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The Power of Play: A Pediatric Role in Enhancing Development in Young Children
Michael Yogman, MD, FAAP, Andrew Garner, MD, PhD, FAAP, Jeffrey Hutchinson, MD, FAAP, Kathy Hirsh-Pasek, PhD, Roberta Michnick Golinkoff, PhD, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COUNCIL ON COMMUNICATIONS AND MEDIA
(doi: https://doi. org/ 10. 1542/ peds. 2018- 2058)
The American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, IL 60007 CLINICAL REPORT
Guidance for the Clinician in Rendering Pediatric Care
The Power of Play: A Pediatric Michael Yogman, MD, FAAP,a Andrew Garner, MD, PhD, FAAP,b Jeffrey Hutchinson, MD, FAAP,c KathyRole Hirsh-Pasek, in PhD, Enhancingd Roberta Michnick Golinkoff, PhD, Developmente COMMITTEE ON PSYCHOSOCIAL ASPECTSin Young OF CHILD AND FAMILY Children HEALTH, COUNCIL ON COMMUNICATIONS AND MEDIA
Children need to develop a variety of skill sets to optimize their development abstract and manage toxic stress. Research demonstrates that developmentally appropriate play with parents and peers is a singular opportunity to promote the social-emotional, cognitive, language, and self-regulation skills that build executive function and a prosocial brain. Furthermore, play aDepartment of Pediatrics, Harvard Medical School, Harvard University and Mount Auburn Hospital, Cambridge, Massachusetts; bDepartment supports the formation of the safe, stable, and nurturing relationships with of Pediatrics, School of Medicine, Case Western Reserve University and University Hospitals Medical Practices, Cleveland, Ohio; cDepartment all caregivers that children need to thrive. of Pediatrics, F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, Maryland; dDepartment of Psychology, Brookings Play is not frivolous: it enhances brain structure and function and promotes Institution and Temple University, Philadelphia, Pennsylvania; and executive function (ie, the process of learning, rather than the content), eSchool of Education, University of Delaware, Newark, Delaware which allow us to pursue goals and ignore distractions. Dr Yogman prepared the first draft of this report and took the lead in reconciling the numerous edits, contributions, and suggestions from When play and safe, stable, nurturing relationships are missing in a child’s the other authors; Drs Garner, Hutchinson, Hirsh-Pasek, and Golinkoff made significant contributions to the manuscript by revising multiple life, toxic stress can disrupt the development of executive function and the drafts and responding to all reviewer concerns; and all authors learning of prosocial behavior; in the presence of childhood adversity, play approved the final manuscript as submitted. becomes even more important. The mutual joy and shared communication This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have and attunement (harmonious serve and return interactions) that parents filed conflict of interest statements with the American Academy and children can experience during play regulate the body’s stress response. of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of This clinical report provides pediatric providers with the information they Pediatrics has neither solicited nor accepted any commercial need to promote the benefits of play and and to write a prescription for involvement in the development of the content of this publication. play at well visits to complement reach out and read. At a time when early Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external childhood programs are pressured to add more didactic components and reviewers. However, clinical reports from the American Academy of less playful learning, pediatricians can play an important role in emphasizing Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. the role of a balanced curriculum that includes the importance of playful The guidance in this report does not indicate an exclusive course of learning for the promotion of healthy child development. treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
To cite: Yogman M, Garner A, Hutchinson J, et al; AAP INTRODUCTION COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, AAP COUNCIL ON COMMUNICATIONS AND MEDIA. The Power of Play: A Pediatric Role in Enhancing Development in Young Children. Pediatrics. 2018;142(3):e20182058 Since the publication of the American Academy of Pediatrics1,2 (AAP) Clinical Reports on the importance of play in 2007, newer research has provided additional evidence of the critical importance of play in PEDIATRICS Volume 142, number 3, September 2018:e20182058 FROM THE AMERICAN ACADEMY OF PEDIATRICS facilitating parent engagement; private reality, contains elements of that the teaching methods of the past promoting safe, stable, and make believe, and is nonliteral. 2 centuries, such as memorization, be nurturing relationships; encouraging replaced by innovation, application, Depending on the culture of the 18 the development of numerous and transfer. adults in their world, children competencies, including executive – learn different skills through play. NATURE OF LEARNING AND PLAY functioning skills; and improving life 3 5 Sociodramatic play is when children course trajectories. An increasing act out the roles of adulthood from societal focus on academic readiness having observed the activities of their 20 (promulgated by the No Child Left Bruner et al stressed the fact that elders. Extensive studies of animal Behind Act of 2001) has led to a play is typically buffered from real- play suggest that the function of play focus on structured activities that life consequences. Play is part of is to build a prosocial brain that can are designed to promote academic 11 our evolutionary heritage, occurs interact effectively with others. results as early as preschool, with a in a wide spectrum of species, is corresponding decrease in playful Play is fundamentally important for fundamental to health, and gives learning. Social skills, which are learning 21st century skills, such us opportunities to practice and part of playful learning, enable as problem solving, collaboration, hone the skills needed21 to live in a children to listen to directions, and creativity, which require the complex world. Although play is pay attention, solve disputes with executive functioning skills that are present in a large swath of species words, and focus on tasks6 without critical for adult success. The United within the animal kingdom, from constant supervision. By contrast, a Nations Convention on the Rights of invertebrates (such as the octopus, recent trial of an early mathematics the Child has enshrined the right to lizard, turtle, and honey bee) to intervention in preschool showed engage in play that is appropriate to mammals (such as rats, monkeys, “ 12 22 almost no gains in math achievement the age of the child in Article 21. and humans), social play is more 7 – ” in later elementary school. Despite In its 2012 exhibit The Century of prominent in animals with a large “ 23 criticism from early childhood the Child: 1900 2000, the Museum neocortex. Studies of animal experts, the 2003 Head Start Act of Modern Art noted, Play is to behavior suggests that play provides reauthorization ended the program the 21st century what work was to animals and humans with skills evaluation of social emotional skills industrialization. It demonstrates a that will help them with survival ” 24 and was focused almost exclusively8 way of 13knowing, doing,14 and creating and reproduction. Locomotor on preliteracy and premath skills. value. Resnick has described 4 skills learned through rough-and- The AAP report on school readiness guiding principles to support creative tumble play enables escape from includes an emphasis on the – learning in children: projects, predators. However, animals play importance of whole child readiness passion, peers, and play. Play is not even when25 it puts them at risk of (including social emotional, ’9 just about having fun but about predation. It is also suggested that attentional, and cognitive skills). taking risks, experimenting, and play teaches young animals what Without that emphasis, children s testing boundaries. Pediatricians they can and cannot do at times ability to pay attention and behave can be influential advocates by when they are relatively free from 26 appropriately in the classroom is encouraging parents and child care the survival pressures of adult life. disadvantaged. providers to play with children and to Play and27 learning are inextricably allow children to have unstructured linked. A Russian psychologist time to play as well as by recognized that learning occurs when The definition of play is elusive. encouraging educators to recognize children actively engage in practical However, there is a growing playful learning– as an important activities within a supportive social consensus that it is an activity that is complement to15 didactic18 learning. context. The accumulation of new intrinsically motivated, entails active Some studies note that the new knowledge is built on previous engagement, and results in joyful information economy, as opposed learning, but the acquisition of new discovery. Play is voluntary and to the older industrial 1, demands skills is facilitated by social and often has no extrinsic goals; it is fun more innovation and less imitation, often playful interactions. He was ’ “ ” and often spontaneous. Children are more creativity and less conformity. interested in what he called the often seen actively engaged in and Research on children s learning zone of proximal development, passionately engrossed in play; this indicates that learning thrives when which consists of mastering skills builds executive functioning skills children are given some agency that a child could not do alone but and contributes to school readiness (control of their own actions) to play could be developed with minimal 10 ’ 19 28 “ ” (bored children will not learn well). a role in their own learning. The assistance. Within the zone of Play often creates an imaginative demands of today s world require proximal development, the how of 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS ’ learning occurs through a reiterative solving, and creativity, according to healthy risks out of childhood: new 33 “ process called scaffolding, in which the 2010 IBM s Global CEO Study. guidelines on play by the national ” new skills are built on previous skills CATEGORIES OF PLAY commission state,41 The goal is not to and are facilitated by a supportive eliminateOutdoor Play risk. social environment. The construct of scaffolding has been extrapolated Play has been categorized in a to younger children. Consider how variety of ways, each with its own Outdoor play provides the a social smile at 6 to 8 weeks of age 32,34 Objectdevelopmental Play sequence. opportunity to improve36,37, 39 sensory invites cooing conversations, which integration skills. These leads to the reciprocal dance of activities involve the child as an social communication even before active participant and address motor, ’ This type of play occurs when an language emerges, followed by social cognitive, social, and linguistic infant or child explores an object referencing (the reading of a parent s domains. Viewed in this light, school and learns about its properties. ’ face for nonverbal emotional recess becomes an essential part of Object play progresses from early 42 content). The balance between a child s day. It is not surprising sensorimotor explorations, including facilitating unstructured playtime that countries that offer more the use of the mouth, to the use of for children and encouraging recess to young children see greater symbolic objects (eg, when a child adult scaffolding of play will vary academic success among the children “ uses a banana as a telephone) for 42,43 depending on the competing needs as they mature. Supporting ” communication, language, and in individual families, but the serve- and implementing recess not only Physical,abstract thought Locomotor,. or Rough-and- and-return aspect of play29 requires sends a message that exercise is Tumble Play caregiver engagement. fundamentally important for physical health but likely brings together Early learning and play are 30 children from diverse backgrounds to fundamentally social activities and This type of play progresses from develop42 friendships as they learn and fuel the development of language pat-a-cake games in infants to the grow.Social or Pretend Play Alone or With and thought. Early learning also acquisition of foundational motor – 35 Others combines playful discovery with the skills in toddlers and the free development of social emotional play seen at school recess. The skills. It has been demonstrated that development of foundational motor This type of play occurs when children playing with toys act like skills in childhood is essential to – – children experiment with different scientists and learn by looking and promoting an active lifestyle and the 15 17 36 39 social roles in a nonliteral fashion. listening to those around them. prevention of obesity. Learning “ ” ’ Play with other children enables However, explicit instructions limit to cooperate and negotiate promotes them to negotiate the rules and a child s creativity; it is argued that critical social skills. Extrapolation learn to cooperate. Play with adults we should let children learn through from animal data suggests that often involves scaffolding, as when observation and active engagement guided competition in the guise of an adult rotates a puzzle to help rather than passive memorization rough-and-tumble play allows all the child place a piece. Smiling and or direct instruction. Preschool participants to occasionally win 40 vocal attunement, in which infants children do benefit from learning and learn how to lose graciously. learn turn taking, is the earliest content, but programs have many Rough-and-tumble play, which is akin example of social play. Older children more didactic components than to the play seen in animals, enables 31 can develop games and activities they did 20 years ago. Successful children to take risks in a relatively through which they negotiate programs are those that encourage safe environment, which fosters relationships and guidelines with playful learning in which children the acquisition of skills needed for other players. Dress up, make believe, are actively engaged in meaningful communication, negotiation, and 32 and imaginary play encourage the discovery. To encourage learning, emotional balance and encourages use of more sophisticated language we need to talk to children, let them the development of emotional to communicate with playmates play, and let them watch what we intelligence. It enables risk taking “ and develop common rule-bound do as we go about our everyday and encourages the development of ” scenarios (eg, You be the teacher, lives. These opportunities foster the empathy because children are guided 25,30, 40 and I will be the student ). development of executive functioning not to inflict harm on others. skills that are critically important The United Kingdom has modified its Play has also been grouped as self- for the development of 21st century guidelines on play, arguing that the directed versus adult guided. Self- skills, such as collaboration, problem culture has gone too far by leaching directed play, or free play, is crucial PEDIATRICS Volume 142, number 3, September 2018 3 ’ ’ “ to children s exploration of the children s active engagement and conversations in which the parents ” world and understanding of19, 32,their44 previous experiences. Scaffolding is utter pleasantries ( Oh, you had a preferences and interests. a part of guided play; caregivers are good lunch! ), and the child responds Guided play retains the child agency, needed to provide the appropriate by vocalizing back. Uncontrollable such that the child initiates the play, amount of input and guidance for crying as a response to stress in a but it occurs either in a setting that children to develop optimal skills. 1-year-old is replaced as the child ’ an adult carefully constructs with a DEVELOPMENT OF PLAY reaches 2 to 3 years of age with the learning goal in mind (eg, a children s use of words to self-soothe, building museum exhibit or a Montessori on caregivers scaffolding their task) or in an environment where emotional responses. Already by 6 How does play develop? Play adults supplement the child-led months of age, the introduction of progresses from social smiling exploration with questions or solid foods requires the giving and to reciprocal serve-and-return comments that subtly guide the child “ receiving of reciprocal signals and interactions; the development of toward a goal. Board games that have ” communicative cues. During these babbling; games, such as peek-a- well-defined goals also fit into this activities, analyses of physiologic 45 boo ; hopping, jumping, skipping, category. For example, if teachers heart rate rhythms of infants with “ and running; and fantasy or rough- want children to improve executive both their mothers and fathers have ” and-tumble play. The human 49,52 functioning skills (see the Tools of shown synchrony. 46 infant is born immature compared the Mind curriculum), they could with infants of other species, with By 9 months of age, mutual create drum-circle games, in which “ substantial brain development regulation is manifested in the way children coregulate their behavior. ” “ occurring after birth. Infants are infants use their parents for social Familiar games such as Simon – 53,54 ” entirely dependent on parents referencing. In the classic visual Says or Head, Shoulders, Knees, to regulate sleep wake rhythms, cliff experiment, it was demonstrated and Toes ask children to control feeding cycles, and many social that an infant will crawl across their individual actions or impulses interactions. Play facilitates the a Plexiglas dropoff to explore if and have been shown to improve 47 progression from dependence to the mother encourages the infant executive functioning skills. Guided independence and from parental but not if she frowns. Nonverbal play has been defined as a child- regulation to self-regulation. It communication slowly leads to led, joyful activity in which adults promotes a sense of agency in the formal verbal language skills through craft the environment to optimize 4,48 child. This evolution begins in the which emotions such as happiness, learning. This approach harkens 28 first 3 months of life, when parents sadness, and anger are identified for back to Vygotsky and the zone (both mothers and fathers) interact the child via words. Uncontrollable of proximal development, which reciprocally with their infants by crying in the 1-year-old then represents the skills that children are reading their nonverbal cues in a becomes whining in the 2-year-old unable to master on their own but are – 49 responsive, contingent manner. and verbal requests for assistance able to master in the context of a safe, ’ Caregiver infant interaction is in the 3-year-old as parents scaffold stable, and nurturing relationship the earliest form of play, known the child s emotional responses and with an adult. The guidance and 50 as attunement, but it is quickly help him or her develop alternative, dialogue provided by the adult allow “ followed by other activities that more adaptive behaviors. Repetitive the child to master skills that would ” also involve the taking of turns. games, such as peek-a-boo and this take longer to master alone and help These serve-and-return behaviors little piggy, offer children the joy of children focus on the elements of promote self-regulation and impulse being able to predict what is about the activity to guide learning. One ’ “ ” control in children and form a strong to happen, and these games also way to think about guided play is 14,’48 foundation for understanding their enhance the infants ability to solicit as constrained tinkering. This interaction with adults. The back- social stimulation. ’ logic also characterizes Italy s Emilio and-forth episodes also feed into the Reggio approach, which emphasizes By 12 months of age, a child s development of language. the importance of teaching children experiences are helping to lay to listen and look. Reciprocal games occur51 with both the foundation for the ongoing mothers and fathers and often development of social skills. The 28 ’ According to Vygotsky, the most begin in earnest with the emergence expression of true joy and mastery ’ efficient learning occurs in a social of social smiles at 6 weeks of on children s faces when they take “ ” “ ” context, where learning is scaffolded age. Parents mimic their infant s their first step is truly a magical by the teacher into meaningful ooh and ah in back-and-forth moment that all parents remember. contexts that resonate with verbal games, which progress into Infant memory, in Piagetian terms, 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS develops as infants develop object and cannot be directly extrapolated suggesting that play deprivation permanence through visible and to humans. interfered with the process of72 11 invisible displacements, such as Jaak Panksepp, a neuroscientist synaptogenesis and pruning. Rat repetitive games like peek-a-boo. and psychologist who has extensively pups that were isolated during peak With the advent of locomotor skills, studied the neurologic basis of play periods after birth (weeks 4 and rough-and-tumble play becomes emotion in animals, suggests that 5) are much less socially active when increasingly available. During the they73, encounter74 other rats later in play is 1 of 7 innate emotional58 second year, toddlers learn to systems in the midbrain. Rats love life. explore their world, develop the rough-and-tumble play and– produce beginnings of self-awareness, and “ ” Play-deprived rats also showed a distinctive sound that42, Panksepp59 64 use their parents as a home base labeled rat laughter. When impaired problem-solving skills, (secure attachment), frequently rats are young, play appears to suggesting that through play, animals checking to be sure that the world 55 initiate lasting changes in areas of the learn to try new things73 and develop they are exploring is safe. As brain that are used for thinking and behavioral flexibility. Socially children become independent, processing social interaction. reared rats with damage to their their ability to socially self-regulate PFC mimic the social deficiencies of The dendritic length, complexity, becomes apparent: they can focus rats with intact brains but who were and spine density of the medial 66 their attention and solve problems – deprived of play as juveniles. The prefrontal cortex (PFC) are refined efficiently, they are less impulsive, 64 67 BDNF absence of the play experience leads by play. The brain-derived and they can better manage56 the to anatomically measurable changes neurotrophic factor ( ) is stress of strong emotions. With in the neurons of the PFC. By refining a member of the neurotrophin increased executive functioning skills, the functional organization of the family of growth factors that acts they can begin to reflect on how they PFC, play enhances the executive to support the survival of existing should respond to a situation rather functioning skills derived from neurons and encourage the growth 66 than reacting impulsively. With this part of the brain. Whether and differentiation of new neurons the development of language and these effects are specific to play and synapses. It is known to be symbolic functioning, pretend play57 deprivation or merely reflect the important for long-term memory and now becomes more prominent. BDNF generic effect of a lack of stimulation social learning. Play stimulates the Fantasy play, dress up, and fort requires further study. Rats that production of in RNA in the building now join the emotional and – were raised in experimental toy-filled amygdala, dorsolateral frontal cortex, social repertoire of older children 65,68 70 cages had bigger brains and thicker hippocampus, and pons. just as playground activities, tag, cerebral cortices and completed Gene expression analyses indicate 67,75 and hide and seek develop motor mazes more quickly. skills. In play, children are also that the activities of approximately one-third of the 1200 genes in the solving problems and learning to Brain neurotransmitters, such frontal and posterior cortical regions focus attention, all of which promote as dopamine made by cells in were significantly modified by play the growth of executive functioning the substantia nigra and ventral within an hour after a 30-minute skills. 69,70 BDNF tegmentum, are also related to the play session. The gene that EFFECTS ON BRAIN STRUCTURE AND reward quality of play: drugs that showed the largest effect was . FUNCTIONING activate dopamine receptors increase Conversely, rat pup adversity, 76 play behavior in rats. depression, and stress BDNFappear Play is not frivolous; it is brain to result in the methylation and Play and stress are closely linked. building. Play has been shown downregulation71 of the gene in High amounts of play are associated to have both direct and indirect the PFC. with low levels of cortisol, suggesting effects on brain structure and Two hours per day of play with either that play reduces stress or 23 functioning. Play leads to changes objects predicted changes in brain that unstressed animals play more. at the molecular (epigenetic), weight and11,66 efficiency in experimental Play also activates norepinephrine, cellular (neuronal connectivity), and animals. Rats that were deprived which facilitates learning at synapses behavioral levels (socioemotional of play as pups (kept in sparse cages and improves brain plasticity. and executive functioning skills) devoid of toys) not only were less Play, especially when accompanied that promote learning and adaptive competent at problem solving later by nurturing caregiving, may and/or prosocial behavior. Most of on (negotiating mazes) but the indirectly affect brain functioning by this research on brain structure and medial PFC of the play-deprived rats modulating or buffering adversity functioning has been done with rats was significantly more immature, and by reducing toxic stress to levels PEDIATRICS Volume 142, number 3, September 2018 5 that are more compatible77,78 with coping improvements in executive more sophisticated95, language96 when and resilience. functioning, language, early math playing with peers. skills (numerosity and spatial In human children, play usually Play in a variety of forms (active concepts), social development, peer enhances curiosity, which facilitates physical play, pretend play, and relations, physical development memory and learning. During states – play with traditional toys and and health, and enhanced sense of ’ of high curiosity, functional MRI 13,32, 56, 57, 84 88 shape sorters [rather than digital agency. The opposite results showed enhanced activity in 89 toys]) improves children s skills. is also likely true; Panksepp healthy humans in their early 20s in When children were given blocks suggested that play deprivation the midbrain and nucleus accumbens to play with at home with minimal is associated with the increasing and functional connectivity to the adult direction, preschool children prevalence of attention-deficit/ hippocampus, which solidifies 90 showed improvements in language hyperactivity disorder. connections between intrinsic acquisition at a 6-month follow-up, motivation and hippocampus-79 Executive functioning, which is particularly low-income children. dependent learning. Play helps described as the process of how we The authors suggest that the children deal with stress, such as learn over the content of what we benefits of Reach Out and Play life transitions. When 3- to 4-year- learn, is a core benefit of play and can may promote development97 just as old children who were anxious be characterized by 3 dimensions: Reach Out and Read does. When about entering preschool were cognitive flexibility, inhibitory playing with objects under minimal randomly assigned to play with toys control, and working memory. adult direction, preschool children or peers for 15 minutes compared Collectively, these dimensions named an average of 3 times as with listening to a teacher reading allow for sustained attention, the many nonstandard uses for an a story, the play group showed a filtering of distracting details, object compared with children who98 twofold decrease24,80 in anxiety after the improved self-regulation and self- were given specific instructions. control, better problem solving, In Jamaica, toddlers with growth intervention. In another study, – preschool children with disruptive and mental flexibility. Executive retardation who were given weekly behavior who engaged with teachers functioning helps children switch play sessions to improve mother in a yearlong 1-to-1 play session gears and transition from drawing child interactions for 2 years were designed to foster warm, caring with crayons to getting dressed for followed to adulthood and showed ’ relationships (allowing children school. The development of the PFC better educational attainment, to lead, narrating the children s and executive functioning balances less depression, and less violent ’ 3 behavior out loud, and discussing the and moderates the impulsiveness, behavior. children s emotions as they played) emotionality, and aggression of Children who were in active play showed reduced salivary cortisol the amygdala. In the presence of for 1 hour per day were better able stress levels during the day and childhood adversity, the role of 22 to think creatively and multitask. improved behavior compared with play becomes even more important 81 Randomized trials of physical play in children in the control group. The in that the mutual joy and shared 7- to 9-year-olds revealed enhanced notable exception is with increased attunement that parents and ’ attentional inhibition, cognitive stress experienced by children with children can experience during play – flexibility, and brain functioning autism spectrum disorders in new downregulates the body s stress 82 91 94 that were indicative of enhanced or social circumstances. Animal response. Hence, play may be 99 executive control. Play with studies suggest the role of play an effective antidote to the changes traditional toys was associated with as a social buffer. Rats that were in amygdala size, impulsivity, an increased quality and quantity previously induced to be anxious aggression, and uncontrolled of language compared with play became relaxed and calm after rough- emotion that result from significant 100 with electronic toys, particularly and-tumble play with a nonanxious childhood adversity and toxic stress. 83 if the video toys did not encourage playful rat. Extrapolating from Future research is needed to clarify 101 interaction. Indeed, it has been these animal studies, one can suggest this association. shown that play with digital shape that play may serve as an effective ’ Opportunities for peer engagement sorters rather than traditional shape buffer for toxic stress. through play cultivate the ability to sorters stunted the102 parent s use of BENEFITS OF PLAY negotiate. Peer play usually involves spatial language. Pretend play problem solving about the rules of encourages self-regulation because the game, which requires negotiation children must collaborate on the The benefits of play are extensive and cooperation. Through these imaginary environment and agree and well documented and include encounters, children learn to use about pretending and conforming to 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS ’ roles, which improves their ability favorite childhood books, parents be contrasted with interactions in – – ’ to reason56,57, about103 105 hypothetical learn to see the world from their which adults direct children s play. events. Social emotional child s perspective and are likely It has been shown that if a caregiver skills are increasingly viewed as to communicate more effectively instructs a child in how a toy works, ’ related to106 academic and economic with their child, even appreciating the child is less likely to discover success. Third-grade prosocial and sharing their child s sense of other attributes of the toy– in contrast behavior correlated with eighth- humor and individuality. Play enables to a child being left to explore the toy 38,’ 116 118 grade reading and math better children and adults to be passionately without direct input. Adults than with third-grade reading and and totally immersed in an activity who facilitate a child s play without 17,107 ’ math. of their choice and to experience being intrusive can encourage the intense joy, much as athletes do child s independent exploration and The health benefits of play involving when they are engaging in their learning. physical activity are many. Exercise optimal performance. Discovering not only promotes healthy weight IMPLICATIONS FOR PRESCHOOL their true passions is another critical and cardiovascular fitness but EDUCATION strategy for helping both children also can enhance the efficacy and adults cope with adversity. One of the immune, endocrine, and 37 study documented that positive cardiovascular systems. Outdoor Scaffolding play activities facilitated parenting activities, such as playing playtime for children in Head Start by adults enable children to work in and shared reading, result in programs has been associated with groups: to share, negotiate, develop 39 decreases in parental experiences decreased BMI. Physical activity – decision-making and problem- of stress and enhancement in the is associated with decreases in solving skills, and discover their own 108 parent child relationship, and these concurrent depressive symptoms. – interests. Children learn to resolve effects mediate relations between Play decreases stress, fatigue, injury, – conflicts and develop self-advocacy the activities and social emotional and depression and increases range 111 113 skills and their own sense of agency. development. of motion, agility, coordination,109 The false dichotomy between play balance, and flexibility. Children Most importantly, play is an versus formal learning is now pay more attention to class lessons opportunity for parents to engage being challenged by educational after free play at recess than they do with their children by observing and reformers who acknowledge the after physical education programs,43 understanding nonverbal behavior in value of playful learning or guided which are more structured. Perhaps young infants, participating in serve- play, which captures the strengths they are more active during free play. andreturn exchanges, or sharing the of both approaches and may be joy and witnessing the blossoming of essential to improving executive Play also reflects and transmits 18,19, 34, 119 the passions in each of their children. functioning. Hirsh-Pasek cultural values. In fact, recess 34 ’ et al report a similar finding: began in the United States as a way Play not only provides opportunities14 children have been shown to discover to socially integrate immigrant for fostering children46s curiosity, causal mechanisms more quickly children. Parents in the United States self-regulation skills, language when they drive their learning as encourage children to play with toys development, and imagination but opposed to when adults display and/or objects alone, which is typical also promotes the dyadic reciprocal solutions for them. of communities that emphasize interactions between children the development of independence. and parents, which is a crucial 114 Executive functioning skills are Conversely, in Japan, peer social play element of healthy relationships. foundational for school readiness and with dolls is encouraged, which is Through the buffering capacity of academic success, mandating a frame caregivers, play can serve as an typical of cultures110 that emphasize shift with regard to early education. interdependence. antidote to toxic stress, allowing The goal today is to support BENEFITS TO ADULTS OF PLAYING WITH the physiologic stress77 response to interventions that cultivate a range of CHILDREN return to baseline. Adult success skills, such as executive functioning, in later life can be related to the in all children so that the children experience of childhood play that enter preschool and kindergarten Playing with children adds value not cultivated creativity, problem curious and knowing how to learn. only for children but also for adult solving, teamwork,18,52, 115 flexibility, and Kindergarten should provide children innovations. caregivers, who can reexperience with an opportunity for playful14 or reawaken the joy of their own Successful scaffolding (new skills collaboration and tinkering, childhood and rejuvenate themselves. built on previous skills facilitated by a different approach from the model Through play and rereading their a supportive social environment) can that promotes more exclusive PEDIATRICS Volume 142, number 3, September 2018 7 didactic learning at the expense is an alternative and innovative way of homes are located129, within130 a of playful learning. The emerging of thinking about early childhood half-mile of a park. Cultural alternative model is to prevent education. Instead of focusing solely changes have also jeopardized the ’ toxic stress and build resilience by on academic skills, such as reciting opportunities children have to play. developing executive functioning the alphabet, early literacy, using From 1981 to 1997, children s skills. Ideally, we want to protect the flash cards, engaging with computer playtime decreased by 25%. brain to enable it to learn new skills, toys, and teaching to tests (which has Children 3 to 11 years of age have and we want to focus on learning been overemphasized to promote lost 12 hours per week of free time. those skills that will be used to buffer18 improved test results), cultivating Because of increased academic the brain from any future adversity. the joy of learning through play is pressure, 30% of US kindergarten42,129 The Center on the Developing Child likely to better encourage long-term children no longer have recess. at Harvard University offers an academic success. Collaboration, An innovative program begun in online resource on play and executive negotiation, conflict resolution, self- Philadelphia is using cities (on functioning with specific activities advocacy, decision-making, a sense everyday walks and in everyday suggested for parents and children of agency, creativity, leadership, neighborhoods) as opportunities (http://developingchild.harvard . and increased physical activity are for creating learning landscapes edu/wp-content/uploads/2015/05/ just some of the skills and benefits that provide opportunities Enhancing-and-Practicing-Executive- children gain through play. for parents and children to Function-Skills-with-Children-from- spark conversation and playful 120 MODERN CHALLENGES 131,132 Infancy-to-Adolescence-1 . pdf). learning.132 For example, Ridge Specific curricula have now been et al have placed conversational developed and tested in preschools prompts throughout supermarkets to help children develop executive For many families, there are and laundromats to promote functioning skills. Many innovative risks in the current focus only language and lights at bus stops programs are using either the on achievement, after-school to project designs on the ground, Reggio Emilia philosophy or enrichment programs, increased enabling children to play a game homework, concerns about of hopscotch that is specifically curricula such as Tools of121 the Mind (developed in California) or test performance, and college designed to foster impulse control. – Promoting Alternative Thinking acceptance. The stressful effects By promoting the learning of of this approach often result in social and emotional skills, Strategies Preschool122 and/or Kindergarten. Caregivers need to the later development of anxiety the development of emotional provide the appropriate amount of and depression and a lack of intelligence, and the enjoyment of creativity. Parental guilt has led to active learning, protected time for input and guidance for children to “ ” develop optimal problem-solving competition over who can schedule free play and guided play can be skills through guided play and more enrichment opportunities used to help children improve their for their children. As a result, there social skills, literacy, and school scaffolding. Optimal learning can ’ be depicted by a bell-shaped curve, is little time left in the day for readiness. Children can then enter which illustrates the optimal zone children s free play, for parental school with a stronger foundation reading to children, or for family for attentional disposition based of arousal123 and stress for complex learning. meal times. Many schools have on the skills and attitudes that cut recess, physical education, art, are critical for academic success Scaffolding is extensively used to and music to focus on preparing and the long-term enjoyment of support skills such as buddy reading, children for tests. Unsafe local learning and love of school. ROLE OF MEDIA IN CHILDREN’S PLAY in which children take turns being neighborhoods and playgrounds lips and ears and learn to read and have led to nature 127deficit disorder listen to each other as an example for many children. A national of guided play. A growing body of survey of 8950 preschool children Media (eg, television, video research shows that this curriculum and parents found that only 51% games, and smartphone and tablet not only improves executive of children went outside to walk applications) use often encourages ’ functioning skills but– also shows or play 128once per day with either passivity and the consumption improvement in6, 124brain126 functioning on parent. In part, this may reflect of others creativity rather than functional MRI. the local environment: 94% of active learning and socially Focusing on cultivating executive parents have expressed safety interactive play. Most importantly, functioning and other skills through concerns about outdoor play, and immersion in electronic media playful learning in these early years access may be limited. Only 20% takes away time from real play, 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS 137 either outdoors or indoors. Real In the 2015 symposium, the provide for their families, but a warm learning happens better in person- AAP clarified recommendations caregiver or extended family as well ’ to-person exchanges rather than acknowledging the ubiquity and as a dynamic community program144 machine-to-person interactions. transformation of media from can help support parents efforts. Most parents are eager to do the primarily television to other The importance of playtime with right thing for their children. modalities, including video chatting. children cannot be overemphasized However, advertisers and the media In 2016, the AAP published 2 new to parents as well as schools and can mislead parents about how to policies on digital media affecting community organizations. Many ’ best support and encourage their young children, school-aged children145 do not have safe places children s growth and development children, and adolescents. These to play. Neighborhood threats, as well as creativity. Parent surveys policies included recommendations such as violence, guns, drugs, and have revealed that many parents for parents, pediatricians, and traffic, pose safety concerns in see media and technology as the researchers139, to140 promote healthy many neighborhoods, particularly best way133 to help their children media use. The AAP has also low-income areas. Children in low- learn. However, researchers launched a Family Media Use Plan income, urban neighborhoods also ’ contradict this. Researchers have to help parents and families create may have less access to quality public compared preschoolers playing healthy guidelines for their children s spaces and recreational145 facilities with blocks independently with media use so as to avoid displacing in their communities. Parents preschoolers watching Baby activities such as active play, and who feel that their neighborhoods Einstein tapes and have shown that guidelines can also be found on the are unsafe may also not permit the children playing with blocks HealthyChildren.org and Common their children to play outdoors or independently developed better Sense Media (commonsensemedia. independently. language and cognitive skills34, than134 org) Web sites. their peers watching videos. Public health professionals are BARRIERS TO PLAY Although active engagement with increasingly partnering with age-appropriate media, especially if other sectors, such as parks and supported by cowatching or coplay recreation, public safety, and community development, to advocate with peers or parents,135 may have There are barriers to encouraging some benefits, real-time social play. Our culture is preoccupied for safe play environments in all communities. This includes efforts interactions remain superior to 136 with marketing142 products to young digital media for home learning. children. Parents of young to reduce community violence, improve physical neighborhood children who cannot afford143 expensive It is important for parents to toys may feel left out. Parents infrastructure, and support planning understand that media use often who can afford expensive toys and and design decisions that foster safe, does not support their– goals of electronic devices may think that clean, and accessible public spaces. encouraging curiosity137 141 and learning allowing their children unfettered ROLE OF PEDIATRICIANS for their children. Despite access to these objects is healthy ’ research that reveals an association and promotes learning. The reality between television watching and a is that children s creativity and play sedentary lifestyle and greater risks is enhanced by many inexpensive Pediatricians can advocate for of obesity, the typical preschooler toys (eg, wooden spoons, blocks, the importance of all forms of watches 4.5 hours of television per balls, puzzles, crayons, boxes, and play as well as for the role of play day, which displaces conversation simple available household objects) in the development of executive with parents and the practice of joint and by parents who engage with functioning, emotional intelligence, attention (focus by the parent and their children by reading, watching, and social skills (Table 1). child on a common object) as well as playing alongside their children, Pediatricians have a critical role ’ physical activity. For economically and talking with and listening to to play in protecting the integrity ’ challenged families, competing their children. It is parents and of childhood by advocating for all pressures make it harder for parents caregivers presence and attention children to have the opportunity to to find the time to play with children. that enrich children, not elaborate express their innate curiosity in the Encouraging outdoor exercise may be electronic gadgets. One-on-one play world and their great capacity for more difficult for such families given is a time-tested way of being fully imagination. For children with special unsafe playgrounds. Easy access to present. Low-income families may needs, it is especially important to ’ electronic media can be difficult for have less time to play with their create safe opportunities for play. parents to compete with. children while working long hours to A children s museum may offer PEDIATRICS Volume 142, number 3, September 2018 9 TABLE 1 Recommendations From Pediatricians to Parents Use play to help meet milestones. From birth, infants use play to explore the world around them as well as to learn and develop important life skills. of how to promote early 0–6 mo learning); Show your infant interesting objects, such as a brightly colored mobile or toy. ’ Talk to your infant often to familiarize him or her with your voice, and respond when he or she coos 2. Advocate for the protection of and babbles. children s unstructured playtime Place your infant in different positions so he or she can see the world from different angles. Let your infant bring safe objects to his or her mouth to explore and experience new textures. because of its numerous benefits, Vary facial expressions and gestures so that your infant can imitate them. Imitate your infant’s including the development of sounds and engage in a back-and-forth conversation using your infant’s sounds as a prompt. foundational motor skills that 7–12 mo may have lifelong benefits Use a mirror to show faces to your infant. for the prevention of obesity, Provide your infant with a safe environment to crawl and explore. Place your infant in a variety of positions, such as on his or her tummy, side, etc. hypertension, and type 2 diabetes; Give your infant opportunities to learn that his or her actions have effects (for example, when he or 3. Advocate with preschool she drops a toy and it falls to the ground). Put a few toys within the reach of your infant so he or educators to do the following: she can take toys out and play with them. Play peek-a-boo. focus on playful rather than 1–3 y didactic learning by letting Allow your child to spend time with objects and toys that he or she enjoys. children take the lead and Give your child pens, markers, or crayons and paper to practice scribbling. follow their own curiosity; Encourage your child to interact with peers. – put a premium on building Help your child explore his or her body through different movements (for example, walking, jumping, and standing on 1 leg). social emotional and executive Provide opportunities to create make-believe situations with objects (for example, pretending to functioning skills throughout the drink out of an empty cup or offering toys that enable pretend play). school year; and protect time for Respond when your child speaks, answer questions, and provide verbal encouragement. recess and physical activity; Provide blocks, plastic containers, wooden spoons, and puzzles. Read regularly to and with your child. Encourage pretend play based on these stories. 4. Emphasize the importance of Sing songs and play rhythms so that your child can learn and join in the fun. playful learning in preschool – 4–6 y curricula for fostering stronger Provide opportunities for your child to sing and dance. caregiver infant relationships Tell stories to your child and ask questions about what he or she remembers. Give your child time and space to act out imaginary scenes, roles, and activities. and promoting executive Allow your child to move between make-believe games and reality (for example, playing house and functioning skills. Communicating helping you with chores). this message to policy makers, Schedule time for your child to interact with friends to practice socializing and building friendships. legislators, and educational Encourage your child to try a variety of movements in a safe environment (for example, hopping, administrators as well as swinging, climbing, and doing somersaults). the broader public is equally Adapted from www.pathway. org. important; and 5. Just as pediatricians support Reach Out and Read, encourage “ playful learning for parents and ’ ” special mornings when it is open For example, encouraging parents infants by writing a prescription only to children with special needs. to recognize their children s for play at every well-child visit Extra staffing enables these children emerging social smile and to in the first 2 years of life. and their siblings to play in a safe respond with a smile of their environment because they may not own is a form of play that also – “ A recent randomized controlled be able to participate during crowded teaches the infants a critical trial of the Video Interaction Project routine hours. social emotional skill: You can (an enhancement of Reach Out get my attention and a smile from The AAP recommends that ” and Read) has demonstrated that me anytime you want just by the promotion of reading and play pediatricians: – smiling yourself. By encouraging during pediatric visits leads to ’ 1. Encourage parents to observe parents to observe the behavior enhancements112 in social emotional and respond to the nonverbal of their children, pediatricians development. In today s world, behavior of infants during their create opportunities to engage ’ many parents do not appreciate the first few months of life (eg, parents in discussions that are importance of free play or guided nonjudgmental and free from responding to their children s ’ play with their children and have emerging social smile) to help criticism (because they are come to think of worksheets and
them better understand this grounded in the parents own other146 highly structured activities as unique form of communication. observations and interpretations play. Although many parents feel 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS CONTRIBUTOR Virginia Keane, MD, FAAP that they do not have time to play versus seeking to encourage active with their children, pediatricians engagement in learning through COMMITTEE ON PSYCHOSOCIAL ASPECTS can help parents understand that play. With our understanding OF CHILD AND FAMILY HEALTH, 2017–2018 playful learning moments are of early brain development, we ’ Michael Yogman, MD, FAAP, Chairperson everywhere, and even daily chores suggest that learning is better Rebecca Baum, MD, FAAP alongside parents can be turned into fueled by facilitating the child s Thresia Gambon, MD, FAAP playful opportunities, especially if intrinsic motivation through play Arthur Lavin, MD, FAAP the children are actively interacting rather than extrinsic motivations, Gerri Mattson, MD, FAAP with parents and imitating chores. •• such as test scores; Lawrence Wissow, MD, MPH, FAAP Young children typically seek more ’ 46 LIAISONS attention from parents. Active play An alternative model for learning stimulates children s curiosity and is for teachers to develop a safe, Sharon Berry, PhD, LP – Society of Pediatric helps them develop the physical and stable, and nurturing relationship Psychology with the child to decrease stress, Amy Starin, PhD, LCSW – National Association of social skills32 needed for school and Social Workers increase motivation, and ensure later life. ’ Edward Christophersen, PhD, FAAP – Society of CONCLUSIONS receptivity to activities that Pediatric Psychology promote skills within each child s Norah Johnson, PhD, RN, CPNP-BC – National •• zone of proximal development. The Association of Pediatric Nurse Practitioners emphasis in this preventive and Abigail Schlesinger, MD – American Academy of Child and Adolescent Psychiatry Cultural shifts, including less developmental model is to promote parent engagement because of resilience in the presence of STAFF parents working full-time, fewer adversity by enhancing executive Karen S. Smith safe places to play, and more functioning skills with free play COUNCIL ON COMMUNICATIONS AND digital distractions, have limited •• and guided play; the opportunities for children MEDIA, 2017–2018 to play. These factors may Play provides ample opportunities David L Hill, MD, FAAP, Chairperson ’ – negatively affect school readiness, for adults to scaffold the foundational Nusheen Ameenuddin, MD, MPH, FAAP children s healthy adjustment, motor, social emotional, language, Yolanda (Linda) Reid Chassiakos, MD, FAAP Corinn Cross, MD, FAAP and the development of important executive functioning, math, and Rhea Boyd, MD, FAAP •• executive functioning skills; self-regulation skills needed to be Robert Mendelson, MD, FAAP successful in an increasingly complex Megan A Moreno, MD, MSEd, MPH, FAAP Play is intrinsically motivated and and collaborative world. Play helps Jenny Radesky, MD, FAAP leads to active engagement and to build the skills required for our Wendy Sue Swanson, MD, MBE, FAAP joyful discovery. Although free Jeffrey Hutchinson, MD, FAAP ’ •• changing world; and Justin Smith, MD, FAAP play and recess need to remain integral aspects of a child s day, Play provides a singular LIAISONS the essential components of play opportunity to build the executive Kristopher Kaliebe, MD – American Academy of can also be learned and adopted functioning that underlies adaptive Child and Adolescent Psychiatry by parents, teachers, and other behaviors at home; improve Jennifer Pomeranz, JD, MPH – American Public caregivers to promote healthy language and math skills in school; Health Association Health Law Special Interest build the safe, stable, and nurturing Group child development and enhance – relationships that buffer against Brian Wilcox, PhD – American Psychological •• learning; Association toxic stress; and build social The optimal educational model emotional resilience. for learning is for the teacher to STAFF ’ ’ Using Joyful Activity To Build engage the student in activities that ResiliencyFor more information,in Children in see Response Kearney to Thomas McPheron promote skills within that child s Toxicet al s Stress zone of proximal development, 147 ABBREVIATIONS . which is best accomplished LEAD AUTHORS through dialogue and guidance, Michael Yogman, MD, FAAP not via drills and passive rote Andrew Garner, MD, PhD, FAAP AAP: American Academy of learning. There is a current debate, BDNF Jeffrey Hutchinson, MD, FAAP Pediatrics particularly about preschool Kathy Hirsh-Pasek, PhD : brain-derived neuro- curricula, between an emphasis on Roberta Golinkoff, PhD trophic factor content and attempts to build skills PFC: prefrontal cortex by introducing seat work earlier PEDIATRICS Volume 142, number 3, September 2018 11 All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
DOI: https://doi. org/ 10. 1542/ peds. 2018- 2058
Address correspondence to Michael Yogman, MD, FAAP. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2018 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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PEDIATRICS Volume 142, number 3, September 2018 15 in children 4 to 12 years old. Science. status families.Mind Brain Educ. 140. American Academy of Pediatrics 2011;333(6045):959–964 2015;9(3):127–135 Council on Communications and Media. Policy statement: media and young 126. Blair C, Granger DA, Willoughby M, 133. Radesky JS, Eisenberg S, Kistin CJ, et al. minds. Pediatrics. 2016;138(5):89 92 et al; FLP Investigators. Salivary Overstimulated consumers or next- – cortisol mediates effects of poverty generation learners? Parent tensions 141. Rich M. Health importance of media and parenting on executive functions about child mobile technology use. Ann on children. In: American Academy in early childhood. Child Dev. Fam Med. 2016;14(6):503–508 of Pediatrics National Conference 2011;82(6):1970–1984 and Exhibition; October 2016; San 134. Anderson DR, Pempek TA. Television Francisco, CA 127. Louv R. Last Child in the Woods: Saving and very young children. Am Behav Sci. Our Children From Nature-Deficit 2005;48(5):505–522 142. Hirsh-Pasek K, Golinkoff RM. The Disorder. Chapel Hill, NC: Algonquin great balancing act: optimizing core 135. Adachi PJ, Willoughby T. The link Books; 2008 curricula through playful learning. between playing video games and 128. Tandon PS, Zhou C, Christakis DA. In: Zigler E, Gilliam W, Barnett S, eds. positive youth outcomes. Child Dev Frequency of parent-supervised The Preschool Education Debates. Perspect. 2017;11(3):202–206 outdoor play of US preschool-aged Baltimore, MD: Brookes Publishing Co; children. Arch Pediatr Adolesc Med. 136. Radesky JS, Zuckerman B. Learning 2011:110–116 2012;166(8):707 712 from apps in the home: parents – 143. Christakis E. The Importance of Being and play. In: Kucirkova N, Falloon G, 129. Hofferth SL, Sandberg JF. Changes in Little. New York, NY: Viking Press; 2016 eds. Apps, Technology, and Younger American children’s time, 1981-1997. Learners: International Evidence for 144. Bodrova E, Leong D. Tools of the Mind: Adv Life Course Res. 2011;6:193–229 Teaching. Oxford, United Kingdom: The Vygotskian Approach to Early 130. Bishop R. Go out and play, but mean Routledge; 2017 Childhood Education, 2nd ed. New York, it: using frame analysis to explore NY: Pearson; 2006 recent news media coverage of the 137. American Academy of Pediatrics. rediscovery of unstructured play. Soc Growing up digital. In: Media Research 145. Child Trends. Neighborhood safety. Symposium; October 1, 2015; Berlin, Available at: https://www. childtrends. Sci J. 2013;50(4):510–520 Germany org/indicators/ neighborhood- safety/ . 131. Hirsh-Pasek K, Golinkoff RM. Accessed October 24, 2017 Transforming cities into learning 138. Lillard AS, Peterson J. The immediate landscapes. Available at: https://ssir. impact of different types of television 146. Fisher EP. The impact of play on org/articles/ entry/ transforming_ on young children’s executive function. development: a meta-analysis. Play cities_into_ learning_ landscapes. Pediatrics. 2011;128(4):644–649 Cult. 1992;5(2):159–181 Accessed October 24, 2017 139. American Academy of Pediatrics 147. Kearney B, Ritzenthaler H, Gray G, 132. Ridge KE, Skolnick Weisber D, Ilgaz Council on Communications and Yoder W. Using Joyful Activity To Build H, Hirsh-Pasek KA, Golnikoff RM. Media. Policy statement: children, Resiliency in Children in Response Supermarket speak: increasing adolescents, and the media. Pediatrics. to Toxic Stress. Brook Park, OH: Ohio talk among low socio-economic 2016;132(5):958–961 Guidestone; 2017
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