Boston Children’s Hospital Early Literacy Screener System

Reading disabilities, including dyslexia, are typically diagnosed after the most effective window for intervention has passed, and after a student has consistently failed to read. Previous studies have shown that it is possible to identify children as early as preschool age who are at risk of later reading difficulty. The Boston Children's Hospital Early Literacy Screener platform addresses this early screening opportunity. The screener is a 20-minute digital, gamified, self-administered app of games that assesses early predictors of later literacy success. The app further provides individualized risk profiles and evidence-based resources for educators, parents and clinicians to address underdeveloped skills. By creating an accessible screener that can be administered to pre-reading children, we can detect risk of reading difficulty earlier, to reduce the debilitating secondary consequences of reading impairments for children’s academic, psychosocial, and economic outcomes. Most importantly, we can help more children discover the joys of reading.

Reading is a fundamental skill that provides the foundation for academic and vocational success. Every child has the right to learn to read well, but in many countries, there are unacceptably low levels of literacy. In 2017, 66% of all U.S. fourth graders scored below proficiency in reading. This statistic is even more staggering among children from low socioeconomic backgrounds, with 78% of these students scoring below proficiency. Self-perception of reading failure and negative response from others leave children with literacy challenges vulnerable to feelings of shame, depression, and low self-esteem. Struggling readers are less likely to complete high school or pursue higher education and are at an increased risk of entering the juvenile justice system. Children’s reading disabilities are typically identified after they have already fallen far behind their peers in reading; by then, the achievement gap is nearly insurmountable and the most effective window for intervention has closed. Our app-based screener will identify children at risk for reading difficulties at ages 4-6, before they start failing. Our resource platform will further provide educators and parents with resources that enable evidence-based responses to screening and ensure adequate early intervention. 

Reading difficulties can have many different etiologies. Our app and accompanying platform serves all children exhibiting low early literacy milestones. These children are considered at-risk for developing reading difficulties. While struggling readers can be found across all children, children from low socio-economic backgrounds and second language learners are particularly vulnerable. Children ages 4-6 can be screened using our developed tool and, therefore, early evidence-based intervention (as part of our solution) can be delivered before children fall behind and show signs of anxiety, depression or low self-esteem, which is often seen in struggling readers. Our system is designed in a way that other languages can be easily added, which underlines its large potential for global scaling and its potential to address bilingual children (e.g. recent immigrants). Our team conducted many preliminary interviews with educators, reading specialists, parents, and other key players who work directly with the population we serve, to learn about how our screener can be best delivered and scaled. Professor Gaab is an expert in the science of reading and has a wide network in the field of reading development, including language-based learning disabilities such as dyslexia. 

The Boston Children's Early Literacy Screener, developed by Dr. Nadine Gaab and the Innovation & Digital Health Accelerator at Boston Children’s Hospital, in partnership with Florida State University, is a gamified, mobile iOS-based screening app that children, as young as four years old, can self-administer. The "app" is hosted in a HIPAA cloud compliant environment that only has access to registered users. It includes a series of games for six early indicators of later reading difficulties. A child completes the screener at their school, pediatrician’s office, library, etc. The "offline-to-online" capability of the app allows users to use it during an offline mode and then sync the offline data with the server upon internet connection in a secure and encrypted manner. After a child completes the screening games, the app creates a report (a web-based application tool) outlining which measures the child scored below the risk cut-off on, indicating a heightened risk for developing reading difficulties. If screened in a school setting, teachers and school administrators can utilize a classroom, school-wide, or district-wide dashboard to review the performance of all students. Recommendations for follow-up resources are also provided in our Evidence-Based Response to Screening (EBRS) Platform to address the specific skill deficits of the child. These resources — such as evidence-based and expert-vetted curricula, referrals to specialists, professional development, apps, and books — will assist professionals to help children build their early pre-literacy and literacy skills. The goal is for this app to be an easy, quick, accessible, and child-centered way to detect risk for later reading difficulty prior to formal reading instruction. The app will provide parents, teachers, specialists, and pediatricians with a tool they need to improve the detection of literacy deficits. By allowing research-validated screening at an age where intervention is most effective at preventing reading disabilities, we can give struggling children the best possible chance at becoming successful readers. The app is currently developed in English, but we are working on incorporating other languages so that the solution can be scaled beyond English speaking countries and also serve bilingual children. In summary, this solution will have a measurable positive impact on the many children who struggle with reading worldwide, is scalable to other geographical regions, and will ensure greater access to literacy resources. This work will maximize children’s intellectual potential, stimulate their literacy development, and allow children to experience the joy of learning to read.

Our early literacy screener is an improvement to those currently on the market, offering a refined approach to identifying children at-risk. Our team analyzed over 100 literacy and language screeners and assessments (mostly paper-based) to examine the current state of the field and to determine where the needs of our population and those who serve them are not addressed. Our screener offers an opportunity for children to be screened as early as preschool, potentially identifying risk of reading difficulty before reading instruction begins. There are very few screeners on the market targeted at this age range, and of those, there are none that are digitalized, gamified, engaging, and comprehensive enough to be most effective. If our screener is implemented globally, more children will be identified as at risk for later reading difficulty at a time where early intervention will be most beneficial to them. In addition, most screeners on the market leave teachers with a list of identified children, but with no specific resources that address the students' needs. The Boston Early Literacy Screener incorporates an Evidence-Based Response to Screening platform, in which a teacher is given resources containing research-based and expert-vetted curricula, teaching methods, books, apps, games, and more that would address the skill deficits of their students. This is the key to effectively changing the literacy outcomes of at-risk children to maximize their true potential. 

The Boston Children's Early Literacy Screener is a two-part solution:    

1. The "app" is a iOs App, that is hosted in a HIPAA cloud compliant environment that only has access to registered users. The app is capable of running in an offline-to-online mode.

Data captured during an offline mode is stored in a secure and encrypted manner until it is synced with online servers. The screener will implement algorithms to deliver adaptive tests that follow the Item Reponse Theory, in order to give children items that are best suited to evaluate their skill level.  Because of the adaptive and automatically scored nature of the screener, along with its child-friendly and gamified basis, the screener is self-adminstered by the child. The ability for students to independently work through the screener is an innovative use of tablet technology. 

2. The dashboard, a web-based application to monitor a child's progress through the screener by seeing the results in real-time.

Because our screener uses tablet technology, we are able to provide users with a dashboard in which they can view and navigate through the screening results of their students in real-time, on individual, classroom, and school-wide levels. Teachers and administrators can find out detailed information on specific tests, skills, or the whole screening battery and design group-based or individualized early intervention strategies. 

Our screener has the potential to move current educational systems for literacy from a deficit-driven to a preventive approach. The six components implemented in the screener are based on various national and international research studies focusing on the Science of Reading. More specifically, the early literacy skills assessed in the screener have all been shown to be reliable early predictors of later reading success. Assessing these research-based early literacy skills to determine risk for subsequent reading difficulties will be the most effective way for maximizing positive impact for at-risk students. According to studies of early reading interventions, the most optimal time to address deficits in preliteracy skills is in the first two years of reading instruction. A meta-analysis has shown that when at-risk children receive early evidence-based intervention, 50-90% of these children reach average reading abilities. Our screener will allow for effective intervention, as children will be able to be identified before this window has passed, and those in charge of their reading instruction will be pointed in the right direction to research-proven and expert-vetted means of addressing deficits through our EBRS platform. Preliminary market interviews indicate that our screener is an excellent fit to address the needs of educators for identifying at-risk students. It provides teachers with an easy, cost-effective, self-adminstered screener that does not take significant classroom time away, and also provides teachers directly with the EBRS resources essential for student success. 

Currently: In Fall 2019, we are aiming to serve 80-100 students through a beta school program in addition to 350 students US nationwide who will be part of the second validation phase.

1 year: In one year, we hope to be in use with over 30,000 students. 

5 years: We hope to reach over 100,000 students.

Over the next year, our goal is two-fold: establish predictive validity and classroom-usability of the screener. We are preparing for a national validation study that will establish predictive validity of the screener from the beginning of the kindergarten school year to end-of-year reading outcomes. We are also conducting a beta launch in schools, allowing teachers to implement the screener in their classrooms and give us valuable feedback on how we can improve our screener and dashboard before full-scale rollout. In the next five years, we hope to have our screener used in schools across the country, effectively screening and intervening for reading risk in pre-reading children, reducing the amount of children struggling to learn to read by the millions. To expand our impact even further, we aim to create multilingual and bilingual editions of the screener, allowing for successful screening and intervening of millions more children who desperately need it.

One large obstacle to overcome is the staffing model for selling directly to schools. School sales are typically personnel-intensive and result in extremely long lead times. We are going to continue diligence on the best distribution model to ensure a seamless sales cycle. 

Another barrier is changing the attitude toward early intervention in schools. We want to ensure that teachers feel equipped to take action with early literacy screening results. By encouraging access to the screener and the Evidence-Based Response to Screening Platform, teachers will be able to understand the needs of their students and tailor their curriculum appropriately. 

Currently, the screener is designed for monolingual English speakers. The ability to conduct and analyze research in other languages, such as among Spanish speakers, and determine how literacy challenges are presented in this population will be immensely important as the population demographics of the United States continue to change. Furthermore, implementing our research conducted in Brazilian -Portuguese (in Northern Brazil) into the current platform. 

We are in active conversations around distribution options and plan to solidify the appropriate method in the next few months. 

By arming the teachers with Evidence Based Response to Screening as a follow up to screener results we plan to provide wraparound support so no general education teachers feel unprepared. The training we are developing on the screener and follow on supports will help ensure that teachers are excited about utilizing the screener rather than fearful.

We have one study underway to understand how English as a Second language learners should be screened (in their native language or English or both) and are seeking funding to continue these efforts. A lot of the potential funders we have spoken with believe that this is an important avenue and we are confident in successful funding asks. 

We have an additional study underway in Natal, Brazil that examines which early literacy precursors are most predictive of subsequent reading outcome in Brazilian-Portuguese. These results will be implemented into the App and we will further design EBRS for Brazilian-Portuguese speakers. 

Our solution team is comprised of research and innovation teams within Boston Children’s Hospital (BCH), an affiliate of Harvard Medical School, pairing scientific research with technology and business strategy. As one of the largest pediatric medical centers in the United States, BCH offers comprehensive health care services for children of all ages. The research enterprise at Boston Children’s Hospital is the largest of any pediatric center worldwide. Dr. Nadine Gaab, the principal investigator of the Gaab Lab, within the Laboratories of Cognitive Neuroscience in the Division of Developmental Medicine at BCH, offers her expertise in the field of cognitive neuroscience and early literacy research to develop the content of the app. Our innovation team, the Innovation and Digital Health Accelerator (IDHA) at BCH, combines data, clinical expertise, and health care technology development experience to transform and improve pediatric care. Through our partnership with FSU, we have collaborated with Dr. Yaacov Petscher, an expert on the deign of psychometric reading assessments and screeners from Florida State University. Our interdisciplinary solution team, with expertise in software development, data analytics, clinical care and early literacy research, work together to accelerate early literacy screening. 

Our interdisciplinary solution team is made of full-time, part-time, and contracted staff at BCH. 

The Innovation and Digital Health Accelerator has supplied 6-8 people as
part of this project throughout its creation and development. Those on the project are full-time employees of the hospital but are part of other efforts within the department. 

Our team incorporates experts from the research, business, and technology fields from Boston Children's Hospital, the number-one pediatric hospital in the world, as well as Florida State University, to drive this project forward to success. Dr. Nadine Gaab has been conducting high-impact reading research for the past sixteen years (twelve years at Boston Children’s Hospital). Her work is well-known and respected in the field, and she conducts many professional development lectures at school districts and dyslexia advocacy events yearly. Furthermore, our partner at FSU, Dr. Yaacov Petscher, is an expert in designing reading screeners and assessments and is part of the Florida Center for Reading Research, one of the leading center for the Science of Reading worldwide. 

The Innovation and Digital Accelerator (IDHA) at Boston Children’s Hospital is compromised of a team of clinicians, researchers, business development, and industry partners focused on addressing the unmet needs of patients/families, clinicians, and health systems across our network and around the globe. The goal is to develop and accelerate BCH digital health offerings to extend access, reach, and scale to BCH expertise, improving child health. The IDHA has successfully spun out five companies thus far, and is well-equipped and motivated to make the screener a successful tool. 

We partnered with over 20 schools in the greater Boston area to establish construct validity of our screener over the 2018-2019 school year, and are settting up partnerships with about 15 more schools nationwide to establish predictive validitiy this year, as well as 10 more for beta testing of the screener. 

Our primary goal is to impact as many students as possible and we are developing the appropriate distribution channels to reach them in schools, at home, in the pediatrician's office, among others. 

We depended on philanthropic support for years 1-3 in order to de-risk development of the screener. The path to sustainability is through a strong sales channel and a lean team. We are confident that we will be profitable by year 2.  

We are currently looking for funding in order to (a) develop videos for the EBRS platform that show educators how to address early literacy challenges in individualized sessions or group interventions within general or special education (b) finish our longitudinal studies that examine which precursors are most predictive for subsequent reading difficulties in Brazilian-Portuguese as well as primarily Spanish speaking children (e.g. recent immigrants) who will enter an English speaking school system. Furthermore, we could greatly benefit from 12 months of personalized support with the intentional introductions to members of Solve’s cross-sector community. These connections will be highly valuable for validating our impact, evaluate our business model and scale our solution. The Solve at MIT workshop will further enable us to connect with other early-stage entrepreneurs in the early childhood space. 

We are interested in partnerships with organizations that help us with the scaling of our solution. This could include Microsoft (especially Microsoft accessibility), Google, social media platforms as well as organizations and initiatives that are present in the school space. This includes initiatives such as Readby 4th (http://readby4th.org/). Furthermore, it will be valuable to partner with organizations that are already in the EBRS space, e.g., intervention providers or awareness platforms such as understood.org.  

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