The two things that consume most of my time are policy and my two-year-old. Given how time-consuming the latter is, I try to integrate her into my work as much as possible—which is one reason I've paid so much attention to the work of Dana Suskind. She's a pediatric otolaryngologist who specializes in, among other things, cochlear implant surgery. Pediatric otolaryngology is something I'm content to leave to the experts, but Suskind's work in that field led her down a more broadly applicable path, beyond children with hearing loss, into the single most universal interaction parents have with their children: talking to them.

It began when Suskind started performing cochlear implant surgeries at the University of Chicago. Giving children the ability to hear is a tremendously powerful experience for children, families, and surgeons like Suskind, but not all of Suskind's patients experienced the same increase in language and communications skills.

So Suskind went back to school, sitting in on a course taught by fellow University of Chicago professor Susan Goldin-Meadow, an influential Guggenheim fellow who has studied the relationship between hearing loss and communication—the theoretical foundation of the physical work Suskind was doing as a surgeon. (I was a lab rat in Goldin-Meadow's department as a broke undergrad scrounging for study-participant dough.) From Goldin-Meadow's course, Suskind learned about an old study in language acquisition, by Betty Hart and Todd Risley of the University of Kansas.

Hart and Risley studied 42 families—13 high-income, 10 middle-class, 13 low-income, and six on welfare—and the number of words their children used. The results were dramatic: "children from families on welfare heard about 616 words per hour, while those from working class families heard around 1,251 words per hour, and those from professional families heard roughly 2,153 words per hour. Thus, children from better financial circumstances had far more language exposure to draw from." From this, they extrapolated that "a child from a high-income family will experience 30 million more words within the first four years of life than a child from a low-income family." That's where Suskind got the name of her Thirty Million Words project.

Furthermore, they found that children from low-income families heard 125,000 more "words of discouragement" than encouragement in the first four years, and children of high-income families heard 560,000 more words of encouragement than discouragement.

Hart and Risley's study, which was based on a small sample size, hasn't been replicated, but the principles have held up. And Suskind has made these principles her project, which is now a book, covering both general principles for parents and more broadly for the policy and medical communities.

And it's made me more conscious of how difficult that can be. One theory for why low-income families speak fewer words with their children is that poverty is a stressor, and carries with it more stress in its wake. More stress means less mental bandwidth, and talking to your child, as any parent knows, takes effort—especially when your child is too young to interact verbally. (Scarcity, by Sendhil Mullainathan and Eldar Shafir, is a great book about "how completely scarcity colonizes the mind.") Even relatively well-off, educated, two-parent families will be aware of how their attention to their children can be limited during times of stress; few of us are capable of never letting television or other distractions take the burden off, even if just for an hour or two. Extend that to greater and more sustained levels of stress and logistical life difficulties, and stress is a plausible factor in that word gap.

I spoke with Suskind about how to do that, and her plans to get parents to pick up the habit. A condensed version of this Q&A ran in the September 2015 issue of Chicago. Here is the fuller version.

What led Hart and Risley to start the study?

It's a really important thing for us to understand. They were in the midst of the War on Poverty in the 1960s. They started off their research working with preschool children, trying to close the achievement gap with vocabulary-intensive interventions. What I think is interesting is that they initially worked with those kids and thought, "oh, they're doing better, their vocabulary is taking off." But pretty soon, once these kids got into kindergarten, there was the fade-out. It's the fade-out we talk about all the time. It was that experience that made them really go to an earlier time, the zero to three space.

The reason I think it's important to learn from history, which human beings don't do a whole lot of, is that, while we have a huge focus on preschool—and I'm all about preschool, there's no doubt about it—if we don't learn from the fact that preschool is too late to start, we're going to be in the same boat as they were. It was the failure of their preschool interventions that made them start earlier.

A lot of it seems to stem from the fact that it's difficult to come to the realization of how much children are picking up, because they can't express it.

The reason early childhood hasn't gotten the serious investment, the serious approach, is because they are all these cute little kids look the same. They can't talk back yet. You can't see the incredible brain development. You can't see the 700 to 1,000 neurons connecting every second. And that's the problem. There is so much going on foundationally during this period that impacts your whole trajectory, but you can't see the impacts until much later.

I think what's really cool is the brain science that's happening right now. It's really helping propel the field. The fact your daughter can't talk back… Pat Kuhl, who is a research scientist at the University of Washington, she has these MEG machines, and you can actually see these babies, as they're hearing language, the motor area of their brains starting to practice to talk back. But the problem is that parents can't see it. Policy makers can't see it—all the stuff going in, these kids are raring to go.

I've been reading research by Jean Decety—he's a neuroscientist who's studying the neurological basis of morality in children—his work, and work that he cites, it's really fascinating to see how scientists are trying to track that development before children can communicate. EEGs, but also things like little puppet plays with eye tracking. Just trying to get to the most subtle forms of expression that little children have.

We're like neuroscientists in the dark. Because you can't see the brain, and we're looking for these outward manifestations of what's going on in here. But as we learn more about here, we're going to learn more about who we are.

It seems like these neuroscience developments make this work possible.

Not just possible, but it's given the credence of what people in the field have intuitively known. But you need to be able to convince policy makers, parents, that it is as critical as we know.

Before you audited Susan Goldin-Meadow's class, did you have any background in childhood development?

I'm a surgeon; we deal with children when they're asleep. Look—the fact that I'm a cochlear implant surgeon, I had an understanding of the importance of language, the importance of parents. I don't think I knew at such a deep level how impactful it was. I didn't. I always say that I probably would have parented my children in a different way. They're okay, thank goodness that they had lots of good language exposure. But I didn't know at the level that I do now.

Were you doing some of these things that you mention in the book when you were raising your kids?

You know, I don't know. I certainly probably talk a lot. There's probably part of it that I did. I probably would have been more mindful. It goes to the question: why do some parents talk more than others? I was raised by a very loquacious mother, and you sort of repeat how you were parented, so I think I probably did.

Some of the strategies you talk about, I've seen my mother do naturally with my daughter. Like when she's changing my daughter's diaper, she'll talk her way through it.

I know. It looks so throwaway, doesn't it? But now you know that it's growing your baby's brain. That's the issue—what looks so intuitive, it's really not as intuitive. It's really a culturally ingrained thing that's been passed down, probably from generation to generation. It's not genetically determined. It's probably how she was raised.

But I do want to mention that parents haven't always been like this. Especially high-income parents. At the turn of the last century, there wasn't this sort of narration interaction.

Sort of seen and not heard—Victorian.

Yeah. I think that's an important point. More to the point that parenting evolves. If there are some segments of the population that may not talk as much, it doesn't mean that that's a static, fixed, thing. These things evolve. So it gives me promise.

Speaking along those lines, despite the tremendous gap that Hart and Risley found, in terms of raw words, in terms of praising, they also found a lot of similarities, universals, across the people they studied. What did they find in those terms?

Ultimately all parents—and hopefully I say this, Hart and Risley said it—all parents want the same things for their kids. They want to help raise them to be healthy, happy, stable adults.

The truth is, as you mentioned, kids look fairly similar because they haven't started talking a ton. The huge differentials can't be manifested because, even at the highest rung, it's not like they're reading Proust and Nietzsche. I think that's why, early on, they do look similar. But most parents want the same for their children; it's how they enact that vision.

One of the missions for our program, and for many people, to allow all parents to make good on the vision that they all have.

Did anything come out of Hart and Risley, or later on, that discussed, or found evidence of, what the barriers are for the lowest socioeconomic families that are saying fewer words, not doing as much praising—why that happens.

It's a multifaceted question. There's not one answer. Parents are heterogeneous, no matter what socioeconomic group they're in.

The largest buckets of why parents wouldn't talk and interact as much, and not necessarily in this order, is how they were parented, the socioeconomic, cultural aspects of parenting. Seen but not heard, as you mentioned. Two is the stressors related to poverty. 

This program is not about "go talk to your kids"; this program is about providing the tools to the families, and advocating for the families. You can't expect a family that doesn't have enough to eat, in a crime-ridden neighborhood where they're worried about being shot, to have the bandwidth—nor should they—to focus on talking to their kid.

So it's their family history; the issues of poverty; and third, which is where we're focusing on, is really understanding the science and the strategies. I think a lot of people don't know the impact of language and language environments on children's brain development. And there's really good research to back that up.

Meredith Rowe had a really nice study, that demonstrated that children from low-income backgrounds, the more knowledge they had of child development, the more facilitative language they did. Which implies that, the more understanding parents have of their children's brain development, the more they're going to enrich their children's language environment.

Because it's not a technically complicated thing to do. You mentioned the book Scarcity…

I love that book.

I was thinking about this last night. I had come home after doing a home inspection, my wife's office had been on lockdown because there was a threat, so we'd had a crazy day. And I was bathing my daughter, and at one point realized that I'd checked out for like five minutes and just didn't say anything. That was my instinct reading about the Hart-Risley study: parents who aren't saying as much have a lot to process.

Absolutely that's true. But it doesn't change the fundamental fact that language is what grows children's brains. So how do you reconcile the fact that we have a nation of children, who will be the adults of our country, who need this language input. And at the same time, understand, among some of these families, there is scarcity. That's why, I think, that advocating for the power of parent talk means that you've got to advocate for families. I'm a social activist; this is not just about "go to talk to your kids." It's about fundamentally changing how we view families and their innate power. 

And I thought the same thing about prohibitive language. "No, don't do that." If you're in a situation that's more risky, whether it's violence or substandard housing, there are a lot of things you have to say no to.

So how do we reconcile that? First of all, we… we're not a parenting program. We're about the power of language and its innate power. How do we approach things like directives? We never say, look, don't do that, because that's obviously a directive. Once we get the parents' buy-in that language is what grows their children's brains, we dissect everything. You know the three Ts: tune in, talk more, take turns. [Those are] the fundamentals of our program—so the idea of directives, you know, put your shoes on!, how do we approach that?

Look. If you say 'put your shoes on,' that's about three words. Tthere's no conversation, and you haven't tuned in. And as you've learned, your baby's brain develops best when you do the three Ts. Instead, you can get the same stuff done by saying "oh, we're going to the park, what do we do now, get your shoes." Dissect it in an agnostic way, of positive-versus-negative, three Ts versus not three Ts.

One thing you talk about in the book is that Hart and Risley was a really intensive, laborious study, but it was a small sample size.

Yeah, 42 [families]. We're doing a five-year longitudinal study here with our home visiting. We have 200.

But their research has held up as people have revisited it?

Yes. Nobody's done the same study, and nobody's ever documented the 30 million word gap, nor do I think [that figure] is important. But there's been tons of studies really emphasizing their important points. Ann Fernald's stuff, looking at language processing, I think it's some of the most interesting…

That was the processing speed of language. You use the metaphor that when you're hearing a second language, and you have to stop and go, oh, wait, what was that word? And then you're already behind.

Yeah, losing opportunities to learn. It's almost the metaphor of the fact that, how much language you're exposed to early on, it doesn't just fill your brain up with vocabulary. It builds a fundamentally different brain. If you're a faster processor, it's like being a faster runner. That's why catching up is so hard.

The reason I like her study is that it makes the connection that language exposure isn't just about vocabulary. It's about the brain. That had some interesting implications for people who speak second languages at home.

What were those—why parents are encouraged to speak their native languages in the home, even?

There are two different issues related to second-language exposure. Talking first about parents being encouraged to use their native language—there is no doubt that, because language exposure is about brain development, being exposed to a parent's native language is not just going to provide richer vocabulary, it's going to provide all the important information that comes through language. Emotion, subtle meanings that you can't necessarily see that parents can only do in their native tongue.

So when people tell a Mexican immigrant, "oh, use English, because that's what this country speaks," not only is it doing a disservice because it makes no sense, but it's negatively impacting their child. So the best thing that a parent can do is talk in their native tongue. With that being said, of course, they have to have an English-language role model, and that's why preschool's so important, and other exposure.

But why is it nice to have a bilingual experience? First of all, it's nice to be able to speak a second language. I so wish I could. But there's the research that bilingualism is related to executive function. There's been some question of it so I don't want to get too far into it, but some research shows that kids who are bilingual are better at regulating their behavior.

They're used to having to keep two things in their mind, so they're able to refocus well. In the same way, they say that's why kids who are bilingual have better executive function. There's been some criticism of the research, though.

The other thing that's interesting to me about speaking in a native language is how it emphasizes that this foundation, in some ways, is really physical—what's being built in the brain. That's what's interesting to me as I've read more about neuroscience, in terms of emotion, morality, language. The actual physical foundation within the brain is important.

I want to make the point that language is the behavioral manifestation of most of those things. Emotion, morality. Language is the conduit of how we express most of those things. That's why getting people to buy into the importance of language is not just about learning how to read or vocabulary, but it's really the foundation of building all these other aspects of human development.

How did you start to build a curriculum out of this, instead of just stopping with "these findings are really important, here you go"?

It's probably because I'm a surgeon. You can put me down as a surgical social scientist. We don't just translate, we do. We like concrete outcomes. You can see, because you deal with all of us crazy professors, that there's a disconnect between science and the practical. I see myself as the bridge. And I really want to emphasize that it's not just me; this is a team of incredible partners. I just happen to be the pusher.

What was really important to me was that here's all this incredible research, saying how important all this is, how do we translate it so the people who need it most can understand it? And that's a science in itself. Just because you understand that this is important in and of itself, that doesn't mean you know how to translate it.

What aspects of the curriculum have been developed?

The most robust curriculum that we've built out is our home visiting curriculum. Do you know the Home Visiting Network?

No.

It's a federally funded program, where people go into the homes of new parents, especially parents of low-income backgrounds, and help with life skills, parenting safety. This curriculum is being developed for them. We go into the home and share the Thirty Million Words curriculum, which is a 12-week curriculum, which uses animation and real-parent videos.

We use a combination of animation and real-parent videos to understand the science and the strategies. And we use the LENA device…

The language pedometer?

Yeah, exactly, to help parents get a mindfulness of how, and how much, they're talking.
I'm a scientist, so we developed it iteratively. We did a small, randomized control trial a couple years ago and had a positive result. We're now doing a five-year study with 200 Early Head Start families in Chicago. It's a partnership with the city of Chicago. Hopefully we're not going to just be following their language, but their executive function, socio-emotional, all that stuff.

What ages?

We're starting at 13 to 16 months. You could say, well, why are you starting so early? First of all, we know that the brain starts from day one. Number two, if Ann Fernald showed language processing differences at 18 months, how could I justify doing older, even though it would have been much easier? It is a very complex study; these studies are so hard. There's a reason people don't do them very much.

So that's one thing. Then we're developing curriculum for the public health infrastructure. So a newborn curriculum, and a well-baby curriculum. Remember when your baby was born, and they did the newborn hearing screen? Did they tell you anything about it?

Not really, no.

They just said your baby passed, right? So, 98 percent of all babies born in this country are screened for hearing loss. It is a wasted opportunity. Why? Why are we doing this hearing screen? It's not simply to see if your baby is deaf. It's because language is food for the developing brain. So what we want to do is harness this opportunity, when the babies are getting their hearing tested, and give parents a single-shot intervention to understand why we're doing it. We're going to be starting the randomized control trial in August with Northwestern and here, with 350 families.

Then we also have a well-baby curriculum. What we want to do is, we have this newborn, and then harness in the pediatrician office visit, over their immunization schedule, at one, two, four, and six months, to again give single-shot interventions that are developmentally appropriate. Obviously how you talk and interact with your children changes as you get older. What our hope is is to develop a curriculum from the day a baby is born, even before, follow them into pediatricians' offices, with home visiting. We have a partnership with the Chicago Children's Museum and the Chicago [Public] Library, where we're going to take our curriculum and do it as exhibits. So you can imagine having this message following families wherever they are. Because really, if you think, if we want to impact a population, if we want to move the needle so that everybody is like your mother, and talking while they're changing the diapers, we can't just think that a single intervention is going to make a difference.

There's one last part of it. These are different curriculum we're developing, but what we really want this to do is for it to come up through the groundwater. We have something called Spread the Words, which really harnesses parents as agents of change. It's not just, "oh, here, let's give you a curriculum." It's about how you can change not just your baby's life, but your community's life.

I was surprised, as a parent, at how little exposure I've gotten to developmental stages. Recently I was talking with some friends, one of whom is married to a pediatrician, and he told me about the Denver developmental chart, and it was simple, but also really rich. Like, here's where 25 percent of children start a thing, here's where 50 percent start, all these different things to look out for. It allayed fears I had, pointed out things to look out for. I was surprised I hadn't been exposed to something like that through pediatrician's visits. 

And here you've got all the resources in the world.

Yeah. Just little things—like, this is the time a child can stack five blocks. I had no idea that was a milestone.

We're using those sorts of milestones in the pediatrician's visit, to not only share how you can talk about stacking blocks—I don't know if blocks is one example—but how you can use language to overlay it.

One of the interesting things to me about the strategies were things that you don't necessarily think about—talking about cardinal numbers, and how girls hear fewer numbers, and how that goes up the socioeconomic spectrum. And space words, like "square," that build spatial knowledge. I can't draw—I maybe draw on the level of a five-year-old—so when my daughter wants to scribble, I can't really draw anything, so I'll just draw her a square or a circle.

You've made her an engineer!

Yes. Inadvertently, I was following that.

It's amazing how powerful how language is. Maybe it's because I fell in love with the research; I just wanted everyone to know. The fact that it builds abilities that aren't just language based… it's so cool.

What is it about television and recorded sound that doesn't work?

I think that it really comes down to the fact that, evolutionarily, our brain is a social brain. The whole point of language developing was to connect with other human beings, responsive human beings. The problem with television and that sort of thing is that it's not responsive, even if it tries to be, like Dora the Explorer. It's pretty clear, especially in the zero to three space—if you're five or six it's probably different—but you just don't learn the language. It's not responsive.

There was a recent study that didn't get into the book, which showed babies with Skype, like Skyping with grandparents. That works. Why does it work? Because it's contingently responsive. It responds to the cues of the child, not a fake response. So I think that, as technology evolves, and can actually be contingently responsive, that will change things. But for now, it's not responsive.

For someone who's just learning about this, what would be the most important advice you would give?

The three Ts. Tune in, talk more, take turns. Being responsive, reading. Why is reading so powerful? It's one of the richest ways to get language in.

Of all the Ts, I think take turns: really viewing your baby as a conversational partner. Responding to your baby's verbal cues, trying to engage him in conversation. I think that's the ultimate.

Could you talk a bit more about the take-turns one?

It goes back to this idea that they can't respond to you—your baby responds, you can have conversations with your baby from day one. Knowing that their response, trying to have a conversation, can be not just real words, but gurgles, eye contact, all these non-verbal cues are conversations. Getting your baby engaged in these early conversations are what is going to help him or her practice to have real-world conversations. It's all practicing.

It reminds me of when my daughter was very, very young, and I'd read a bit about how children pick up colors slowly; black and white is really, really vivid to them. And I would be changing her, and her changing table was right across from this window where we have translucent lace black and white curtains. And she'd immediately just start staring at these curtains. That was when I realized that I could pick up on stuff she was interested in.

It's really being in tune with your child. The tune-in is key too. I wish I could do it all over again. It was great, but I think if I'd gone in with the knowledge I had, and the sensitivity to what you were talking about, it would have been really cool.