This is the moment, Suskind once believed, when she set each child on the path to understanding words, then speaking them, then reading them, then thriving. Perform the surgeries early enough and you can give children the ability to hear while their malleable brains are still developing, feeding off the language around them.
Several years ago, though, Suskind realized some children who'd received the surgery continued to struggle anyway. She describes in her new book, "Thirty Million Words," one little girl from a poor family who could still barely speak by the third grade. "When I looked at her lovely face," Suskind writes, "it was hard to say whether I was seeing the tragedy of deafness or the tragedy of poverty."
Studies show that children in poor families are spoken to less often. By the time they're 3, according to one famous estimate, they have heard 30 million fewer cumulative words than kids who come from wealthier homes. They can suffer, like children born without hearing, from what Suskind calls the lifelong effects of silence.
That discovery has made the surgeon, who has the voice and patient temperament of someone who works with small kids, a devout advocate for poor children. Now she researches what they hear at home and how that language influences their brain development. And her work is behind a series of efforts in different corners of the country to translate this emerging science into public programs — in doctors' offices, nursing schools and family living rooms — that might actually change how low-income parents talk to their kids.
"Sometimes, I look back and I think, 'Gosh, how did I get here? I’m a surgeon, I’m not supposed to be doing this,'" Suskind says.
"I look at children in such a different way,” she adds. “You can almost look into their eyes and see neural connections happening."
She still performs those cochlear implant surgeries every Tuesday. “I don’t want to lose that part of it,” she says, “although this has sort of taken over my life.”
Her Thirty Million Words initiative (and her book) takes its name from a small but seminal study conducted in the 1980s by psychologists Betty Hart and Todd Risley. They spent more than 1,300 hours observing interactions between parents and their children in 42 families of varying incomes. When Hart and Risley transcribed all of it, they uncovered a startling word gap: The average child from a "professional" family heard 2,153 words per hour; the average child from a family on welfare heard 616.
Over a child's first few years, Hart and Risley concluded that gap could add up to 30 million words. Other studies since have confirmed the divide, even if they've found smaller differences. The pattern is not just about reading but about talk — and quality talk — of all kinds. "Let's put on your socks" talk. "What do we see outside?" talk. "This is why we brush our teeth" talk. Researchers now know that early exposure to language like this helps build a child's brain, and it predicts later school performance and reading skills. Young children who don't grow up in a dense world of words fall behind before they enter pre-K.
It's alluring to think that their lives might be altered with a little parental coaching. Especially given that talk, as Suskind emphasizes, is free. But policy interventions that reach so deeply into a family's home, into the space between a parent and her child, are delicate. And they may bump up against a tradition in the United States that government has historically played little role in a child's education until the moment he or she starts school.
"It’s analogous to my children's hospital not seeing patients until they’re 3 and 5," Suskind says. Language skills, though, perceptibly lag in children as young as 18 months. "So how could you ethically start later?"
The interventions she has in mind are not about persuading parents to use a different dialect or grammar. Rather, she wants to teach parents that the words they already use — wielded more intentionally — have the power to shape their babies' brains. That’s not paternalistic, she argues; it’s empowering.
And longitudinal studies she's running now could help prove if this idea really changes children's lives.
"I’m learning more that it’s up to me," says Denesha Gorman, a 20-year-old mother in Chicago who is enrolled, with her 16-month-old son, Kingsley, in a home-visiting program that is part of one study. "I have to get him together before I send him off and expect someone else to get him together."
'We have to trust the science'
Two years ago, Providence, R.I., won a grant from the Bloomberg Foundation to put some of Suskind's ideas to work. The city designed a pilot program for 175 families. Each received regular home visits and a small recording device akin to a pedometer for words.
The recorder, capable of capturing 16 consecutive hours, tucks into specially designed vests that the children wear. It then plugs into software that can automatically do what Hart and Risley did by hand, counting the words a child hears, as well as the conversational turns with parents that matter, too. (The device also recognizes the difference between the TV and a talking human.)
After each recording, parents are given charts tracking their progress.
"It’s the same as wearing a Fitbit or doing Weight Watchers and tracking your results," says Courtney Hawkins, the executive director of the program, Providence Talks. "We know if you want to change behavior, you have to know how you’re doing over time."
This fall, Providence released some initial results from the pilot. Among the 120 families that completed at least four coaching sessions, children heard on average an additional 1,191 words a day. (The average for kids with advanced language skills is about 15,000 words a day total.) And the progress was larger for children who started further behind.
Rosa Aldana, a 40-year-old mother of three in Providence, believes she can already see some change in her 3-year-old daughter, Geovana, who's doing recordings now. A second child, Geovana was slow to speak and prone to letting her sister talk for her.
Through the program, Aldana receives coaching on how to tune in to her daughter's interests ("what's that you're baking?") or how to fill the air even with words that seem unnecessary ("now we're changing our shoes!"). Geovana now runs up to books and asks "Mommy, what it says?" She plays by pretending to make her mother dinner. And imaginary dinner, Geovana explains, is — once again — chocolate cake!
"She went almost two years without saying much," Aldana says. "Now, it’s like sometimes I have to say, 'Keep quiet for a little bit.'"
Other families never quite figure out the recorder, and if the first try doesn't go well, Hawkins says, families are more likely to drop out of the program. The city is planning an aggressive expansion to 2,500 families over the next two years, some who will receive home visits, others group coaching.
The city, and Brown University researchers working with it, doesn't know yet if families maintain their progress after the coaching and recording stops. And the program's ultimate success — in a city where 2 in 5 children live in poverty — won't be measured in word counts, anyway.
“The next question is kindergarten readiness," Hawkins says. Then you want to know if third-grade reading levels improve. And eighth-grade performance and — to keep going — graduation rates and job prospects. "We’re going to have to trust the science," Hawkins says, "because we know the results are so far off."
Suskind, back in Chicago, is also thinking about population-level change. How would you seed this idea among a thousand mothers at once? How would you take what Providence has tried, prove its value and spread it all over the country?
Suskind is running one study in Chicago that will follow over time families that receive home visiting, like Gorman's. She's working on another model where parents would learn about the power of talk during newborn hearing screens. Her team is developing exhibits for libraries and videos for doctors' offices that families could watch each time they come in for vaccinations.
Policymakers in Georgia have followed Suskind's work since the White House convened a conference on the word gap in 2013. The Georgia group, which includes the state departments of health and education, is targeting not parents, but the workforce that frequently interacts with them. Nurses trained at Emory will now learn about the importance of parent talk, too.
"We're looking at this as a population-level crisis," says Arianne Weldon, the director of the Get Georgia Reading campaign, which partners on that program. In Georgia, two-thirds of children don't read proficiently by the end of third grade.
None of these programs will change the circumstances low-income parents face that contribute to the word gap. They won't solve for the single mother who doesn't have time to read at night because she works two jobs, or the father too preoccupied by the heating bill to play a game of peek-a-boo.
But research suggests there are other socioeconomic differences in how parents behave that speak to more than disparities in time. Sociologist Annette Lareau has described the kind of high-intensity, hands-on parenting style of middle-class parents as "concerted cultivation." Low-income parents are meanwhile more likely to emphasize discipline and authority, using more prohibitions ("don't go outside!" versus "we don't want to go outside right now because it's raining").
These differences aren't evidence that wealthy parents are inherently better parents. "We seem to think that [well-off] families have always been such cognitively based parents," Suskind says. But they acquired their behavior, too. Not long ago, plenty of wealthy parents still believed children should be "seen and not heard."
It also wouldn't be surprising, Suskind adds, if struggling parents who lack control over so much else in their lives don't recognize they have this much control over their children.
Denesha Gorman, who lives on Chicago's South Side with her family and her fiancé, Kingsley's father, was originally looking for preschool programs for her son. She believed she needed to enroll him in a classroom — to hand him over to trained educators — to give him what he needed.
"I honestly relied on these schools," she says. Now she sees differently the conversations she and Kingsley have every morning when they pick out the clothes he will wear. "I’m basically teaching him, but without him feeling like it’s school. It’s like I’m his teacher. And I am where it starts."