Nurturing the Inquiring Mind Through the Nonfiction Read-Aloud
A classroom teacher examines the importance of the nonfiction read aloud as part of ongoing daily instruction, and highlights the need to empower students in both academic achievement, and as life long lovers of nonfiction, through focused informational literature.
As a classroom teacher I always treasured read-aloud time in my classroom. It was a time for my children to fall into exciting new worlds and ignite their imaginations with possibilities. It wasn't until one of my first graders brought in a book from home about lions and asked if I could read it to the class that I realized that nonfiction literature was sadly lacking in my classroom.
As soon as I held up the book and showed the children the cover, the reaction was instantaneous. Every child had some information to contribute or a connection to make. It took me five minutes to settle them down before I could even turn to the first page of the book. Their minds were alight, but in a different way than when I held up the cover of a story. With nonfiction literature they already had prior knowledge to contribute and weren't passively waiting to hear a story unfold.
Sadly some 20 years on I find in most classrooms where I work that nonfiction literature especially in the form of the read-aloud, is still lacking. Duke (2000) found that an alarmingly low amount of nonfiction was being used in classrooms. What concerns me is that now in 2014, nonfiction literature is still in the backseat when it comes to our daily read-alouds.
The research on the powers of read-aloud in facilitating comprehension is extensive. As so aptly stated by Mem Fox (2001):
"If we want our children to learn how to read anything—let alone to read more or to read more diverse or more difficult material—it helps immeasurably if we can give them as much experience of the world as possible. We can provide a great deal of information by the act of reading itself. The more we read aloud to our kids and the more they read by themselves, the more experience they'll have of the world through the things they encounter in books." (p. 100)
If anything, daily read-alouds appear to be woven into the fabric of instruction in just about every classroom across the country. If this is the case, then why do children struggle with comprehension of informational texts? After all, if they are being read to, isn't that enough to deepen vocabulary acquisition? The simple answer is yes if the nonfiction read-aloud constitutes part of daily practice.
However, I don't believe this to be the case. When I asked the teachers I work with why nonfiction literature was not an integral part of their daily read-alouds, their answers were unilateral. Although more than 98% acknowledged that they didn't do enough read-alouds with nonfiction, 75% of these teachers didn't have or know how to locate appropriate nonfiction materials to read to their children.
Their second concern was they didn't feel confident in how to read and use informational literacy in an engaging fashion. They were masters of reading fiction. Lastly, most of the teachers acknowledged that apart from getting students to write about what they had learned when hearing informational literature, few were confident in finding alternative and engaging ways to have students actively respond to the informational texts read.
Nonfiction constitutes much of adult reading and writing and is an integral component of the literacies in today's society. Indeed, much of the Common Core State Standards for literacy, social studies, science, and technical subjects highlight the importance of students understanding informational texts for a variety of purposes. To achieve this goal, nonfiction literature needs to be an integral component of daily teacher modeling. To understand and control informational texts, students need to first hear such texts. The daily read-aloud provides the perfect platform to achieve this goal.
What to look for when selecting informational literature to read to students
Consider the beginning of Nicola Davies book, Surprising Sharks: “You're swimming in the warm blue sea. What's the one word that turns your dream into a nightmare? What's the one word that makes you think of a giant man eating killer? Shaaaaarrrkk!”
What Davies has achieved is instantly engaging her readers. She provides a wonderful hook that begs the listener to hear more. As teachers we need to be selective in the nonfiction literature we read to our students. Just like a boring story, a list of dry facts in nonfiction will have our students disengaged from the outset. The challenge for most teachers is finding such material. Consulting the school librarian is one way to infuse powerful nonfiction real-alouds into the classroom. School librarians are a wonderful resource and often have information about latest releases. There are hundreds of wonderful books released each year, and keeping up with what's new can be difficult without the assistance of the school librarian or making a conscious effort to actively seek out rich materials.
I found keeping a log of engaging nonfiction read-aloud texts invaluable. This gave me an ongoing list of materials to use for future read-aloud experiences. Having students help me rate the material proved enlightening. I had to consider that just because I found the texts interesting didn't necessarily mean my students thought the same. I would ask them for their input and disregard materials they found dull or uninteresting.
Sharing logs with other teachers helped extend my repertoire of material. A small sample from my own nonfiction read-aloud log with books that I found engaged my students and enriched their world knowledge is included in the Table.1 Chapter 8 in Lynne Dorfman and Rose Cappelli's book entitled Nonfiction Mentor Texts gives an extensive and rich selection of wonderfully crafted nonfiction literature that can be used as part of the read-aloud experience. The Good Reads website also lists great selections.
Table 1. Sample of informational literature from Tony Stead's log
|Name of book||Author||Publisher|
|Crows! Strange and Wonderful||Laurence Pringle||Boyd's Mills (2002)|
|Twenty-One Elephants and Still Standing||April Jones Prince||Houghton Mifflin (2003)|
|Faithful Elephants||Yukio Tsuchiya||Houghton Mifflin (1951)|
|Cool Kids Cook||Donna Hay||Harper Collins (2000)|
|Sharks Strange and Wonderful||Laurence Pringle||Boyd's Mills (2001)|
|A Voice for the Animals||Evelyn Brooks||Benchmark Education (2011)|
|Should There Be Zoos?||Tony Stead||Mondo (2000)|
|The Snow Show||Carolyn Fisher||Harcourt (2008)|
|What Is My Dog Thinking? What Is My Cat Thinking?||Gwen Bailey||Hamlyn London (2002)|
|Rosa||Nikki Giovanni||Square Fish (2005)|
|One Tiny Turtle||Nicola Chapman||Candlewick (2001)|
|Water Dance||Thomas Locker||Harcourt (2002)|
|When Night Comes||Ron Hirschi||Boyd's Mills (2000)|
|Under New York||Linda Oatman High||Holiday House (2001)|
|Voices of Ancient Egypt||Kay Winters||National Geographic Society (2003)|
|Swirl by Swirl||Joyce Sidman||Houghton Mifflin (2011)|
|African Critters||Robert B. Haas||Sacova (2002)|
|Egyptology||Said to be that of diaryentries made by EmilySands during the1920s||Five Mile (2004)|
|Actual Size||Steve Jenkins||Houghton Mifflin (2004)|
|America Is Under Attack: September 11, 2001. The Day the Towers Fell||Don Brown||Flashpoint (2011)|
|Can We Save the Tiger?||Martin Jenkins||Candlewick (2011)|
|The Boy Who Harnessed the Wind||William Kamkwamba||Dial (2012)|
|Our Solar System||Seymour Simon||Harper Collins (1992)|
|The Case of theMummified Pigs andOther Mysteries inNature||Susan E. Quinlan||Boyd's Mills (1995)|
|Totally Bizarre:Exploring the Worldof Unsolved Mysteries||Celia Bland||Kidsbooks (2002)|
|Guinness WorldRecords||Various||Gullane EntertainmentCompany (Yearly)|
Thinking beyond books
When we consider the notion of children's literature, and the read-aloud experience, our usual thoughts are using books. In fact much of informational literature is in the form of magazines, newspaper articles, brochures, and websites. With this realization, the possibilities of locating nonfiction materials to read to our students is massive. In Helen's fourth-grade classroom in the Bronx where I have been working, our major challenge was getting quality nonfiction literature into the classroom. With an outdated school library and little money for books, we found nonbook resources a wonderful tool. We soon built up a collection of interesting articles. We placed these into file folders under specific topics and themes. Sharing these articles with other teachers on the same grade level soon gave us a rich array of quality material to read to our children.
In selecting material from newspapers, magazines, brochures, and websites, we selected only those that were written in an engaging manner and stemmed from our students' interests. Often we would take articles and rewrite them to provide our learners with engaging listening experiences. Initially many of the teachers I worked with found this task challenging, but soon they found themselves experts in writing wonderfully crafted and engaging pieces of nonfiction. As teachers we need to become experts in writing informational pieces to share with our students, especially if we expect the same from them as writers.
Ensuring a variety of text types
Students need exposure to a wide variety of text types across the full spectrum of the curriculum to ensure deep content retention and transferability of writing forms (Harwayne, 2000; Hoyt, 2006; 2009; Stead, 2000; Taberski, 2011).
For the most part, when we do read nonfiction literature to our students, it is in the form of descriptions and explanations that deal with animals, plants, or historical events. Although these text types are important, we need to give consideration to reading texts that argue, persuade, instruct, and respond. This will in turn strengthen students' understandings of the linguistic structure and features of all types of informational texts. This will deepen both comprehension and their ability to independently write for a variety of purposes.
In Natalie's second-grade classroom, we began using persuasive brochures about different places around the world as part of the read-aloud experience. Many of these we had gathered from our local travel agent. It was not long before her students began to actively write their own brochures. The exposure to a different text type had given her students the confidence and skills necessary to craft pieces beyond simple descriptions. Book reviews, letters, procedural pieces, and labeled diagrams all need to be included as part of informational literacy that students see and hear on a regular basis.
Guidelines in reading informational literature to students
My work in classrooms in the New York City Schools and across the country has led to many discussions and experiments with the nonfiction read-aloud to optimize engagement and comprehension retention. Although most of the teachers I work with were masters of reading daily to their children, the use of informational texts was for the most part new. Most acknowledged that the only time they read informational texts to their children was part of social studies and science units and that the material was mostly written in a dry and disengaging manner. It was usually more of a chore than pleasure.
Alarmingly, in many grade 3–5 classrooms, the novel is the only read-aloud that students get to hear during the literacy block. As teachers we need to rewire our thinking and practices when it comes to reading nonfiction to our students. If it is always driven by content studies that are occurring in the classroom, then our students will quickly become disengaged. Taking time to locate well-crafted nonfiction literature about topics that students find compelling and integrating them into the literacy block is the first step.
Another shift in thinking is that not all of an informational text needs to be read in one sitting or for that matter over a series of days. The beauty with nonfiction, especially descriptive texts, is that the information is organized under categories that can be read in a random order. Reading only part of a longer texts or reading shorter pieces allows for more meaningful and focused discussions. I recall the excitement when reading the book Crows in Lisa's third-grade classroom. After only five pages, I stopped the reading to invite discussions. The conversations were rich as the children were able to process a small part of the text. They weren't inundated with massive amounts of information.
The question of academic vocabulary
All to often I have seen students become totally disengaged when hearing an informational piece that is loaded with unfamiliar academic or content-specific vocabulary. Although the introduction of new vocabulary is to be encouraged, the amount presented needs to be considered. Having to stop every two minutes to explain new vocabulary compromises comprehension retention and pleasure for our students. I usually find that nonfiction texts that present more than 10% of unfamiliar vocabulary in one sitting are not suitable for the read-aloud experience.
Apart from the guidelines just discussed, further considerations for reading informational literature are as follows:
- Always give children the opportunity to talk to each other about what they are hearing. Stop the reading at different intervals and ask children what they are thinking at that moment.
- Put expression into your reading. Be as dramatic as needed to fully engage your children. Demonstrate that you are a lover of informational texts and that they are an important component of your own daily reading.
- Make certain all the children can see the text if you are showing them pictures.
- All children should be able to hear you clearly.
- Revisit favorite nonfiction read-alouds. As with fiction, children enjoy hearing information more than once.
- Place favorite nonfiction read-alouds in a basket or tub so that children can refer back to these during independent reading time or at other opportune times.
Responding to informational literature
As with fiction there are many ways students can respond to what they are hearing. What we don't want is students mindlessly recording a list of facts after they have heard every informational piece read. This is a sure way to destroy the joys of informational literature. Most of the time inviting students to talk about what they are hearing and wondering in pairs, groups, or as a class is adequate. As so aptly said by James Britton (1970), “Reading and writing floats on a sea of talk.” We need to infuse talk into the read-aloud and give our students time to reflect, wonder, and question.
Using the Reading and Analyzing Nonfiction Strategy (R.A.N.)
One strategy to enrich the nonfiction read-aloud experience and have students respond is the Reading and Analyzing Nonfiction Strategy (R.A.N.). I first devised this strategy when working with teachers at The Manhattan New School in New York. Based on Dona Ogle's K-W-L, the R.A.N. strategy can be used to both deepen content understandings and spark students' talk, natural inquiry, and curiosity during read-aloud encounters. It is also an excellent organizer for students to use when they independently research and write about a given topic. An explanation of each category and implementation procedures follow. You will need to construct a R.A.N. chart with the five categories (see Figure 1). Laminating the chart will enable you to reuse the chart for future read-alouds. Note: Not all read-aloud encounters with informational literature need to involve using the R.A.N. strategy. Be selective when using this strategy, and confine it to topics for which students' may possess background knowledge.
The RAN categories
The first category in the R.A.N. is called “What I Think I Know.” This category allows the reader to acknowledge that not all of their background knowledge may be accurate. In essence it allows for approximations of prior knowledge. This is an important consideration when reading informational literacy to students. Most students possess some prior knowledge on certain nonfiction topics, and we need to acknowledge this before the read-aloud.
Before the read-aloud, invite students to tell you what they think they know about the specific topic. Chart their responses using sticky notes or index cards. Alternatively, each student could quickly write some of their information onto a card or sticky note then place it onto the chart. This will ensure all students have their thinking recorded. It is recommended that students limit their information to what they consider to be their best few facts. This will ensure that there is not an overload of information to process.
The second category in the R.A.N. is titled “Confirmed.” This category gives learners an opportunity to confirm prior knowledge as they listen to the text. It gives them a sense of success as they hear facts presented by the author that they already knew. Read part of the text to the students and have them see if they can confirm any of their recorded prior knowledge that has been posted under the heading “What We Think We Know.”
The third category in the R.A.N. is called “We Don't Think This Anymore” or “We've Changed Our Minds.” This category helps students understand that when listening to informational literature, the facts presented by the author may be different from their own prior knowledge. It gives students an opportunity to rethink what they previously thought to be correct. Ask students to listen for any misconceptions they had after hearing part of the text read and move this into the third column.
The fourth category in the R.A.N. is called “Exciting New Information.” This category encourages students to think about information that is new learning that they find interesting and gather new literal understandings presented by the author. This helps deepen their content understandings about a topic. Revisit the text again and have students locate new information and record this onto sticky notes or index cards onto the fourth column of the chart.
The final category in the R.A.N. is called “Wonderings.” This is the same as the second category in the K-W-L, namely, “What I Want to Know.” In the R.A.N. this category is placed after students have heard information and not before. This is because readers tend to raise more centered and appropriate questions during and after they hear an informational piece because their knowledge base has been extended. Chart students' wonderings in the fifth column on the chart. You may want to read other materials on the same topic so that students can look to see if their wonderings can be answered. Alternatively, students can research independently to find answers to their wonderings. This makes for active engagement for student-led inquiry.
The power of raising wondering and inferring
It is the category of “Wondering” in the R.A.N. strategy that I find most exciting. This category takes students beyond simple retention of literal facts and encourages them to question, infer, and actively seek out new information. This alone is a powerful tool to encourage students to respond to informational literature.
My recent work with fourth and fifth graders at P.S. 196 in the Bronx proved a thought-provoking experience. The teachers had been using lots of nonfiction literature as read-aloud experiences with their students. The children had become confident in using the R.A.N. strategy but became stuck when it came to raising wonderings. For the most part they were content to just confirm and negate prior knowledge and gather new information during the read-aloud experience. They were used to answering questions, not raising them. When we did invite them to raise questions, most began with “Why.” We began to use other lead words such as “Where, When, Who, How, Where, and Did” to help them raise different types of questions about the information they were hearing. We started by taking one fact from a book on whales, namely “People hunted and killed them for food,” and encouraged them to think deeply about questions that the particular fact raised (see Figure 2).
We then encouraged the students to form hypotheses on possible answers to some of the questions raised. This proved an exciting venture. Rachel formed the hypothesis that it was men who hunted whales because back in the early days women stayed home to cook, clean, and look after the children. She further remarked, “I'm so glad times have changed because if it was me I'd want to be out there hunting and having fun. The men need to learn how to cook and clean.” This comment brought a universal “yes” by the girls in the classroom.
It wasn't long before the students in the grade 4 and 5 classrooms were not just collecting facts when they heard informational literacy, but raising questions and making connections with what they were hearing. Our next step was to scaffold them into raising higher order thinking questions.
Deepening thought through powerful questioning
Crystal Hyman, a second-grade teacher at P.S. 196 in the Bronx, is a master teacher. My work with her proved that even young children can raise high-level questions from informational texts if they are provided with modeling and repeated experiences. At first, her students found it difficult to raise what I term a level two or level three question. Level one questions are those for which the answers can be found in the body of the text. Many students tend to listen selectively and ask questions that are already answered later in the text. Level two questions are those that have obvious answers such as, Why do lions hunt? Although the answer may not be stated explicitly within the body of the text, the answer is easily inferred. Level three questions are those for which the answers are not within the text nor can be easily inferred. To answer these types of questions, the reader needs to research further.
Crystal and I spent many sessions moving her students from level one questions to level three wonderings. It took time, patience, and repeated think-aloud demonstrations by us as teachers, but soon the children were thinking deeply about what they had heard. The results were amazing. A sample of some of the questions raised by her students on different topics that were read as part of the read-aloud experience follows.
Do snails have pores so the bubbles come out?
Foam bubbles. I want to know if they come out of the snail because it boils like water?
Snails make a lot of foam bubbles but I don't know what it's for.
Why does the snail move so slow? Is it always tired?
How do tornadoes get speed to go faster? The author should have told us this.
How does a tornado pick his path?
It's perplexing that tornadoes come from nowhere because no one did nothing.
Do marsupials have a tiny pouch when they are born?
Are marsupials born with hair?
I wonder if ice keeps continuing to melt if there will be a place for us and the marsupials to live?
The preceding wonderings raised by Crystal's students show that deep comprehension has occurred. To raise such questions, the students needed to reflect on the information they had heard and then consider information not included that they wanted to know more about. This is the heart of what nonfiction literacy needs to ignite: learners who bring a love of and passion for critically thinking about what they are hearing and reading. This can only be accomplished if nonfiction literature is an integral part of daily instruction. No longer should nonfiction literature be included only as a part of content studies. We need to embrace it, love it, and be inspired by it. As so aptly said by Nell Duke (2006):
"What we too often forget when considering the importance of nonfiction reading is the pleasure, the art, the wonder of it. We do not want to develop students who read nonfiction just for function, or for school success, but students who read nonfiction for enjoyment, to be fascinated, to discover" (Foreward, p. ix)
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- Booth, D. (2002). Even hockey players read: Boys: Literacy and learning. Portland, ME: Stenhouse.
- Brailsford, A., & Coles, J. (2004). Balanced literacy in action. Markham, ON: Scholastic Canada.
- Britton, J. (1970). Language and learning. London, UK: Penguin.
- Carreiro, P. (1998). Tales of thinking: Multiple intelligences in the classroom. Portland, ME: Stenhouse.
- Cazden, C. (1988). Classroom discourse; The language of teaching and language. Portsmouth, NH: Heinemann.
- Cambourne, B. (1988). The whole story: Natural learning and the acquisition of literacy in the classroom. New York, NY: Scholastic.
- Chambers, A. (1996). The reading environment: How adults help children enjoy books. Portland, ME: Stenhouse.
- Chambers, A. (1996). Tell me: Children, reading and talk. Portland, ME: Stenhouse.
- Cunningham, P.M., & Allington, R.L. (1999). Classrooms that work: They can all read and write. New York, NY: Longman.
- Daniels, H., & Steineke, N. (2011). Text and lessons for content area reading. Portsmouth, NH: Heinemann.
- Derewianka, B. (1990). Exploring how texts work. Rozelle, New South Wales, Australia: Primary English Teaching Association.
- Dillion, J.T. (1983). Teaching and the art of questioning. Bloomington, Indiana: Phi Delta Kappa Educational Foundation.
- Dorfman, L.R. and Cappelli, Rose (2009). Nonfiction mentor texts. York, ME: Stenhouse.
- Dorn, J., French, C., & Jones, T. (1998). Apprenticeship in literacy: Transitions across reading and writing. Portland, ME: Stenhouse.
- Duke, N.K., & Bennet-Armistead, V.S. (2003). Reading and writing informational text in the primary grades. Researches-based practices. New York, NY: Scholastic.
- Duke, N.K. (2000). 3.6 minutes per day: The scarcity of informational texts in first grade. Reading Research Quarterly, 35(2), 202–224.
- Duthie, C. (1996). True stories. Portland, ME: Stenhouse.
- Fountas, I., & Pinnell, G.S. (2001). Guiding readers and writers grades 3–6. Portsmouth, NH: Heinemann.
- Fox, M. (2001). Reading magic: Why reading aloud to our children will change their lives forever. New York, NY: Harcourt.
- Freeman, Y., & Freeman, D. (2009). Academic language for English language learners and struggling readers: How to help students succeed across content areas. Portsmouth, NH: Heinemann.
- Graves, D. (1989). Investigate non fiction. Portsmouth, NH: Heinemann.
- Harvey, S. (1998). Nonfiction matters: Reading, writing and research in grades 3–8. Portland, ME: Stenhouse.
- Harste, J., Woodward, V., & Burke, C. (1984). Language stories and literacy lessons. Portsmouth, NH: Heinemann.
- Holdaway, D. (1979). The foundations of literacy. Sydney, Australia: Ashton Scholastic.
- Hoyt, L. (2002). Make it real: Strategies for success with informational texts. Portsmouth, NH: Heinemann.
- Hoyt, L. (2007). Interactive read alouds, 2–3. Portsmouth, NH: Heinemann.
- Keene, E.O., & Zimmermann, S. (1997). Mosaic of thought: Teaching comprehension in a reader's workshop. Portsmouth, NH: Heinemann.
- Krashen, D. (2004). The power of reading: Insights from the research. Portsmouth, NH: Heinemann.
- Lattimer, H. (2003). Thinking through genre: Units of study in reading and writing workshops 4–12. Portland, ME: Stenhouse.
- Marzano, R. (2004). Building background knowledge for academic achievement. Alexandria, VA: ASCD.
- MCLaughlin, M., & DeVoogd, G.L. (2004). Critical literacy: Enhancing students' comprehension of text. New York, NY: Scholastic.
- Mooney, M. (1990). Reading to, with, and by children. New York, NY: Richard C. Owen.
- Moore, W.H. (1991). Some thoughts on talking with children. In D. Booth & C. Thornley-Hall (Eds.), The talk curriculum (p p. 11–19). Portsmouth, NH: Heinemann.
- Ogle, D. (1986). KWL: A teaching model that develops active reading of expository text. The Reading Teacher, 39(6), 563–570.
- Saunders-Smith, H. (2009). Nonfiction text structures for better comprehension and response. Gainesville, FL: Maupin.
- Smith, F. (1988). Joining the literacy club: Further essays into education. Portsmouth, NH: Heinemann.
- Stead, T. (2002). Is that a fact? Teaching nonfiction writing K-3. Portland, ME: Stenhouse.
- Stead, T. (2004). Time for nonfiction. Video Series. Portland, ME: Stenhouse.
- Stead, T. (2006). Reality checks: Teaching reading comprehension with nonfiction. Portland, ME: Stenhouse.
- Stead, T., & Brailsford, A. (2007). Literacy place for the early years. Grades K-3. Markham, Ontario, Canada: Scholastic Canada.
- Stead, T., & Brailsford, A. (2008). Moving up with literacy place. Grades 4-6. Markham, Ontario, Canada: Scholastic Canada.
- Stead, T. (2009). Good choice: Supporting independent reading and response K-6. Portland, ME: Stenhouse.
- Stead, T., & Hoyt, L. (2011). Explorations in nonfiction writing K-2. First hand. Portsmouth, ME: Heinemann.
- Stead, T., & Hoyt, L. (2012). Explorations in nonfiction writing 3-5. First hand. Portsmouth, ME: Heinemann.
- Szymusiak, K., & Sibberson, F. (2003). Still learning to read: Teaching students in grades 3–6. Portland, ME: Stenhouse.
- Taberski, S. (2000). On solid ground: Strategies for teaching reading K-3. Portsmouth, NH: Heinemann.
- Zemelman, S., Daniels, H., & Hyde, A. (1993). Best practice: New standards for teaching and learning in America's schools. Portsmouth, NH: Heinemann.
- Zimmermann, S., & Hutchins, C. (2003). 7 keys to comprehension. New York, NY: Three Rivers.
Click the "Endnotes" link above to hide these endnotes.
- Deborah Kozdras, Christine Joseph, Jenifer Jasinski Schneider, Reading Games Close Viewing and Guided Playing of Multimedia Texts, The Reading Teacher, 2015, n/a
Wiley Online Library
- Douglas Fisher, Nancy Frey, Closely Reading Informational Texts in the Primary Grades, The Reading Teacher, 2014, 68, 3, 222
Wiley Online Library
Tony Stead (2014). Nurturing The Inquiring Mind Through The Nonfiction Read-Aloud. The Reading Teacher, 67(7), 488–495. doi: 10.1002/trtr.1254