s ability to succeed in school and later in life.¹ Five recognized domains of SR include: Physical Well-Being and Motor Development; Social and Emotional Development; Approaches Toward Learning; Language Development; and Cognition and General Knowledge (including early literacy and math skills).² Within the US, 30–50% of children enter kindergarten without the skills needed to be ready to learn, and children from economically disadvantaged households are at higher risk for poor SR.^2,3

Shared reading is an important strategy to assist children in becoming ready for school, and more frequent shared reading predicts a decreased risk of developmental, social, and behavioral delays in preschool-age children.⁴ Shared reading is an interactive process in which an adult and child look at and engage with a book together. Parent-child shared reading is pivotal to language development and emergent literacy.^4–7 Outside of language and literacy development, shared reading also benefits a child’s socio-emotional development and fosters a positive parent-child relationship.^8,9 Additionally, singing to an infant does have a positive impact on the infant’s language development¹⁰ and oral storytelling can increase a child’s story comprehension, word learning, and on-task behavior,¹¹ important factors for SR.

Adverse childhood events (ACEs) impact a child’s life and long-term health outcomes, as well as negatively affect their ability to be prepared for school,^12,13 with research showing its effect on classroom behavior and literacy skills.¹⁴ An ACE is a traumatic event that occurs in childhood (0–17 years), and within the US, just under half of children have one ACE, while 10% have three or more ACEs.¹⁵ The chronic stress from exposure to ACEs can adversely affect a child’s socio-emotional, neurological, immunological, and hormonal development.¹⁶ Children exposed to ACEs have difficulties with self-regulation, math, and task engagement.¹³ ACEs may also have a dose-dependent impact on a child’s development, the higher the ACEs a child has the higher the risk of poorer health and developmental outcomes.¹⁷ The objective of this study was to assess if early literacy developmental activities were equally associated with improved SR among children with and without ACEs. Given the complex disadvantages children with ACEs may face in attaining SR, we hypothesized that early literacy developmental activities (ie, shared reading, singing, or storytelling), would only be associated with improved SR among children with no exposures to ACEs.

METHODS

Deidentified data used in this study were obtained from the 2020–2021 National Survey of Children’s Health (NSCH), funded by the Health Resources and Services Administration’s Maternal and Child Health Bureau. This population-based survey was designed to assess the physical and emotional health of children 0–17 years of age in the United States. US households with children were invited to complete a survey by Web or mail regarding the health and development of one randomly selected sample child (ages 0–17 years) in each household.¹⁸ For this study, we restricted the sample to children ages 3–5 years, to focus on SR as measured among preschool-age children. Children outside this age range and children for whom data on study variables were missing were excluded from the study.

Children’s exposure to ACEs was ascertained through a set of 9 questions examining exposure to parental divorce, parental death, parental incarceration, witnessing domestic violence, being a victim/witness of neighborhood violence, living with a household member with mental illness, living with a household member with substance abuse problems, and being treated unfairly due to race or ethnic group (child discrimination), and material hardship. To facilitate the interpretation of the interaction terms in our regression analysis, we focused on a binary measure of exposure to any compared to no ACEs.¹⁹ In a sensitivity analysis, we also categorized ACEs as none, 1–3, or 4+. Based on prior work, we used two questions about the number of times in a week that a family member read to the child and or sang songs/told stories to the child to create a composite variable for early literacy developmental activities (shared reading, singing, or storytelling 0–3 days a week, 4–6 days a week, or every day).²

Four domains were examined to assess SR: cognitive development, self-regulation, social-emotional development, and health, (Appendix Table 1). Adapting a similar framework from prior studies, we recoded each item to a three-point scale (0 = at risk, 1 = needs support, 2 = on-track) based on age-specific cut-offs within each domain.^2,20 The cognitive development domain included seven questions with a score range of 0–14. A score of 0–6 indicated “at-risk,” a score of 7–11 indicated “needs support,” and a score of 12–14 indicated “on track.” For the self-regulation and social-emotional development domains, each domain had four questions with a maximum score of eight for each domain. A score range between 0–3 indicated that the child was at overall risk for skills pertaining to that specific domain. A score range between 4–6 indicated needing support for the overall domain. A score range of 7–8 indicated that the child was on track overall in that domain. To be considered on track overall in a domain, the child was also only allowed to have a score of “Needs Support” for no more than one item in that domain. For the health domain, there were three questions with a maximum score of six points. A score of 0–2 indicated “at-risk”, a score of 3–4 indicated “needs support,” and a score of 5–6 indicated “on track.” We created the overall SR score by summing the results from the four domains. For overall SR, a child was deemed “at risk” if they were on track in 0–1 domains, “needs support” if on track in two or three domains, and “on track” if on track in all four domains. For each domain, we calculated the average score on the three-point scale using all component items that had a valid response. Children were considered “on track” in domains where their average score was > 1.66 and ≤2. The primary outcome was the total count of domains in which children were considered “on track” (range: 0–4 domains). Standards for each response were based on a coding scheme used in a prior study.^2,20

Covariates for the study were selected based on plausible correlates or confounders of the association between shared reading/singing/storytelling and SR.^2,8,20,21 These included child sex, race and ethnicity, age at the time of the survey, and whether the primary household language was English or any other language. Measures of child health included the presence of special health care needs (SHCN) and caregiver-rated general health (recoded as excellent/very good vs good/fair/poor). Socioeconomic characteristics included caregiver education (highest of either caregiver, and classified as high school or less; some college; or a 4-year college degree); caregiver employment (at least one caregiver working full-time; at least one caregiver working part-time but none working full-time; or no caregivers working); family income, defined as percent of the Federal Poverty Level (FPL); recent experience of food insecurity (if the family could not afford nutritious food, or could not afford enough food to eat)²² and household structure (two parents, single mother, or any other). Caregivers’ general physical and mental health were reported by the adult respondent on a five-point scale from excellent to poor and were categorized based on the highest response (indicating worse health) of either caregiver. Caregivers also reported whether they had someone they could turn to for day-to-day emotional support in raising their child. Lastly, we controlled for family routines and community resources that could directly impact early literacy developmental activities: child screen time on weekdays (> 2 hours vs 2 hours or fewer); bedtime (always/usually, sometimes, or rarely/never going to bed at the same time each night); the presence of a library or bookmobile in the neighborhood; and the presence of a community center, Boys and Girls Club, or similar centers in the neighborhood.

Data were summarized using weighted proportions and compared according to the frequency of early literacy developmental activities using Wald tests. The composite outcome of SR (0–4 scale) was analyzed using ordinal logistic regression, including all study covariates and interaction terms between ACEs exposure and early literacy developmental activities. Secondary outcomes (each domain of SR) were analyzed using Poisson regression, to calculate risk ratios (RRs). All analyses included survey weights and were adjusted for the complex sampling design. Analyses including family income were adjusted for the inclusion of multiply-imputed income data in the data set, with six implicates created by NSCH survey staff. Data analysis was conducted in Stata/SE 16.1 (College Station, TX: StataCorp, LP), and P < .05 was considered statistically significant. This study using de-identified publicly available data did not include human subjects research and, as such, did not require Institutional Review Board approval.

RESULTS

The 2020–2021 NSCH included 18,766 children ages 3–5 years, of whom 1221 were excluded due to missing data. Based on the remaining sample of 17,545 children, 29% met all four domains of SR; 31% met three of the four domains; 22% met two of the domains; 13% met one of the domains; and 6% met none of the domains. Twenty-nine percent were exposed to ACEs, including 17% exposed to one ACE, 7% exposed to two ACEs, 3% exposed to three ACEs, and 3% exposed to four or more ACEs. Considering shared reading, storytelling, and singing, 50% of children ages 3–5 were read to, told stories to, or sung to by their caregiver every day, while 20% participated in the activities 4–6 days a week, and 30% participated in either activity for no more than 3 days per week. Complete descriptive statistics calculated based on the overall sample are presented in Appendix Table 2.

Bivariate comparisons of study outcomes by shared reading/singing/storytelling frequency are summarized in Table 1, while bivariate comparisons of covariates by shared reading/singing/storytelling frequency are summarized in Table 2. More frequent early literacy developmental activities were associated with greater SR, such that 35% of children who were read, told stories, or sung to daily met all four domains of SR, compared to 19% of children who were read, told stories, or sung to 0–3 days a week (Table 1). Meanwhile, children who experienced daily shared early literacy developmental activities were also more likely to have no ACEs, identify as non-Hispanic White, live with both parents, have college-educated caregivers, have higher family income, and have lower exposure to food insecurity (Table 2). Among contextual factors, the availability of caregiver emotional support, access to a library, and access to a community center were all correlated with increased frequency of early literacy developmental activities. Shared reading, storytelling, and singing were also more frequent among children with limited screen time and those who had an established bedtime routine.

Table 1.

School Readiness Domains, by Frequency of Shared Reading, Singing, or Storytelling (N = 17,545)

Outcome	Shared Reading, Singing, or Storytelling 0–3 days/week N = 3844	Shared Reading, Singing, or Storytelling 4–6 days/week N = 3351	Shared Reading, Singing, or Storytelling Daily N = 10,350	P
Number of school readiness domains in which the child is on-track
0	0.08 (0.06, 0.12)	0.07 (0.05, 0.10)	0.04 (0.03, 0.05)	.05
1	0.17 (0.14, 0.20)	0.12 (0.10, 0.14)	0.11 (0.90, 0.12)	< .01
2	0.26 (0.22, 0.30)	0.23 (0.20, 0.26)	0.19 (0.18, 0.21)	< .01
3	0.30 (0.26, 0.34)	0.31 (0.27, 0.34)	0.31 (0.29, 0.33)	.82
4	0.19 (0.16, 0.22)	0.28 (0.25, 0.31)	0.35 (0.33, 0.37)	< .01
Proportion on-track in specific domains of school readiness*
Cognitive development	0.35 (0.31, 0.39)	0.46 (0.42, 0.50)	0.54 (0.52, 0.57)	< .01
Self-regulation	0.52 (0.48, 0.56)	0.60 (0.56, 0.64)	0.66 (0.64, 0.68)	< .01
Social/emotional development	0.70 (0.66, 0.73)	0.73 (0.69, 0.76)	0.75 (0.73, 0.77)	.05
Health	0.78 (0.74, 0.81)	0.83 (0.80, 0.86)	0.86 (0.85, 0.88)	< .01

^*Not mutually exclusive.

Table 2.

Characteristics of Children and Households, by Frequency of Shared Reading, Singing, or Storytelling (N = 17,545)

Variable	Shared Reading, Singing, or Storytelling 0–3 days/week N = 3844	Shared Reading, Singing, or Storytelling 4–6 days/week N = 3351	Shared Reading, Singing, or Storytelling Daily N = 10,350	P
ACE exposure
None	0.60 (0.56, 0.64)	0.71 (0.67, 0.74)	0.77 (0.75, 0.79)	< .01
Any	0.40 (0.36, 0.44)	0.29 (0.26, 0.33)	0.23 (0.21,0.25)	< .01
1–3 ACEs	0.37 (0.33, 0.41)	0.26 (0.23, 0.30)	0.20 (0.19, 0.22)	< .01
4+ ACEs	0.03 (0.02, 0.04)	0.03 (0.02, 0.04)	0.03 (0.02, 0.04)	.89
Age (years)
3	0.30 (0.26, 0.34)	0.31 (0.28, 0.35)	0.37 (0.35, 0.39)	< .01
4	0.35 (0.31, 0.39)	0.35 (0.31, 0.39)	0.34 (0.32, 0.36)	.77
5	0.35 (0.32, 0.39)	0.34 (0.30, 0.37)	0.29 (0.27, 0.31)	.08
Sex
Female	0.48 (0.43, 0.52)	0.50 (0.46, 0.54)	0.49 (0.47, 0.51)	.69
Male	0.52 (0.48, 0.57)	0.50 (0.46, 0.54)	0.51 (0.49, 0.53)	.69
Race and ethnicity
Non-Hispanic White	0.33 (0.30, 0.36)	0.48 (0.44, 0.51)	0.61 (0.59, 0.63)	< .01
Non-Hispanic Black	0.18 (0.15, 0.21)	0.13 (0.11, 0.16)	0.09 (0.08, 0.11)	< .01
Hispanic or Latino	0.38 (0.34, 0.43)	0.26 (0.22, 0.31)	0.18 (0.16, 0.21)	< .01
None of the above	0.11 (0.09, 0.13)	0.13 (0.10, 0.16)	0.12 (0.10, 0.13)	.53
Child SHCN	0.10 (0.08, 0.12)	0.14 (0.12, 0.17)	0.15 (0.13, 0.17)	< .01
Child health
Excellent/very good	0.91 (0.88, 0.93)	0.93 (0.90, 0.95)	0.95 (0.94, 0.96)	< .01
Good/fair/poor	0.09 (0.07, 0.12)	0.07 (0.05, 0.10)	0.05 (0.04, 0.06)	< .01
Household language
English	0.75 (0.70, 0.79)	0.88 (0.85, 0.91)	0.92 (0.91, 0.93)	< .01
Any other	0.25 (0.21, 0.30)	0.12 (0.09, 0.15)	0.08 (0.07, 0.09)	< .01
Caregiver education
High school or less	0.35 (0.31, 0.40)	0.18 (0.14, 0.22)	0.13 (0.11, 0.15)	< .01
Some college	0.31 (0.27, 0.34)	0.24 (0.21, 0.27)	0.20 (0.18, 0.22)	< .01
College degree	0.34 (0.31, 0.38)	0.59 (0.55, 0.62)	0.67 (0.65, 0.69)	< .01
Caregiver employment
Full-time	0.83 (0.80, 0.86)	0.88 (0.85, 0.91)	0.89 (0.87, 0.91)	< .01
Part-time	0.06 (0.05, 0.08)	0.04 (0.03, 0.05)	0.05 (0.04, 0.06)	.11
Not employed	0.11 (0.08, 0.14)	0.08 (0.06, 0.11)	0.06 (0.05, 0.08)	.01
Household income (%FPL)
< 100%	0.29 (0.24, 0.33)	0.17 (0.14, 0.21)	0.13 (0.11, 0.14)	< .01
100–199%	0.25 (0.22, 0.29)	0.20 (0.16, 0.23)	0.17 (0.15, 0.19)	< .01
200–399%	0.29 (0.25, 0.32)	0.30 (0.26, 0.33)	0.29 (0.27, 0.31)	.88
400% or greater	0.17 (0.14, 0.20)	0.33 (0.30, 0.37)	0.42 (0.39, 0.44)	< .01
Food insecurity	0.41 (0.37, 0.45)	0.21 (0.18, 0.24)	0.19 (0.17, 0.21)	< .01
Household structure
Two parents	0.68 (0.64, 0.71)	0.72 (0.68, 0.76)	0.82 (0.81, 0.84)	< .01
Single mother	0.22 (0.19, 0.26)	0.19 (0.16, 0.23)	0.12 (0.11, 0.14)	< .01
Any other	0.10 (0.08, 0.13)	0.08 (0.06, 0.11)	0.05 (0.05, 0.06)	< .01
Caregiver physical health
Excellent	0.21 (0.18, 0.25)	0.19 (0.16, 0.22)	0.23 (0.22, 0.25)	.05
Very good	0.34 (0.30, 0.38)	0.45 (0.41, 0.48)	0.42 (0.39, 0.44)	< .01
Good	0.31 (0.27, 0.35)	0.28 (0.25, 0.32)	0.28 (0.26, 0.30)	.37
Fair	0.12 (0.09, 0.15)	0.07 (0.05, 0.09)	0.07 (0.05, 0.08)	.07
Poor	0.03 (0.02, 0.05)	0.01 (0.01, 0.03)	0.01 (0.005, 0.01)	.02
Caregiver mental health
Excellent	0.29 (0.25, 0.33)	0.25 (0.22, 0.29)	0.27 (0.25, 0.29)	.38
Very good	0.33 (0.30, 0.37)	0.40 (0.37, 0.44)	0.38 (0.36, 0.40)	.03
Good	0.25 (0.22, 0.28)	0.27 (0.23, 0.30)	0.24 (0.23, 0.26)	.55
Fair	0.11 (0.08, 0.14)	0.06 (0.05, 0.08)	0.09 (0.07, 0.10)	< .01
Poor	0.02 (0.01, 0.03)	0.01 (0.01, 0.02)	0.01 (0.01, 0.02)	.79
Caregiver has someone to turn to for help with caring for child	0.68 (0.64, 0.72)	0.84 (0.80, 0.87)	0.85 (0.83, 0.87)	< .01
Child’s daily screen time
Two hours or less	0.60 (0.56, 0.64)	0.68 (0.64, 0.72)	0.76 (0.74, 0.78)	< .01
More than 2 h	0.40 (0.36, 0.44)	0.32 (0.28, 0.36)	0.24 (0.22, 0.26)	< .01
Child has bedtime routine
Always or usually	0.80 (0.76, 0.83)	0.88 (0.85, 0.90)	0.92 (0.90, 0.93)	< .01
Sometimes	0.14 (0.11, 0.18)	0.09 (0.07, 0.12)	0.05 (0.05, 0.06)	< .01
Rarely or never	0.06 (0.04, 0.09)	0.03 (0.02, 0.05)	0.03 (0.02, 0.04)	.03
	0.58 (0.54, 0.62)	0.67 (0.63, 0.71)	0.69 (0.67, 0.71)	< .01
Access to library in neighborhood
Access to community center in neighborhood	0.41 (0.37, 0.45)	0.45 (0.41, 0.49)	0.49 (0.47, 0.51)	.06

ACE indicates adverse childhood experience; FPL, Federal poverty level; and SHCN, special health care needs.

The multivariable ordinal logistic regression model for the primary outcome of SR is shown in Table 3. Among children not exposed to ACEs, everyday exposure to early literacy developmental activities was associated with 56% greater odds of higher SR (being in the next higher category of SR on the 0–4 scale; odds ratio [OR]: 1.56; 95% confidence interval [CI]: 1.29, 1.88; P < .01). The interaction term between daily shared reading/singing/storytelling and exposure to ACEs was not statistically significant (P = .78), implying that among children exposed to ACEs, shared reading/singing/storytelling was still associated with significantly higher odds of improved SR (OR: 1.50; 95% CI: 1.06, 2.13; P = .02). Child SHCN or poor health, lower caregiver educational attainment, presence of food insecurity, rarely having a bedtime routine, and more than 2 hours of screen time were all associated with lower SR.

Table 3.

Multivariable Ordinal Logistic Regression of School Readiness (Range: 0–4; N = 17,545)

Variable	aOR	95% CI
Shared reading, singing, or storytelling frequency†
0–3 days	Ref.
4–6 days	1.21	0.96, 1.53
Daily	1.56***	1.29, 1.88
ACE exposure (any vs none)‡	1.00	0.71, 1.42
ACEs × early literacy developmental activities§
4–6 days × any ACEs	0.93	0.57, 1.52
Daily × any ACEs	0.97	0.65, 1.43
Age (years)
3	Ref.	Ref.
4	1.17*	1.01, 1.36
5	1.64***	1.37, 1.96
Sex
Female	Ref.	Ref.
Male	0.61***	0.53, 0.70
Race and ethnicity
Non-Hispanic White	Ref.	Ref.
Non-Hispanic Black	1.47**	1.15, 1.89
Hispanic or Latino	0.97	0.78, 1.21
None of the above	1.04	0.86, 1.27
Child SHCN	0.32***	0.26, 0.39
Child health
Excellent/very good	Ref.	Ref.
Good/fair/poor	0.22***	0.16, 0.31
Household language
English	Ref.	Ref.
Any other	0.94	0.71, 1.24
Caregiver education
High school or less	Ref.	Ref.
Some college	1.33*	1.05, 1.67
College degree	1.43***	1.15, 1.79
Caregiver employment
Full-time	Ref.	Ref.
Part-time	0.87	0.63, 1.20
Not employed	1.00	0.71, 1.40
Household income (%FPL)
< 100%	Ref.	Ref.
100–199%	1.13	0.84, 1.53
200–399%	1.25	0.95, 1.64
400% or greater	1.22	0.92, 1.61
Food insecurity	0.77**	0.64, 0.93
Household structure
Two parents	Ref.	Ref.
Single mother	0.95	0.72, 1.25
Any other	0.86	0.63, 1.15
Caregiver physical health
Excellent	Ref.	Ref.
Very good	0.86	0.70, 1.07
Good	0.69**	0.53, 0.91
Fair	0.63*	0.42, 0.94
Poor	0.61	0.23, 1.62
Caregiver mental health
Excellent	Ref.	Ref.
Very good	0.72**	0.57, 0.89
Good	0.56***	0.43, 0.75
Fair	0.59**	0.41,0.84
Poor	0.80	0.33, 1.94
Caregiver has someone to turn to for help with caring for child	0.86	0.70, 1.06
Child’s daily screen time
Two hours or less	Ref.	Ref.
More than 2 h	0.71***	0.60, 0.83
Child has bedtime routine
Always or usually	Ref.	Ref.
Sometimes	0.46***	0.34, 0.61
Rarely or never	0.24***	0.13, 0.45
Access to library in neighborhood	0.86	0.73, 1.02
Access to community center in neighborhood	1.01	0.86, 1.18

ACE indicates adverse childhood experience; aOR, adjusted odds ratio; CI, confidence interval; FPL, Federal poverty level; Ref., reference; and SHCN, special health care needs.

^†Estimated associations of shared reading/singing/storytelling with school readiness among children not exposed to ACEs.

^‡Estimated association of ACE exposure with school readiness among children in the lowest category of shared reading/singing/storytelling frequency.

^§Modification of the association between early literacy developmental activities and school readiness for children who have been exposed to ACEs. Multiplying the main effect OR for each shared reading/singing/storytelling category by the corresponding interaction OR yields the association of shared reading/singing/storytelling with school readiness among children exposed to ACEs.

^*P ≤ .05.

^**P ≤ .01.

^***P ≤ .001.

Multivariable Poisson regression models estimating the association of shared reading/singing/storytelling with individual domains of SR are summarized in Table 4. Among children not exposed to ACEs, daily early literacy developmental activities were associated with improved SR only in the cognitive development and self-regulation domains. As in the primary analysis, there was no evidence that exposure to ACEs significantly moderated the association of early literacy developmental activities with any domain of SR. For example, daily shared reading/singing/storytelling increased the likelihood of being on track in the cognitive development domain by 28% among children without ACE exposure (RR: 1.28; 95% CI: 1.14, 1.45; P < .01), and by 38% among children exposed to ACEs (RR: 1.38; 95% CI: 1.13, 1.68; P = .02). Likewise, daily early literacy developmental activities increased the likelihood of being on track in the self-regulation domain by 16% among children without ACE exposure (RR: 1.16; 95% CI: 1.07, 1.26; P = .01), and by 16% among children exposed to ACEs (RR: 1.16; 95% CI: 0.99, 1.34; P = .06), although this association was not statistically significant in the group exposed to ACEs. Our findings were consistent when stratifying ACE exposure further as none, 1–3, or 4+ ACEs (Appendix Table 3).

Table 4.

Summary of Multivariable Poisson Regressions of Each Domain of School Readiness (N = 17,545)

Variable†	Cognitive Development aRR (95% CI)	Self-Regulation aRR (95% CI)	Social/Emotional Development aRR (95% CI)	Health aRR (95% CI)
Shared reading, singing, or storytelling frequency‡
0–3 days	Ref.	Ref.	Ref.	Ref.
4–6 days	1.17 (1.01, 1.34)*	1.06 (0.95, 1.17)	1.02 (0.95, 1.10)	1.00 (0.95, 1.04)
Daily	1.28 (1.14, 1.45)***	1.16 (1.07, 1.26)**	1.03 (0.97, 1.10)	1.00 (0.96, 1.03)
ACE exposure (any vs none)§	0.99 (0.80, 1.22)	0.96 (0.82, 1.13)	1.05 (0.94, 1.17)	0.97 (0.89, 1.06)
ACEs × early literacy developmental activities††
4–6 days × any ACEs	0.97 (0.74, 1.27)	1.05 (0.85, 1.28)	0.89 (0.76, 1.05)	1.02 (0.90, 1.15)
Daily × any ACEs	1.07 (0.85, 1.35)	1.00 (0.84, 1.19)	0.94 (0.83, 1.07)	1.02 (0.93, 1.13)

ACE indicates adverse childhood experience; aRR, adjusted risk ratio; CI, confidence interval; and Ref., reference.

^†Each model is adjusted for all covariates shown in Table 3.

^§Estimated association of ACE exposure with school readiness among children in the lowest category of shared reading/singing/storytelling frequency.

^††Modification of the association between early literacy developmental activities and school readiness for children who have been exposed to ACEs. Multiplying the main effect RR for each shared reading/singing/storytelling category by the corresponding interaction OR yields the association of shared reading/singing/storytelling with school readiness among children exposed to ACEs.

^‡Estimated associations of shared reading/singing/storytelling with school readiness among children not exposed to ACEs.

^*P ≤ .05.

^**P ≤ .01.

^***P ≤ .001.

DISCUSSION

This study provides important insights into the relationship between SR, early literacy developmental activities, and exposure to ACEs. We assessed whether the association of shared reading, storytelling, and singing with SR among children ages 3–5 was moderated by children’s exposure to ACEs. Counter to our hypothesis, children who had daily early literacy developmental activities, regardless of exposure to ACEs, exhibited higher levels of SR. Interestingly our study indicates that it is the frequency of daily early literacy developmental activities that is most significant, likely because it is incorporated into a routine and more likely to occur every day. These findings have direct implications for primary care, public health, and educational sectors. Research and policy changes need to continue to find ways to encourage early literacy developmental activities within the home and reduce obstacles that families face around these activities.

One striking finding of this study was the relationship between early literacy developmental activities and self-regulation in children. Self-regulation is one of the critical foundational behavioral skills children need to learn in the early preschool years to be able to thrive in kindergarten and beyond.²³ Our study found that children who were read to/sung to/told stories consistently have a higher likelihood of being on track within this domain, regardless of exposure to ACEs. Previous single-site work has also shown the importance specifically of shared reading on social-emotional functioning in children.⁸ Our nationally representative results suggest that early literacy developmental activities may help mitigate the effects of ACEs exposure. Children who endure ACEs have challenges with emotional regulation which can pose difficulty in school, resulting in challenges in learning and increased rates of suspensions and expulsions.^13,24 We theorize that shared reading/singing/storytelling may mitigate the effect of ACEs exposure through building relational health. Relational health is the quality of the early relationship and interactions between a child and their caregiver, which is pivotal to the socioemotional, cognitive, and neurobiological development of a child.^9,25 Relational health has also been cited by the American Academy of Pediatrics to be both the “treatment for and mitigation of childhood toxic stress”.²⁶ Shared reading/singing/storytelling build relational health, and may likely mitigate the effect of ACEs exposures.⁹ Recent research also suggests that children with more positive early childhood experiences, of which relational health plays a part, are more ready to learn which correlates with the findings of this study.²⁷ More research needs to expand on the potential role shared reading/singing/storytelling plays in building relationships and relational health.

This study also demonstrates the importance of the home literacy environment (HLE) and the neighborhood literacy environment (NLE) in facilitating early literacy developmental activities and SR. The HLE consists of access to books, parental attitudes toward reading, and literacy-centered routines.²⁸ We found that factors that contribute to the HLE (ie, routines with shared reading, lower screen time) were associated with more frequent shared reading/singing/storytelling. The NLE is defined as a child’s access to print materials, especially books, and pro-literacy programs within their neighborhood.²⁹ The NLE is less robust in areas of economic disadvantage, creating “book deserts” and barriers for caregivers to read to their children.^29,30 We found that the NLE, such as access to a library and community center, was associated with more frequent early literacy developmental activities. Notable interventions such as Reach Out and Read (ROR), which provides children’s books at pediatric well-child visits and anticipatory guidance around book sharing³¹; and Imagination Library, which is a book distribution program that mails books to children’s homes from birth to 5 years,³² improve the HLE. However, further investment is needed to bring books to areas that have experienced disinvestment and high poverty. Future research should also expand upon interventions within the NLE to increase access to books, removing that barrier for families.

While this study demonstrates the benefits of shared reading/singing/storytelling for SR, it also sheds light on barriers to early literacy developmental activities including lower caregiver education and poverty. Previous literature has demonstrated similar findings regarding low parental education and shared reading, where parents with lower educational attainment reported difficulty with reading as well as describing this activity as uncomfortable or not enjoyable.³³ If a parent has a lower literacy level, they may be less likely to engage with books and utilize shared reading at home with their children. In the US, 54% of adults lack literacy proficiency, highlighting the need to assist adults with literacy so that they can feel comfortable reading to their children.³⁴ Additionally, our study showed that poverty is a risk factor associated with decreased early literacy developmental activities. Parents in high-poverty homes are less likely to read to their children, likely secondary to the stress and adversities associated with poverty. Justice et al found that poverty led to caregiver distress and depression which negatively affected children’s language development.³⁵ Our results highlight the necessity for additional interventions to both increase shared reading, singing, and storytelling, and decrease barriers families face around these activities. In the clinical setting, there may be opportunities to better link the provision of books with addressing additional household social needs related to food access and other unmet basic needs which may pose a competing priority compared to engaging in shared reading.²¹ On a national level, policy measures to reduce poverty include raising the federal minimum wage as well as expanding access to the Earned Income Tax Credit, child care subsidies, and nutrition assistance programs.³⁶ These measures may have downstream effects on early childhood by providing economic stability which could alleviate sources of parental stress and competing priorities, thus providing possible additional opportunities to increase early literacy developmental activities which can improve language outcomes for their child.

The importance of language interactions outside of shared reading, that is, singing and telling stories are important to highlight. Singing and storytelling and their impact on language development and SR are not as commonly studied as compared to shared reading. It is important to note the contributions of singing and telling stories as shared reading is often a valued practice of non-Western middle-class families.^37–39 Including oral storytelling and singing, along with shared reading, as interventions for parents to help their children prepare for school could be a more culturally appropriate method. To improve families’ comfort with shared reading pediatric clinicians can include modeling using the ROR framework during pediatric well-child visits,³¹ to demonstrate ways to use books to read as well as a source of storytelling and singing.

The conclusions from our study are subject to certain limitations. As with any survey study, caregiver reports may introduce recall bias, as well as associated social desirability and reporting biases. Additionally, the response rate for the survey was 40.3%, which may introduce nonresponse bias. While we sought to include the multitude of ACE exposures, the survey did not directly ask about child abuse or neglect, so it is unclear how this omission would have impacted our results. Despite these limitations, our study reveals additional data on the value of early literacy developmental activities for enhancing SR, especially among those who have endured ACEs and are in particular need of several avenues for relational health that can build resiliency and buffer against adversity. Additionally, our findings are suggestive of the importance of enriching the literacy environments of children both in their home and their neighborhood.

In sum, our analysis finds that while ACEs are associated with lower exposure to early literacy developmental activities, exposure to ACEs does not weaken the positive association between early literacy developmental activities and SR (particularly in the self-regulation and cognitive skills domains). Barriers still exist within both the home and the neighborhood that affect caregivers’ ability to engage in early literacy developmental activities, and until those barriers are removed, the benefits of shared reading, singing, and storytelling will not be able to be equitably obtained for all children. Further research can focus on the specific ways in which ACE exposure affects the ability to engage in early literacy developmental activities. Our results highlight the necessity for additional interventions to both increase shared reading/singing/storytelling and decrease barriers families face around early literacy developmental activities. Addressing poverty and its many downstream effects across the lifespan is complex. Policies and interventions that support caregivers in meeting basic needs for their households may have positive downstream effects in creating the opportunity to build nurturing relationships through mechanisms such as shared reading to prepare young children to thrive in school and beyond.

WHAT’S NEW.

Early literacy activities were associated with improved school readiness in children exposed to adverse childhood experiences (ACEs) and those not, though fewer children with ACEs received early literacy activities. Early literacy activities may act as a buffer to ACEs.