UNIT 2: Developmental Characteristic of children

2.1 Prenatal Development

Three periods of prenatal development: the germinal period, the embryonic period, and the fetal
period.

The Germinal Period (Weeks 1-2)

Conception occurs when a sperm fertilizes an egg and forms a zygote, which begins as a one-cell
structure. The mother and father’s DNA is passed on to the child at the moment of conception. The
genetic makeup and sex of the baby are set at this point. The germinal period (about 14 days in
length) lasts from conception to implantation of the zygote (fertilized egg) in the lining of the
uterus.
During the first week after conception, the zygote divides and multiplies, going from a one-cell
structure to two cells, then four cells, then eight cells, and so on. The process of cell division is
called mitosis. After the fourth division, differentiation of the cells begins to occur as well.
Differentiated cells become more specialized, forming different organs and body parts. After 5
days of mitosis, there are 100 cells, and after 9 months there are billions of cells. Mitosis is a fragile
process, and fewer than one-half of all zygotes survive beyond the first two weeks.[1]
After the zygote divides for about 7–10 days and has 150 cells, it travels down the fallopian tubes
and implants itself in the lining of the uterus. It’s estimated that about 60 percent of natural
conceptions fail to implant in the uterus. The rate is higher for in vitro conceptions. Once the
zygote attaches to the uterus, the next stage begins.

The Embryonic Period (Weeks 3-8)

The embryonic period begins once the zygote is implanted in the uterine wall. It lasts from the
third through the eighth week after conception. Upon implantation, this multi-cellular organism is
called an embryo. Now blood vessels grow, forming the placenta. The placenta is a structure
connected to the uterus that provides nourishment and oxygen from the mother to the developing
embryo via the umbilical cord.
During this period, cells continue to differentiate. Basic structures of the embryo start to develop
into areas that will become the head, chest, and abdomen. During the embryonic stage, the heart
begins to beat and organs form and begin to function. At 22 days after conception, the neural tube
forms along the back of the embryo, developing into the spinal cord and brain.
Growth during prenatal development occurs in two major directions: from head to tail
(cephalocaudal development) and from the midline outward (proximodistal development). This
means that those structures nearest the head develop before those nearest the feet and those
structures nearest the torso develop before those away from the center of the body (such as hands
and fingers).
The head develops in the fourth week and the precursor to the heart begins to pulse. In the early
stages of the embryonic period, gills and a tail are apparent. But by the end of this stage, they
disappear and the organism takes on a more human appearance. The embryo is approximately 1
inch in length and weighs about 4 grams at the end of this period. The embryo can move and
respond to touch at this time.
About 20 percent of organisms fail during the embryonic period, usually due to gross chromosomal
abnormalities. As in the case of the germinal period, often the mother does not yet know that she
is pregnant. It is during this stage that the major structures of the body are taking form making the
embryonic period the time when the organism is most vulnerable to the greatest amount of damage
if exposed to harmful substances. Potential mothers are not often aware of the risks they introduce
to the developing child during this time.

The Fetal Period (Weeks 9-40)

When the organism is about nine weeks old, the embryo is called a fetus. At this stage, the fetus
is about the size of a kidney bean and begins to take on the recognizable form of a human being
as the “tail” begins to disappear.
From 9–12 weeks, the sex organs begin to differentiate. By the 12th week, the fetus has all its body
parts including external genitalia. In the following weeks, the fetus will develop hair, nails, teeth
and the excretory and digestive systems will continue to develop. At the end of the 12th week, the
fetus is about 3 inches long and weighs about 28 grams.
At about 16 weeks, the fetus is approximately 4.5 inches long. Fingers and toes are fully developed,
and fingerprints are visible. During the 4-6th months, the eyes become more sensitive to light and
hearing develops. The respiratory system continues to develop. Reflexes such as sucking,
swallowing, and hiccupping develop during the 5th month. Cycles of sleep and wakefulness are
present at that time as well. Throughout the fetal stage, the brain continues to grow and develop,
nearly doubling in size from weeks 16 to 28. The majority of the neurons in the brain have
developed by 24 weeks although they are still rudimentary and the glial or nurse cells that support
neurons continue to grow. At 24 weeks the fetus can feel pain. [2]
The first chance of survival outside the womb, known as the age of viability is reached at about
22 to 26 weeks. [3] By the time the fetus reaches the sixth month of development (24 weeks), it
weighs up to 1.4 pounds. The hearing has developed, so the fetus can respond to sounds. The
internal organs, such as the lungs, heart, stomach, and intestines, have formed enough that a fetus
born prematurely at this point has a chance to survive outside of the mother’s womb.
Between the 7th and 9th months, the fetus is primarily preparing for birth. It is exercising its
muscles, its lungs begin to expand and contract. It is developing fat layers under the skin. The fetus
gains about 5 pounds and 7 inches during this last trimester of pregnancy which includes a layer
of fat gained during the 8th month. This layer of fat serves as insulation and helps the baby regulate
body temperature after birth.
Around 36 weeks, the fetus is almost ready for birth. It weighs about 6 pounds and is about 18.5
inches long, and by week 37 all of the fetus’s organ systems are developed enough that it could
survive outside the uterus without many of the risks associated with premature birth. The fetus
continues to gain weight and grow in length until approximately 40 weeks. By then, the fetus has
very little room to move around and birth becomes imminent.

Environmental Risks
Teratology

Good prenatal care is essential. The developing embryo is most at risk for some of the most severe
problems during the first three months of development. Unfortunately, this is a time at which most
women are unaware that they are pregnant. It is estimated that 10% of all birth defects are caused
by a prenatal exposure or teratogen. Teratogens are factors that can contribute to birth defects
which include some maternal diseases, drugs, alcohol, and stress. These exposures can also include
environmental and occupational exposures. Today, we know many of the factors that can
jeopardize the health of the developing embryo and fetus. Some teratogen-caused birth defects are
potentially preventable.
The study of factors that contribute to birth defects is called teratology. Teratogens are usually
discovered after an increased prevalence of a particular birth defect. For example, in the early
1960’s, a drug known as thalidomide was used to treat morning sickness. Exposure of the fetus
during this early stage of development resulted in cases of phocomelia, a congenital malformation
in which the hands and feet are attached to abbreviated arms and legs.

Alcohol
One of the most commonly used teratogens is alcohol. Because half of all pregnancies in the United
States are unplanned, it is recommended that women of child-bearing age take great caution against
drinking alcohol when not using birth control and when pregnant.[4] Alcohol consumption,
particularly during the second month of prenatal development, but at any point during pregnancy,
may lead to neurocognitive and behavioral difficulties that can last a lifetime.
There is no acceptable safe limit for alcohol use during pregnancy, but binge drinking (5 or more
drinks on a single occasion) or having 7 or more drinks during a single week places an embryo
and fetus at particularly high risk. In extreme cases, alcohol consumption can lead to fetal death,
but more frequently it can result in fetal alcohol spectrum disorders (FASD). This terminology
is now used when looking at the effects of exposure and replaces the term fetal alcohol syndrome.
It is preferred because it recognizes that symptoms occur on a spectrum and that all individuals do
not have the same characteristics. Children with FASD share certain physical features such as
flattened noses, small eye openings, small heads, intellectual developmental delays, and behavioral
problems. Those with FASD are more at risk for lifelong problems such as criminal behavior,
psychiatric problems, and unemployment. [5]
The terms alcohol-related neurological disorder (ARND) and alcohol-related birth defects
(ARBD) have replaced the term Fetal Alcohol Effects to refer to those with less extreme symptoms
of FASD. ARBD include kidney, bone and heart problems.
Tabaco
Smoking is also considered a teratogen because nicotine travels through the placenta to the fetus.
When the pregnant woman smokes, the developing fetus experiences a reduction in blood oxygen
levels. Tobacco use during pregnancy has been associated with low birth weight, placenta previa,
birth defects, preterm delivery, fetal growth restriction, and sudden infant death syndrome.
Smoking in the month before getting pregnant and throughout pregnancy increases the chances of
these risks. Quitting smoking before getting pregnant is best. However, for women who are already
pregnant, quitting as early as possible can still help protect against some health problems for the
mother and baby.[6]

Drugs
Prescription, over-the-counter, or recreational drugs can have serious teratogenic effects. In
general, if medication is required, the lowest dose possible should be used. Combination drug
therapies and first trimester exposures should be avoided. Almost three percent of pregnant women
use illicit drugs such as marijuana, cocaine, Ecstasy and other amphetamines, and heroin. These
drugs can cause low birth-weight, withdrawal symptoms, birth defects, or learning or behavioral
problems. Babies born with a heroin addiction need heroin just like an adult addict. The child will
need to be gradually weaned from the heroin under medical supervision; otherwise, the child could
have seizures and die

Environmental Chemicals
Environmental chemicals can include exposure to a wide array of agents including pollution,
organic mercury compounds, herbicides, and industrial solvents. Some environmental pollutants
of major concern include lead poisoning, which is connected with low birth weight and slowed
neurological development. Children who live in older housing in which lead-based paints have
been used have been known to eat peeling paint chips thus being exposed to lead. The chemicals
in certain herbicides are also potentially damaging. Radiation is another environmental hazard that
a pregnant woman must be aware of. If a woman is exposed to radiation, particularly during the
first three months of pregnancy, the child may suffer some congenital deformities. There is also
an increased risk of miscarriage and stillbirth. A pregnant woman’s exposure to mercury can also
lead to physical deformities and intellectual disabilities.[7]

Sexually Transmitted Infections

Sexually transmitted infections (STIs) can complicate pregnancy and may have serious effects on
both the pregnant woman and the developing fetus. Most prenatal care today includes testing for
STIs, and early detection is important. STIs, such as chlamydia, gonorrhea, syphilis,
trichomoniasis, and bacterial vaginosis can all be treated and cured with antibiotics that are safe to
take during pregnancy. STIs that are caused by viruses, like genital herpes, hepatitis B, or HIV
cannot be cured. However, in some cases these infections can be treated with antiviral medications
or other preventive measures that can be taken to reduce the risk of passing the infection to the
baby.[8]

Maternal Diseases
Maternal illnesses increase the chance that a baby will be born with a birth defect or have a chronic
health problem. Some of the diseases that are known to potentially have an adverse effect on the
fetus include diabetes, cytomegalovirus, toxoplasmosis, rubella, varicella, hypothyroidism, and
Strep B. If the pregnant woman contracts Rubella during the first three months of pregnancy,
damage can occur in the eyes, ears, heart, or brain of the developing fetus. On a positive note,
Rubella has been nearly eliminated in the industrial world due to the vaccine created in 1969.
Diagnosing these diseases early and receiving appropriate medical care can help improve the
outcomes. Routine prenatal care now includes screening for gestational diabetes and Strep B.[9]

Maternal Stress
Stress represents the effects of any factor able to threaten the homeostasis of an organism; these
either real or perceived threats are referred to as the “stressors” and comprise a long list of
potentially adverse factors, which can be emotional or physical. Because of a link in blood supply
between a pregnant woman and her fetus, it has been found that stress can leave lasting effects on
a developing fetus, even before birth. The best-studied outcomes of fetal exposure to maternal
prenatal stress are preterm birth and low birth weight. Maternal prenatal stress is also considered
responsible for a variety of changes in the child’s brain, and a risk factor for conditions such as
behavioral problems, learning disorders, high levels of anxiety, attention deficit hyperactivity
disorder, autism, and schizophrenia. Furthermore, maternal prenatal stress has been associated
with a higher risk for a variety of immune and metabolic changes in the child such as asthma,
allergic disorders, cardiovascular diseases, hypertension, hyperlipidemia, diabetes, and obesity.[10]

Factors influencing prenatal risks

There are several considerations in determining the type and amount of damage that might result
from exposure to a particular teratogen.[11] These include:
• The timing of the exposure: Structures in the body are vulnerable to the most severe
damage when they are forming. If a substance is introduced during a particular structure’s
critical period (time of development), the damage to that structure may be greater. For
example, the ears and arms reach their critical periods at about 6 weeks after conception.
If a pregnant woman exposes the embryo to certain substances during this period, the arms
and ears may be malformed.
• The amount of exposure: Some substances are not harmful unless the amounts reach a
certain level. The critical level depends in part on the size and metabolism of the mother.
• Genetics: Genetic make-up also plays a role in the impact a particular teratogen might
have after the child is born. This is suggested by fraternal twin studies who are exposed to
the same prenatal environment, yet do not experience the same teratogenic effects. The
 genetic make-up of the mother can also have an effect; some mothers may be more resistant
to teratogenic effects than others.
• Biological sex: Males are more likely to experience damage due to teratogens than are
females. It is believed that the Y chromosome, which contains fewer genes than the X, may
have an impact.

Complications of Pregnancy and Delivery

There are a number of common side effects of pregnancy. Not everyone experiences all of these
nor do women experience them to the same degree. And although they are considered “minor”
these problems are potentially very uncomfortable. These side effects include nausea (particularly
during the first 3-4 months of pregnancy as a result of higher levels of estrogen in the system),
heartburn, gas, hemorrhoids, backache, leg cramps, insomnia, constipation, shortness of breath or
varicose veins (as a result of carrying a heavy load on the abdomen). What is the cure? Delivery!

Major Complications
The following are some serious complications of pregnancy which can pose health risks to mother
and child and that often require special care.
• Gestational diabetes is when a woman without diabetes develops high blood sugar levels
during pregnancy.
• Hyperemesis gravidarum is the presence of severe and persistent vomiting, causing
dehydration and weight loss. It is more severe than the more common morning sickness.
• Preeclampsia is gestational hypertension. Severe preeclampsia involves blood pressure
over 160/110 with additional signs. Eclampsia is seizures in a patient who is pre-eclamptic.
• Deep vein thrombosis is the formation of a blood clot in a deep vein, most commonly in
the legs.
• A pregnant woman is more susceptible to infections. This increased risk is caused by an
increased immune tolerance in pregnancy to prevent an immune reaction against the fetus.
• Peripartum cardiomyopathy is a decrease in heart function which occurs in the last
month of pregnancy, or up to six months post-pregnancy.

Maternal Mortality
Maternal mortality is unacceptably high. About 830 women die from pregnancy or childbirth-
related complications around the world every day. It was estimated that in 2015, roughly 303,000
women died during and following pregnancy and childbirth. Almost all of these deaths occurred
in low-resource settings, and most could have been prevented. The high number of maternal deaths
in some areas of the world reflects inequities in access to health services and highlights the gap
between rich and poor. Almost all maternal deaths (99%) occur in developing countries. More than
half of these deaths occur in sub-Saharan Africa and almost one third occur in South Asia.
Almost all maternal deaths can be prevented, as evidenced by the huge disparities found between
the richest and poorest countries. The lifetime risk of maternal death in high-income countries is
1 in 3,300, compared to 1 in 41 in low-income. [12]
Even though maternal mortality in the United States is relatively rare today because of advanced
in medical care, it is still an issue that needs to be addressed. The Centers for Disease Control and
Prevention define a pregnancy-related death as the death of a woman while pregnant or within
1 year of the end of a pregnancy–regardless of the outcome, duration, or site of the pregnancy–
from any cause related to or aggravated by the pregnancy or its management, but not from
accidental or incidental causes. The reasons for the overall increase in pregnancy-related mortality
are unclear.

2.2 Early Childhood Years: Developmental Characteristics across Domains (bio social,
behavioral shifts)

There are four main domains of a child's development: physical, cognitive, language, and social-
emotional.

Physical Domain
This domain involves the senses (taste, touch, sight, smell, hearing, and proprioception — or
bodily awareness of one’s orientation in space), gross motor skills (major movements involving
large muscles), and fine motor skills (involving small muscles, particularly of the fingers and
hands). Here's a deeper look at the difference between gross and fine motor skills.

• Gross motor skills: Gross motor skills involve moving large muscles such as the arms,
legs, torso, and back. Gross motor involves whole-body movements and allows us to
do physical activities such as walking, running, jumping, balancing, and lifting.
• Fine motor skills: Fine motor skills involve small body muscles, such as hands, wrists,
and fingers. The development of these skills refers to coordinating these muscles with
eyes to achieve daily activities such as grasping food, turning door knobs, opening
zippers, and brushing teeth.

Humans develop physical ability directionally, from top to bottom and the center outward. A
baby will at first have the ability to turn the head and sit upright, before being able to reach, grab,
and eventually walk and run as they progress into toddlerhood (2-3 years). All the while child
should be able to instinctively respond and react to stimuli in his or her physical environment.

Cognitive Domain
The cognitive domain of development refers to the ability to mentally process information — to
think, reason, and understand what’s happening around you. Developmental psychologist Jean
Piaget divided cognitive development into four distinct stages.
1. During the sensorimotor stage of cognitive development (0-2 years), humans are
essentially limited to perceiving the world on a purely sensory level. And adult makes a
funny face at you? Laugh at what you see. Dangles a toy in front of you? Reach for it.
 2. By the time a child reaches the preoperational stage (2-6 years), he or she is beginning
to incorporate language into his or her analysis of people and surroundings. However, in
most cases, logical functioning isn’t quite there yet — the child may yet have trouble
“putting it all together.”
3. Prior to hitting puberty, a child should have arrived in the concrete operational stage (7-
11 years), where he or she can process events and information at face value, but will still
generally not be able to accommodate abstracts or hypotheticals.
4. Persons 12 years and up are said to be in the formal operational stage, able to perform
the intricate mental gymnastics that make human beings so remarkable. Thinking in the
abstract — such as envisioning hypothetical scenarios, forming strategies, and parsing
through different viewpoints — becomes a regular part of interfacing with one’s reality.

Language Domain

The ability to comprehend, utilize, and manipulate language may be the single most powerful
skill a person can develop. The four aspects of language development are phonology (forming a
language’s constituent sounds into words), syntax (fitting those words together into sentences
according to language’s rules and conventions), semantics (meaning and shades of meaning), and
pragmatics (how the language is applied in practical and interpersonal communication). The
maturation of verbal communication skills can vary markedly between individuals — but by two
years, many toddlers are capable of at least telegraphic speech, simple sentences
communicating the essence of a want or need.

Socioemotional Domain

The social-emotional domain focuses on how children begin to interact and form relationships
with others and how they experience, express, and manage their own emotions, as well as the
emotions of others. Children start to gain an understanding of who they are, what they’re feeling,
and how they interact with other people. As a child develops within the socioemotional dimension,
he or she learns how to successfully regulate his or her own internal emotional state and read the
social cues of others. Strong emotions can be controlled or expressed properly; confrontation can
be managed without violence; we can evolve empathy toward others.
• By 6 months, a baby should be reacting to facial expressions and reciprocating.
• By a year, clear preferences in terms of likes and dislikes should begin to surface — as
well as recognition of the familiar versus the unfamiliar.
• By two years, a child should be engaging in parallel play with his or her peers. Each child
may be involved in a separate activity, but they are interested in each other’s activities and
comfortable in each other’s company.
• By three years, the awareness of self should have begun to form, and an ability to express
feelings.
• By four years, the child should be able to cooperate with others, abide by simple rules, and
manage emotions without tantrums or aggression.

2.3 Developmental Progression in Play Behaviour, Functions of Play and types of Play
Three Stages of Developmental Play: Sensory Play, Projective Play and Role Play.
Understanding the stages of play also allows us to better identify any gaps in development. Play
can be used as part of an assessment and/or diagnostic process: for example, a five year old who
is not engaging in any projective play will need additional support, and there may well be
associated behavioural challenges that correlate with this gap.
Play is the language of children. Professionals working with parents and families can use this
‘language’ to connect and communicate. It’s important to be comfortable with playing and using
playful engagement.
STAGE 1: SENSORY PLAY
WHAT IT IS: This first stage, from birth to age three-and-a-half or four, is essential to developing
a sense of trust. Babies learn to trust in a physical way, not through words. This is a very sensory
stage of play, in which touch plays a vital role. It is about learning and integrating that sense of
having a body and skin. The toddler learns that they have a body, what it can do, and where it ends.
It is about containment.
EXAMPLES OF SENSORY PLAY: Suggest to parents that they play games such as peek-a-boo
and making objects disappear and then re-appear (quickly). This allows their toddler to accept that
objects (and later people) still exist even when they can’t see them, and that they will return. A pot
and a wooden spoon is a perfectly effective instrument, as are dried peas in a Pringles tube with
the lid taped on.
STAGE 2: PROJECTIVE PLAY
WHAT IT IS: Between age four and five-and-a-half, there is increased focus on stories and
narrations. Children at this age are responding to the world outside of the body. They want to
further explore and investigate objects, people and their general environment at a deeper level.
EXAMPLES OF PROJECTIVE PLAY: When toddlers use toys to introduce possible scenarios
or friends, the representation of multiple perspectives occurs naturally. Taking on different roles
allows children the unique opportunity to learn social skills such as communication, problem
solving, and empathy. Play with puppets, dolls, cars (and anything else they can talk to and use to
interact with each other to play out scenarios) is effective here.
STAGE 3: ROLE PLAY
WHAT IT IS: From five-and-a-half to age seven, children engage in dramatic play. This serves
to help them re-structure/re-arrange aspects of their life events to gain a better understanding of
themselves and the world around them. Aspects of Embodiment and Projective Play are evident in
this final stage.
EXAMPLES OF ROLE PLAY: Play such as ‘Doctors & Nurses’ and ‘Mummies & Daddies’
are examples of Role Play. Children may play at being a parent and punish a doll for not eating
dinner or sleeping in their own bed as a way of better understanding why they have to do such
things themselves.
There is a big difference between dress-up and Role Play. Dress-up may involve dressing up in a
Disney costume and playing at being that character and re-enacting scenes in which that character
features. Role Play is about taking a prop and using it to create a story and become a character
around the prop. A large scarf might become a superhero’s cape or a bandage, or a magical flying
carpet that can transport a toddler and their teddy anywhere in the world. The play is designed
around the prop. With dress-up, it’s the other way around.

Type of play

• Physical play. When children run, jump, and play games such as chase, hide-and-seek, and
tag, they engage in physical play. This play has a social nature because it involves other
children. It also provides exercise , which is essential for normal development.
• Expressive play. Certain forms of play give children opportunities to express feelings by
engaging with materials. Materials used in expressive play include tempera paints,
fingerpaints, watercolors, crayons, colored pencils and markers, and drawing paper; clay,
water, and sponges; beanbags, pounding benches, punching bags, and rhythm instruments;
and shaving cream, pudding, and gelatin. Parents can take an active role in expressive play
by using the materials alongside the child.
• Manipulative play. Children control or master their environment through manipulative
play. They manipulate the environment and other people as much as possible. Manipulative
play starts in infancy. Infants play with their parents; for example, they drop a toy, wait for
the parent to pick it up, clean it, and return it, and then they drop it again. This interaction
brings the infant and parent together in a game. Children move objects such as puzzle
pieces and gadgets to better understand how they work.
• Symbolic play. Certain games can symbolically express a child's problems. Because there
are no rules in symbolic play, the child can use this play to reinforce, learn about, and
imaginatively alter painful experiences. The child who is in an abusive family may pretend
to be a mother who loves and cuddles her child rather than one who verbally or physically
abuses her child. Or in play this same child might act out abusive experience by hitting or
screaming at a doll that symbolizes the child. Parents can be surprised by their child's
perception of family issues. Children mimic their parents in certain play; in other games
they may pretend they are the heroes they read about in books or see on television. At
certain developmental stages children believe they can fly or disappear. Symbolic play may
be used by children to cope with fear of separation when they go to school or to the hospital.
• Dramatic play. Children act out situations they suspect may happen to them, that they are
fearful will happen, or that they have witnessed. Dramatic play can be either spontaneous
or guided and may be therapeutic for children in the hospital.
 • Familiarization play. Children handle materials and explore experiences in reassuring,
enjoyable ways. Familiarization prepares children for potentially fearful and painful
experiences, such as surgery or parental separation.
• Games. Some video and card games are played by one child alone. Games with rules are
rarely played by children younger than four years of age. Board games, card games,
and sports are enjoyed typically by school-age children. In these games children learn to
play by the rules and to take turns. Older children enjoy games with specific rules; however,
younger children tend to like games that allow them to change the rules.

Functions of play
Play reinforces the child's growth and development. Some of the more common functions of play
are to facilitate physical, emotional, cognitive, social, and moral development .
PHYSICAL DEVELOPMENT Play aids in developing both fine and gross motor skills .
Children repeat certain body movements purely for pleasure, and these movements develop body
control. For example, an infant will first hit at a toy, then will try to grasp it, and eventually will
be able to pick it up. Next, the infant will shake the rattle or perhaps bring it to the mouth. In these
ways, the infant moves from simple to more complex gestures.
EMOTIONAL DEVELOPMENT Children who are anxious may be helped by role playing.
Role playing is a way of coping with emotional conflict. Children may escape through play into a
fantasy world in order to make sense out of the real one. Also, a child's self-awareness deepens as
he explores an event through role-playing or symbolic play.
When a parent or sibling plays a board game with a child, shares a bike ride, plays baseball, or
reads a story, the child learns self-importance. The child's self-esteem gets a boost. Parents send
positive messages to their child when they communicate pleasure in providing him or her with
daily care. From these early interactions, children develop a vision of the world and gain a sense
of their place in it.
COGNITIVE DEVELOPMENT Children gain knowledge through their play. They exercise
their abilities to think, remember, and solve problems. They develop cognitively as they have a
chance to test their beliefs about the world.
Children increase their problem-solving abilities through games and puzzles. Children involved in
make-believe play can stimulate several types of learning. Language is strengthened as the children
model others and organize their thoughts to communicate. Children playing house create elaborate
narratives concerning their roles and the nature of daily living.
Children also increase their understanding of size, shape, and texture through play. They begin to
understand relationships as they try to put a square object in a round opening or a large object in a
small space. Books, videos, and educational toys that show pictures and matching words also
increase a child's vocabulary while increasing the child's concept of the world.
SOCIAL DEVELOPMENT A newborn cannot distinguish itself from others and is completely
self-absorbed. As the infant begins to play with others and with objects, a realization of self as
separate from others begins to develop. The infant begins to experience joy from contact with
others and engages in behavior that involves others. The infant discovers that when he coos or
laughs, mother coos back. The child soon expects this response and repeats it for fun, playing with
his mother.
As children grow, they enjoy playful interaction with other children. Children learn about
boundaries, taking turns, teamwork, and competition. Children also learn to negotiate with
different personalities and the feelings associated with winning and losing. They learn to share,
wait, and be patient.
MORAL DEVELOPMENT When children engage in play with their peers and families, they
begin to learn some behaviors are acceptable while others are unacceptable. Parents start these
lessons early in the child's life by teaching the child to control aggressive behavior . Parents can
develop morals while reading to children by stressing the moral implications in stories. Children
can identify with the moral fictional characters without assuming their roles. With peers they
quickly learn that taking turns is rewarding and cheating is not. Group play helps the child
appreciate teamwork and share and respect others' feelings. The child learns how to be kind and
charitable to others.

Age-related play
As children develop, their play evolves, too. Certain types of play are associated with, but not
restricted to, specific age groups.

• Solitary play is independent. The child plays alone with toys that are different from those
chosen by other children in the area. Solitary play begins in infancy and is common in
toddlers because of their limited social, cognitive, and physical skills. However, it is
important for all age groups to have some time to play by themselves.
• Parallel play is usually associated with toddlers, although it happens in any age group.
Children play side by side with similar toys, but there is a lack of group involvement.
• Associative play involves a group of children who have similar goals. Children in associate
play do not set rules, and although they all want to be playing with the same types of toys
and may even trade toys, there is no formal organization. Associative play begins during
toddlerhood and extends though preschool age.
• Cooperative play begins in the late preschool period. The play is organized by group goals.
There is at least one leader, and children are definitely in or out of the group.
• Onlooker play is present when the child watches others playing. Although the child may
ask questions of the players, there is no effort to join the play. This type of play usually
starts during toddler years but can take place at any age.
Common problems

Promoting play for a sick child is a challenge when the child cannot voluntarily engage in play.
Parents need to realize the importance of play to the well being of a sick child. Children can bring
favorite books, games, and stuffed animals to the hospital. In hospitals young children need toys
that they can manipulate independently, so that parents are free sometimes to focus on medical
issues and the healthcare team.
Play activities vary depending on cultural and socioeconomic circumstances. When children do
not speak the group's language, games such as stacking blocks or building with tinker toys are
appealing. Playing tapes of well-loved children's songs can be effective too. The child does not
need to be able to understand the words to enjoy the music or clap with the rhythm.

Assessing child health through play

Acutely ill children do not have the strength, the attention span, or the interest in play. They may
enjoy being read to and the comfort of holding a favorite stuffed animal. Once the acute phase of
an illness is over, the child's interest in playing returns. Spontaneous interest in play is a good
index of health. The toys selected for play are good indicators of the child's recovery progress.

Play in a medical setting

When a child goes to see the doctor, the waiting room is likely to have other children in it. The
arriving child may hear other children cry as they leave the examining room. The child may dread
the examination. Parents should pack a favorite toy or book with which to distract the child. Having
a parent sit with them is comforting, and they may venture a few feet away to examine toys in the
toy box. Older children who go with the parent and the sick sibling to see the doctor should have
toys and games for their entertainment, too, so the parent can focus on the sick child.
Hospitalized children can release fear, anger, or tension through effective play. Children in the
hospital for a week or longer may enjoy playing school or socializing in the playroom with other
children of their age. However, physical play for sick children must be supervised by a parent or
healthcare provider.

Therapeutic play
When a child is ill or traumatized the care plan may include therapeutic play. Unlike normal play
in design and intent, therapeutic play is guided by the health professional to meet the physical and
psychological needs of the child. Because play is the language of children, children who have
difficulty putting their thoughts in words can often speak clearly through play therapy. There are
three divisions of therapeutic play, including:
 • Energy release. Children release anxiety by pounding, hitting, running, punching, or
shouting. Toddlers pound pegs with a plastic hammer or pretend to cut wood with a toy
saw. An anxious preschooler pounds a ball of modeling clay flat; a relaxed child may build
the clay into shapes. Balloons tied over the bed of a school-age child or adolescent can be
punched.
• Dramatic play. Children act out or dramatize real-life situations. They act out anxiety and
emotional stress from abuse, neglect, abandonment , and various painful physical
experiences. Imaginative preschool children enjoy dramatic play. An abused or wounded
child might not communicate the experience verbally but may be able to use an
anatomically correct doll to show what happened. Therapeutic play can teach children
about medical procedures or help them work through their feelings about what has
happened to them in the medical setting.
• Creative play. Some children are too angry or fearful to act out their feelings through
dramatic play. However, they may be able to draw a picture that expresses their emotions
or communicates what they know. To encourage this expression children can be given
blank paper and crayons or markers and asked to draw a picture about how they feel. Some
children are so concerned about a particular body part that instead of drawing a self portrait,
they will draw only the body part that worries them.

Many children draw pictures that reflect punitive images to explain unhappy experiences. They
need reassurance that they are not being punished. Health-care providers need to make sure that
these children are not being abused. Other children may draw pictures that are symbolic of death
(an airplane crashing, boats sinking, burning buildings, or children in graves). These children need
assurances that they are not going to die. Some drawings express the child's fear of abandonment
and loss of independence. Pictures may suggest the parent cannot find the little child who is in the
hospital. The child needs to be reassured that their parents know where they are. They need to
know when the parents will visit and the parents should appear when they say they will be there.
Older school-age children and adolescents may not be interested in drawing, but they can make a
list of experiences they like and dislike.

Type of play

• Physical play. When children run, jump, and play games such as chase, hide-and-seek, and
tag, they engage in physical play. This play has a social nature because it involves other
children. It also provides exercise , which is essential for normal development.
• Expressive play. Certain forms of play give children opportunities to express feelings by
engaging with materials. Materials used in expressive play include tempera paints,
fingerpaints, watercolors, crayons, colored pencils and markers, and drawing paper; clay,
water, and sponges; beanbags, pounding benches, punching bags, and rhythm instruments;
 and shaving cream, pudding, and gelatin. Parents can take an active role in expressive play
by using the materials alongside the child.
• Manipulative play. Children control or master their environment through manipulative
play. They manipulate the environment and other people as much as possible. Manipulative
play starts in infancy. Infants play with their parents; for example, they drop a toy, wait for
the parent to pick it up, clean it, and return it, and then they drop it again. This interaction
brings the infant and parent together in a game. Children move objects such as puzzle
pieces and gadgets to better understand how they work.
• Symbolic play. Certain games can symbolically express a child's problems. Because there
are no rules in symbolic play, the child can use this play to reinforce, learn about, and
imaginatively alter painful experiences. The child who is in an abusive family may pretend
to be a mother who loves and cuddles her child rather than one who verbally or physically
abuses her child. Or in play this same child might act out abusive experience by hitting or
screaming at a doll that symbolizes the child. Parents can be surprised by their child's
perception of family issues. Children mimic their parents in certain play; in other games
they may pretend they are the heroes they read about in books or see on television. At
certain developmental stages children believe they can fly or disappear. Symbolic play may
be used by children to cope with fear of separation when they go to school or to the hospital.
• Dramatic play. Children act out situations they suspect may happen to them, that they are
fearful will happen, or that they have witnessed. Dramatic play can be either spontaneous
or guided and may be therapeutic for children in the hospital.
• Familiarization play. Children handle materials and explore experiences in reassuring,
enjoyable ways. Familiarization prepares children for potentially fearful and painful
experiences, such as surgery or parental separation.
• Games. Some video and card games are played by one child alone. Games with rules are
rarely played by children younger than four years of age. Board games, card games,
and sports are enjoyed typically by school-age children. In these games children learn to
play by the rules and to take turns. Older children enjoy games with specific rules; however,
younger children tend to like games that allow them to change the rules.