With trusted, frequent access to families during early childhood, pediatricians are poised to conduct developmental screening and provide guidance promoting school readiness, as recommended by the AAP.4 However, while early literacy screening has shown promise,8 there is currently no established approach to numeracy screening in pediatric practice. Further, commonly used screening measures (e.g., Ages & Stages Questionnaire, SWYC) do not specifically assess numeracy skills. This reflects an important gap and opportunity, as a large and increasing number of children arrive at kindergarten (typically age 5-6 in the US) with low math readiness, particularly those from socioeconomically disadvantaged households.4,15,16 The goal of this study was to test a children’s book-based approach to numeracy screening during pediatric primary care.

Psychometric properties of TNF were strong, particularly for a new measure capturing a complex cognitive domain. We attribute this to an evidence-based conceptual model involving well-defined component numeracy skills,17 and a book-based approach that has been successful in screening emergent literacy skills at this age.8 TNF and PENS total scores were highly correlated (rρ = 0.94), suggesting strong concurrent validity, and internal consistency was excellent (rCo-α = 0.94), suggesting high coherence among screener items.

In terms of internal psychometrics, Rasch analyses of TNF items were also promising. TNF item and total scores were all positively correlated, with all response options selected by no less than 6% of the sample (an accepted standard), and monotonic ordering for each response option (i.e., full credit, partial credit, no credit, in a uniform direction). Item difficulty was balanced between easier and harder items, with addition (item 10) and numeral comparison (item 9) scoring most difficult, and 1-1 counting (item 5) and verbal counting (item 4) scoring easiest (Table 2). This is consistent with expected skill trajectories, where more abstract concepts and mental manipulation thereof (i.e., concept of number size, addition) were harder, while rote concepts (e.g., counting aloud, counting small groups) were easier.1,17 Item 5 (1-1 counting of sets) was by far the easiest item, potentially attributable to the small number of animals in each set tested (1 to 4 per set). Item revision to optimize these metrics is planned for a subsequent version of TNF.

Item-measure correlations were largely moderately positive, below 0.80, suggesting measure coherence and that each item contributed uniquely to the TNF total score. Exceptions were items 4 (verbal counting) and 5 (counting sets), which were also the easiest. This finding may reflect the influence of overall cognitive development on total score, rather than mastery of specific skills, evidenced by the strong correlation between TNF score and child age. Revision of these items, as mentioned above, may help minimize this effect.

TNF scores were strongly correlated with child age and preschool enrollment but not significantly with sex, consistent with developmental maturation, established benefits of preschool,4,18 and lagging sex disparities in math abilities.19 They were marginally positively correlated with reported parental enjoyment of math and marginally negatively correlated with parental reported difficulties in math, likely reflecting varying parental abilities and/or educational experiences. They were significantly, positively correlated with the reported number of children’s books at home, days/week of shared reading and playing math-related games, each reflecting empowering ways for parents to help the child at home.18 They were not correlated with digital media use, surprising considering the potential displacement of parent-child interaction and recent evidence of negative effects.20 However, such evidence is scant in terms of risks or benefits of digital media, warranting further study.

Responses to parent and child surveys were strongly favorable, suggesting that TNF screening may be feasible, useful, and enjoyable during well-visits. Administration time was under 10 minutes, which is excessive for most clinics, yet attributable to the research stage of this work. Published work involving literacy screening has found that screening time improves substantially with practice, which seems a reasonable investment, especially if reimbursable as developmental surveillance,3 when utilized by embedded school readiness staff,5,9 in specialty clinics where visits are often longer, and/or as a pediatric resident teaching tool.21 Further refinement of TNF to improve efficiency is planned.

This study has limitations. The sample size was small and collected at an academic primary care clinic serving largely socioeconomically disadvantaged, primarily Black families, limiting generalizability, though this is a vital demographic in terms of school readiness.4 TNF was administered by pediatric residents functioning as clinical research coordinators. Future studies are needed to explore TNF screening during usual clinic workflows (e.g., via medical assistants, clinicians).21 This study also has strengths, including randomization of TNF/PENS screening to minimize fatigue effects, robust psychometric analyses, and leveraging of a successful book-based approach to literacy screening.8,9 TNF is family-centered, inexpensive ($3.00/book, given to the child to take home), requires minimal training, and is scalable within existing programs (e.g., Reach Out and Read22), with substantial advantages relative to kit-based measures. Altogether, this pilot provides compelling data that TNF may be an appealing option for early numeracy screening in pediatric settings in the preschool age range (3–5 years old), complementing existing school-based tools. More expansive studies are warranted, with a goal to help align efforts by pediatricians and early childhood educators in this vital school readiness domain, including timely screening with familiar, reliable tools and tailored guidance for families to help their child succeed.

For more information about The Number Farm or to order for research or clinical use, visit http://www.bluemanateepress.com/nonprofit/ or email press@bluemanateebooks.com or John.Hutton@utsouthwestern.edu.