By Ashley Pagenkopf, MS, CCLS, Child Life Specialist at Cook Children's

It’s amazing to see what one bright-colored toy or fidget can do to change the feeling in an exam room. Recently, I have started grabbing something to take to patients when I get a call to help prepare them for a procedure or support them.

Typically, I grab something small – a pop-it, a Hot Wheels car or something else that I can offer them upon entering the room. You can see kids’ eyes when you walk into the room. They are scanning your hands to see why you came and what you are there for. They are really looking for a SHOT!

When they scan my hands, they often see an iPad and some small toy or fidget of some kind, and their face melts a bit. They soften. Why does this happen? Because play is magical…

Play is the act of engaging in something for fun or enjoyment. We know that play is universal and crosses many cultural and language barriers. In fact, child life specialists would say that play can be a language of its own. Play is a pillar of child life practice, and we could not engage patients and families without it.

We see the expression of a child’s emotions and experiences being worked out in play often more than words. We also know that play is an integral part of cognitive, speech/language, social/emotional, and gross and fine motor development.

This makes play essential in a pediatric health care setting. It is our goal to continue the normal growth and development of children even during stressful experiences like hospitalizations, traumatic experiences and chronic illnesses.

There are several ways that we utilize play in the health care environment. We use play for normalizing the environment, preparing and teaching the patient and family about medical procedures, and for processing their experiences.

Normalizing the Hospital Experience

Developmentally appropriate play is the most natural aspect of childhood that kids know and understand. We use developmentally-appropriate play to help normalize what is otherwise a very stressful place. Just as I referenced in the story above, walking in with a toy or a stuffed animal immediately changes the atmosphere.

Basic things like coloring, Play-Doh and bubbles are the framework of breaking barriers with kids in this seemingly very scary place. You will notice in many exam rooms around the hospital and medical center that there are eye-spy art pictures for children to engage in while they wait.

Each age group plays differently and has different needs. When I would meet kids as an inpatient child life specialist, I would often ask kids what they loved to do if they were stuck in bed at their house. We want to start with their favorite things and what brings the most comfort. Thankfully, we are able to provide play opportunities to every kid that enters our doors in some way.

Through hospital allocations and community donations, play is always possible. I’ve played countless hours of Barbies and Battleship with kids. UNO tournaments were a norm in our inpatient playroom. Nerf guns and over the door basketball hoops can bring incredible laughter and smiles even on the worst of days.

Even in the NICU, our babies experience play. We make sure that babies have stimulation at the bedside with mobiles and textured lovies, and jumpers are provided as they are able.

Developmentally appropriate play is just a standard part of childhood. We want to meet the basic needs of children in the health care environment, too. Play is essential.

Processing - Therapeutic Play

While a large part of the play within the health care environment is just for fun, we also spend a lot of time playing with purpose. This is therapeutic play. Therapeutic play can be led by a patient (non-directive) or led by the child life specialist (directive) with the goal of emotional expression, medical teaching or to be physiologically enhancing (blowing bubbles to encourage deep breaths) (Koller).

Some could argue that all play is therapeutic allowing a child to express themselves and process their experiences. However, therapeutic play within the hospital environment is vital. These type of play experiences allow children to build their resilience while developing and practicing new coping skills. We utilize specific medical play often which is discussed in detail a little later.

We also provide art and music opportunities through our CARPE program and other play modalities for patients to express their feelings and work out their thoughts. Remembering that play is a language, we can learn a lot about our patients and families by watching them play or engaging in play with them. These things allow us to better serve our patients and families and develop care and coping plans during their stay.

Preparing for Procedures or Teaching a New Diagnosis

We also utilize play when preparing children for procedures or teaching them about a new diagnosis. This is a type of therapeutic play with a very specific purpose. We often utilize a stuffed animal or doll to first demonstrate a procedure. We may tie a tourniquet around a stuffed animal’s arm so that a child can see what that looks like. We frequently place IVs in dolls and stuffed animals so that the child feels less alone in their experiences while also seeing the steps and understanding the process.

As child life specialists, we facilitate what is called medical play. This may be as simple as a toy doctor’s kit to more complex play using real medical supplies while teaching with a patient and/or sibling.

One of my favorite activities is using an insulin syringe to inject dye into a medical play doll. This ultimately makes a tie-dyed doll, but it also allows a patient to get comfortable with the needle and syringe (under the supervision of a child life specialist).

At Cook Children’s, we host a Kid’s Clinic for patients to come down for a specific time just to do patient-led medical play. Patients are given a medical play doll and then are invited to use medical equipment on their doll. Patients place IVs, casts, and more.

This play often mimics their own experiences while giving them an opportunity to get more comfortable with medical equipment and process their feelings around their own story. Children not only learn from this type of play, but they leave feeling more empowered in their own medical care.

As child life specialists, play is not only essential but also at the forefront of every interaction with a patient and family. Cook Children’s recently lost a precious child life specialist. Amy Johnson was a child life specialist extraordinaire. As we were attending her funeral, many past patients’ families shared stories of Amy.

I was profoundly impacted that what the patients and parents remembered most fondly about Amy was her ability to PLAY – nerf gun wars, water gun fights and more! She had SO much fun during some of the worst moments, and this is the memory that the patients and families had ingrained in their hearts forever. Play is not only essential, but it also changes the environment and allows children to be the very best versions of themselves!

When children are struggling, they may not be able to fully articulate their emotions like teens or adults. This is where a trained play therapist, such as Lizzy Brown, can help.

Brown is a licensed professional counselor and registered play therapist at Cook Children’s. She explains how she uses the ‘universal language’ of children to help them process their emotions and work through unresolved trauma.

Raising Joy is part of Cook Children’s Health Care System’s Joy Campaign, a communications initiative aimed at preventing youth suicides. For more information about the Joy Campaign, visit cookchildrens.org/joy.

New episodes of the Raising Joy podcast will be available each Tuesday. It is currently available on all major streaming platforms including Apple, Spotify and Google Podcasts.

But spend some time in one of those rooms and you will see a big part of the child life specialist’s job is to help patients through tests and procedures, as well as coping with any life changes they may face. Even though NICU patients are tiny, child life specialists still play a vital role in not only providing support and stimulation for the child, but for the whole family.

“A lot of our parents need support during this time,” said Lauren Bridge, one of two child life specialists in the NICU. “In a way, it's a loss for them because they didn't have the pregnancy they expected. If they delivered early, they may have never had some of the experiences they anticipated.”

With the young patients, Bridge says she tries to focus on infant development and milestones. She and the other child life specialist, Lisa Pool, are always looking for ways to foster development, which could mean putting a mobile over the infant’s bed, making sure the lights are turned down or even just talking to them.

The other huge role they play is working with siblings. Often, parents aren’t sure whether or not they should bring their other children into the NICU. Bridge encourages NICU parents to include siblings in the baby’s care, though she says regressive behavior is common, especially among preschool age kids. This can mean wetting the bed even though they are potty trained, becoming clingier or refusing to sleep in their own bed. Child life specialists are there to help families navigate this stressful time and help siblings understand what is happening to their little brother or sister.

Ultimately, Bridge says she hopes she can help make NICU families’ time at Cook Children’s a little better.

“The best part of my job is seeing families become increasingly comfortable in the NICU and being an integrated part of their child’s care.”

So I got home the other day from a LOOOOOOONGday at work. You know what I’m talking about …It was a Monday (few things go right on a Monday), the beginning of the work week. And my son was off his schedule from a long three-day weekend because his grandparents spoil him.

All my wife and I want to do is get home and lay on the couch. WAIT! I can’t because we have a 2 year old who just wants a little attention. All he wants to do is … eat a snack, wrestle, play the tickle game, go outside, go on a bike-ride, kick the ball, throw the ball, go see the ducks, eat another snack, watch a movie, run up and down the stairs, go on another bike-ride, play hide-n-go seek and wrestle some more. No big deal, we can do this. To think, it’s only MONDAY!! Oh, and someone has to make dinner.

As hectic as that sounds, and believe me it is, it’s worth the time we spend with him. It would be so easy to put an iPad in front of him or even just sit him in front of the TV for a few hours until bedtime. Remember all those activities that my son wants to do? Think about each one and consider the number of vocabulary words and the amount of rich language I would be able to provide him in each of those activities.

It really is endless.

The only way a child will learn words is by hearing words. Wouldn’t it be awesome if we just had a magic wand and anytime we wanted our children to learn a new word, all we had to do was wave it at them, “Abracadaba!” Wave the wand with me two times. My child needs another word, I’m thinking of an animal, so he will say, ‘BIRD”!” There it is, BOOM!! He just improved his vocabulary. That just isn’t the way life works. Believe me, if it was that easy, I wouldn’t have a job as an SLP. The models that my wife and I provide my son Dominic has influenced his language and now he says things like “Where is it?” because we play hide-n-seek. He says “Let’s go!” because he wants to go on a bike-ride.

I recently went to a course where the presenter said that about 90 percent of what young children learn is through play. When you look back, isn’t that what a child’s life should look like? Sleep, play, eat, play, poop and some more play. Their lives revolve around play. At one point, I thought that in order for a child to play, they had to be in a soccer or basketball league, a club or camp, etc. That isn’t true! Play can be anything you make it and you can even play during activities that you are already more than likely doing at home.

1.Bathtime - Get some toys and make them swim, splash, dry them, make them jump.

2. Ball - You can kick, throw, catch, run with it

3. Hide-n-seek- Hide a favorite toy under, on top, in various objects

4. Super Hero Game - use action words(verbs). You can run, jump, roll, throw, etc. Caregivers can even carry their child and make them fly or vice-versa.

These are only a few activities. The best thing to do is go through your day and reflect back on a time or multiple times where you are already interacting with your child doing daily activities. Now think of how you can make the activity into a play activity. Just have FUN!!

Stephen Baker said it best when he said “Of all the toys available, none is better designed than the owner himself. A large multipurpose plaything, its parts can be made to move in almost any direction.It comes completely assembled, and it makes a sound when you jump on it.” We don’t have to buy things to play with our children. All they need is US.

About the author

Jonathan Suarez is a speech pathologist at Cook Children's. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury. 

At least not yet, but both school districts are considering adopting a policy and Dallas ISD could have one by the end of the day.

That news makes Kim Mangham, M.D., a Cook Children’s pediatrician in Keller, both relieved and happy. Dr. Mangham focuses on nutrition and activity with her patient families and she believes this is a good start for area schools to get kids moving.

As early as January 2007, A Clinical Report in the Journal of Pediatrics emphasized the benefits of free play for children, “but since that time it seems we have drifted farther and farther away from this concept,” Dr. Mangham said. “Kindergarten and even preschool curriculums are emphasizing academics over social and emotional development, and kids are presenting at younger ages with anxiety and depression due to academic pressures.”

For all children, especially those with ADHD, Dr. Mangham said it is vital that they are offered unstructured free time to allow them to process the information they have learned and to get their exercise. Only then can they return to the classroom and focus.

Children have an innate need to be outside and run and play, according to Dr. Mangham. This helps them to connect socially with their peers and allows them to settle back down in the classroom and learn again.

“I hear from so many of my parents that their children do so much better with homework if they are allowed to play outside after school,” Dr. Mangham said. “Kids are so worn out by the end of the day, they need to decompress and let their brains rest before they can focus again on school work. I tell my parents that if they want well behaved children, to let them run and play outside and to burn off all of their energy. “

Why not focus on the things that are free from side effects and cost nothing? We have so much to gain, says Dr. Mangham.

Children have so much adult-directed time – in the classroom, with sports, with extracurricular activities and with chores in the home. Adults even try to interfere with free play. Children need that free time to learn to share, play nicely, make up games, follow rules, get along and just enjoy friends.

As reported in December 2015 by KERA news and a recent segment on the Today show, schools are starting to see the benefits of recess.

Cook Children’s offers Go Noodle to 18 ISDs (including public, private and charter elementary schools in Cook Children’s six-county region) and 515 schools. The 120,619 students and 4,918 teachers have logged over 35 million aggregate minutes of physical activity.

“My 12 year old daughter started sixth grade this year,” Dr. Mangham said. “Her biggest complaint is not being able to be outside all day. Their only break is the four minute transition time between classes and lunch. “She says, ‘I miss being outside and seeing the sky and the trees.’ My 8 year old son loves climbing trees. The reflection and relaxation he gets while sitting in the top of his tree is just as important as the exercise he gets while climbing.”

About the source

Kim Mangham, M.D., is a Cook Children's pediatrician at 1601 Keller Parkway in Keller, Texas. She earned her medical degree at University of Texas Southwestern Medical School in Dallas. She completed the pediatric residency program at University of Oklahoma Health Sciences Center in Oklahoma City. Her interests include breastfeeding education as well as disease and injury prevention. Dr. Mangham is board certified in pediatrics.

Ball sports and games have many benefits for kids besides being a lot of fun. Playing ball helps kids develop skills:

Increased coordination with both hands

How?

o Stand in one place and dribble a basketball.

o Run while dribbling a ball.

o Playing/bumping a volleyball.

Increased hand eye coordination

How?

o Playing catch.

o Batting practice.

o Playing mini golf.

o Playing a racquet sport like tennis or ping pong.

Improved balance

How?

o Kicking a ball while standing in place.

o Kicking a ball while running.

o Jumping and reaching to catch a throw.

There are great ball options for kids of all ages and abilities. 

For kids 3 and under

Once babies can sit on their own, they can begin to roll a medium sized ball. As they grow, they will begin to use two hands to attempt to catch by pulling a ball closet to their body. Kicking is something that we should start to see with toddlers. At first your little one will walk into a ball to move it forward. As your child matures they will begin to lift one leg to kick. This requires balance and is a good challenge for toddlers and preschoolers. As their balance improves they will be able to the kick the ball harder and farther and in a straight line.

For grade school kids

At this age, kids are ready to be challenged with balls of different shapes and sizes like soccer balls, footballs, baseballs and tennis balls. These balls can be thrown and caught, but also can be used in more complex ways as part of a game. A great way to get this age group active is to create a game that they can play with friends.

For the preteen and teenagers

If your child is not yet involved in a team sport, it is important to continue to encourage them to be active with their friends, including games that include ball skills.

Sports are beneficial whether played on formal teams or as part of pick-up game with friends. Sports not only challenge your child physically, but encourage them to work on things like taking turns and being a good sport. Activities like soccer, baseball, and basketball require children to coordinate their own movements with the movements of other children in order to be successful. Teamwork and compromise are great skills for all kids to work on and will benefit them in many areas of their life.

So whether it is on their own, with siblings and friends, or as part of a team, encourage your kids to be active this summer and get involved with ball games. Remember that all kids should be getting at least one hour of physical activity a day and they will need lots of water when playing outside in the Texas summers. 

About the author

Kate Mcgee, PT, DPT, is a physical therapist at Cook Children's. Physical therapy at Cook Children's focuses on large motor and functional skils to enhance development, restore function and prevent disability from pediatric conditions, illness or injury. Cook Children's has Rehabilition Services in locations in Fort Worth, Hurst and most recently in Mansfield.

From birth, your child is undergoing changes at a rapid pace and many factors may influence these changes, including your child’s genetic makeup, the environment in which you raise your child, nutrition, and medical care, to name a few. 

Though there are ranges in which kids attain developmental milestones, a delay in achieving certain skills does not necessarily mean that your child is ‘developmentally delayed.’ One should remember that "normal" is expressed in many different ways.

A child’s body systems can be categorized into motoric, sensory and cognitive components and can encompass a wide variety of changes, not to mention the defining personality and emotional changes that are occurring at the same time.

Typical development does occur in stages and can help you track your child’s progress, as listed below:

• Developmental milestones by age/dimension:
  • 3 months:
    • Physical development: Your baby is beginning to explore his/her environment and will start to push up on his/her arms and lift the head up against gravity for a short period of time.
    • Speech development: As you feed your baby, you will notice he/she will refine his/her ability to suck and swallow, will coo to the sound of your voice and smile, and turn his/her head in response to sound.
    • Play development: When playing with your baby, you will notice he/she will be able to follow toys with his/her eyes and reach for them. Your baby will also be able to position his/her head in the middle during interaction with people/environment.
  • 6 months:
    • Physical development: As your baby gets stronger, he/she will be able sit up with the use of his/her hands, will be able to explore his/her environment with rolling from back to stomach. When you hold your baby, notice that your baby can tolerate supported standing with full weight through his/her legs.
    • Speech development: What an exciting time for progress with your baby’s communication! Your baby will now start to babble in order to get your attention. Make sure to keep cereals and pureed foods handy, as your baby is now ready to eat these items.
    • Play development: ‘Tummy’ time is important during this stage of development and you will notice your baby reaching for objects when placed on his/her stomach, and will be able to hold onto his/her feet during play when placed on his/her back.
  • 9 months:
    • Physical development: Your baby is getting stronger during this age and should be able to sit up and reach for toys without a loss of balance, can transition from the floor to sitting, and can crawl using opposite hand/knee movement.
    • Speech development: During this time, your baby will be able to visually recognize familiar people and toys when named; and will now begin eating mashed table foods.
    • Play development: At this time, your baby will use both of his/her hands to play with toys, and will start mimicking others.
  • 12 months:
    • Physical development: During this time of rapid growth, your baby’s leg strength will truly begin to progress with pull-to-stand movements and walking alongside furniture with two-handed support. Your baby may begin to stand independently and take a few steps!
    • Speech development: Get ready to hear ‘mama’ and ‘dada’ frequently as your baby now will be able to call you by name and will be able to follow 1-step instructions!
    • Play development: With play, your baby will be able to use a pincer grasp to hold onto tiny objects/toys, and be able to grab and release toys/objects; at this time, your baby will also be able to start feeding himself using his/her finger.

Though the above characteristics of movement, speech, and play development are TYPICALLY observed in normal developing babies, do not be alarmed if milestones are not met right on time. Some kids develop at a more rapid rate while others may take more time.

There are some red flags to watch for and may indicate a possible need to make an appointment with your baby’s pediatrician, and potentially be referred to a developmental therapist (physical, speech, or occupational). These include (not inclusive of all signs):

• Stiff movements that are consistent throughout the first 3-6 months
• Decreased arm movement or asymmetrical arm movements that lasts through 9 months
• Rounded back
• Difficulty with or inconsistent visual tracking or lack of turning towards auditory stimuli
• Difficulty putting full weight through legs or needed hand support during sitting at 12 months
• Frequent toe-walking at 12 months onwards

Remember, each child is unique and though it is crucially important to monitor your child’s development, it is also important to allow your child to develop at his/her own pace and realize that ‘normal’ can be defined differently for each child.

[Source: Developmental milestones handouts (Cook Children’s), Pathways Awareness Foundation 2006, endorsed by the American Academy of Pediatrics, revised 09/10]

About the author

Radhika Trivedi, PT, MSPT, DPT, is a physical therapist at Cook Children's. Physical therapy focuses on large motor and functional skills to enhance development restore function and prevent disability from pediatric conditions, illness or injury. Cook Children's offers Rehabilitation Services in Fort Worth, Hurst and Mansfield.