Reflections: Early Relational Health and Reach Out and Read™ Next Chapter

Reach Out and Read™ (ROR), an evidence-based approach to promoting early child development within pediatrics, celebrates its 30th anniversary this year. With a vision to improve the parent-child relationship, child development and education readiness, pediatricians, Barry Zuckerman and Robert Needleman, and early education educator, Kathleen Fitzgerald-Rice, founded ROR at Boston City Hospital in 1989. Now, the approach is widely adopted as a model that brings anticipatory guidance to parents for the importance of reading aloud, distributes developmentally and culturally appropriate books at well-child visits, and brings careful attention to strengthening the parent-child relationship as core to literacy and future wellbeing.  With over 15 peer-reviewed studies, ROR has documented the association between ROR and positive changes in parental attitudes toward reading aloud, the frequency of which parents read aloud, increased attendance at well-child visits, and child language development. As a result, ROR has become the nation’s premier literacy promotion model within pediatric primary care and is taught to the next generation of clinicians at most of the nation’s pediatric residency training programs. The 3rd Edition of Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents cites ROR as “an important and successful practice-based intervention for healthcare professionals to consider, especially those serving low-income populations.” And the recent American Academy of Pediatrics (AAP) Policy statement on school readiness cites the Reach Out and Read program as “the most studied and scaled primary prevention program” seeking “to prevent gaps in readiness before they occur.”

Over the years, as ROR has become recognized as an essential component of the advanced medical home, ROR has developed a networked infrastructure of more than 30 regional ROR affiliates and 6,400 clinical sites with activities in all 50 states. This spread and scale now serves nearly 4.8 million children annually, half of whom are from under-resourced families. The original vision of the ROR founders to strengthen the parent-child relationship, child development, and literacy, by promoting the shared experience of reading in the home, has become a standard of care in pediatric primary healthcare. Thus, the ROR community has great cause to celebrate this success with its founders and its vast ROR network of child health providers. And now as ROR looks to its future, it is seeking innovations, expansion, and greater impact for its next chapter.

On November 6, 2019, the ROR National Center, supported by the Robert Wood Johnson Foundation, convened over 100 leaders in early childhood development, including champions and partners, visionaries, and luminaries, in primary care, pediatric training, and child health transformation, to its Reach Out and Read Next Chapter Forum. The purpose of this gathering at the Boston City Library was to celebrate, connect, and inspire a next chapter of development and innovation for ROR. The gathering brought joyful reunions, a collective enthusiasm, and widespread interest to advance ROR beyond its foundational history. convening launched the ROR Next Chapter, which aims to “maximize the potential of pediatric primary care to support the positive interactions that foster healthy development during the critical early years of a child’s life.” The forum aim to elevate the ROR network’s  new frontiers and activities that might further promote healthy, attuned, and positive parent-child interactions, guided by the continued march of the science of early brain and child development (EBCD), the primacy of early relational experiences, and the protection from trauma and adversity by buffering relationships. The keynote speaker, Andrew Garner, MD PhD, who is a practicing pediatrician, addressed a public health approach to harness the power of EBCD, relational and community supports to transform the family-centered medical home in partnership with parents, and communities for improved child and family wellbeing.5  Dr. Garner highlighted that the ROR Next Chapter efforts should encourage, celebrate, and support the strengths and assets of all families in the loving relationships as well as the hope they bring to their young children. In pediatric primary care, we are witnesses to the truth that future health development and resiliency lies in the relationships happening in the early years of a child’s life.


I was so delighted to be invited to follow Dr.Garner to a second framing presentation to the Forum, titled,”Early Relational Health: Foundations for Health, Early Learning and Future Wellbeing.” This venue allowed me to build on Dr Garner’s scientific presentation and to discuss how we can further elevate early relational health (ERH) in pediatric primary care and build on the history and networks of ROR to advance ERH within a transforming medical home. I discussed what we mean by ERH, gave video examples of what it looks like, and offered current evidence-based practices that already promote ERH (e.g. ROR, Video Interaction Project, Promoting First Relationships – Pediatrics, Healthy Steps, DULCE, etc.). I also proposed a vision of partnering with those ready communities with place-based early childhood systems to champion a scaling and saturating strategy of ROR/ERH, as an “all-in” innovation, for the child health sector.

Formal and information conversations continued throughout the day about emerging opportunities to advance ERH, including topics as child health practice transformation, early childhood system development, family engagement and equity, and innovations driven by the Pediatrics Supporting Parents funding collaborative. In a round-up at the end of the day, David Lawrence reminded us of the importance of narrative, language, and messaging to advance any public campaign, noting that the public would have no idea what we mean by “relational health.” This perspective resonates with some of our first findings from the focus groups convened in our Framework Institute ERH study, where a number of parents and ECE providers reported that they did not know that child health providers are committed to supporting and promoting strong parent-child interactions and relationships. This discovery brings a notable opportunity to educate our parents and communities that pediatric care providers, who are increasingly focused on strengthening and promoting strong and healthy parent-child relationships, in order to enhance social-emotional development and wellbeing.  This might offer a very important communication strategy for ROR Next Chapter, especially in its effort to expand its impact on both child health practice transformation and ERH.

And finally, at a gathering of the ROR network the next day, ROR co-founder Robert Needleman presented his work on developing best practices for promoting effective ERH as part of the ROR model, the MOC approach: Modeling of positive interactions through shared book reading, followed by Observation and Coaching parents from a strength-based perspective as they are encouraged to do the same. Dr. Needleman also suggested the use of video for training, study, and feedback to residents learning the MOC approach with ROR.

As I have reflected on the Forum experience, I was reminded of 2018 AAP Past President Colleen Kraft’s message that “relationships are a vital sign in pediatrics.” ROR is ready to bring the training, observation skills, practices, and elevation of the vital signs of ERH. I believe it will lead efforts across its vast network to make ERH/ROR a universal and standard practice to address the growing epidemic of social-emotional and school readiness weaknesses and guide child health practice transformation in essential new directions. I commend the leaders of the ROR network for their bold and visionary efforts and am eager to see what else will unfold.



  1. Zuckerman B, Khandekar A. Reach Out and Read: evidence based approach to promoting early child development. Curr Opin Pediatr. 2010;22(4):539-544.
  2. Needleman RD, Dreyer BP, Klass P, Mendelsohn AL. Attendance at Well-Child Visits After Reach Out and Read. Clinical Pediatrics. 2019;58(3):282-287.
  3. Williams PG, Lerner MA. School Readiness. Pediatrics. 2019;144(2):e20191766.
  4. Childhood CoE. Literacy Promotion: An Essential Component of Primary Care Pediatric Practice. Pediatrics. 2014;134(2).
  5. Garner AS. Thinking Developmentally: The Next Evolution in Models of Health. Journal of Developmental & Behavioral Pediatrics. 2016;37(7):579-584.

You can also find David Willis’s presentation, “Early Relational Health: Foundations for Health, Early Learning, and Future Wellbeing,” here. For questions or more information on this topic, please reach out to the author at