Kenneth R. Ginsburg, MD, MS Ed, and the Committee on Communications and the Committee on Psychosocial Aspects of Child and Family Health
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Play is essential to development because it contributes to the cognitive, physical, social, and emotional well-being of children and youth. Play also offers an ideal opportunity for parents to engage fully with their children. Despite the benefits derived from play for both children and parents, time for free play has been markedly reduced for some children. This report addresses a variety of factors that have reduced play, including a hurried lifestyle, changes in family structure, and increased attention to academics and enrichment activities at the expense of recess or free child-centered play. This report offers guidelines on how pediatricians can advocate for children by helping families, school systems, and communities consider how best to ensure that play is protected as they seek the balance in children’s lives to create the optimal developmental milieu.
Play is so important to optimal child development that it has been recognized by the United Nations High Commission for Human Rights as a right of every child.1 This birthright is challenged by forces including child labor and exploitation practices, war and neighborhood violence, and the limited resources available to children living in poverty. However, even those children who are fortunate enough to have abundant available resources and who live in relative peace may not be receiving the full benefits of play. Many of these children are being raised in an increasingly hurried and pressured style that may limit the protective benefits they would gain from child-driven play. Because every child deserves the opportunity to develop to their unique potential, child advocates must consider all factors that interfere with optimal development and press for circumstances that allow each child to fully reap the advantages associated with play.
No single set of guidelines could do justice to the many factors that impact on children’s play, even if it was to focus only on children living in the United States. These guidelines will focus on how American children with adequate resources may be limited from enjoying the full developmental assets associated with play because of a family’s hurried lifestyle as well as an increased focus on the fundamentals of academic preparation in lieu of a broader view of education. Those forces that prevent children in poverty and the working class from benefiting fully from play deserve full, even urgent, attention, and will be addressed in a future document. Those issues that impact on play for children with limited resources will be mentioned brie.y here to reinforce that play contributes to optimal child development for all children and that we must advocate for the changes specific to the need of each child’s social and environmental context that would enhance the opportunities for play.
These guidelines were written in response to the multiple forces that challenge play. The overriding premise is that play (or some available free time in the case of older children and adolescents) is essential to the cognitive, physical, social, and emotional well-being of children and youth. Although the guidelines were written in defense of play, they should not be interpreted as being against other forces that compete for children’s time. Academic enrichment opportunities are vital for some children’s ability to progress academically, and participation in organized activities is known to promote healthy youth development.2,3 It is essential that a wide variety of programming remain available to meet the needs of both children and families. Rather, these guidelines call for an inclusion of play as we seek the balance in children’s lives that will create the optimal developmental milieu to prepare our children to be academically, socially, and emotionally equipped to lead us into the future.
THE BENEFITS OF PLAY
Play allows children to use their creativity while developing their imagination, dexterity, and physical, cognitive, and emotional strength. Play is important to healthy brain development.4–6 It is through play that children at a very early age engage and interact in the world around them. Play allows children to create and explore a world they can master, conquering their fears while practicing adult roles, sometimes in conjunction with other children or adult caregivers.7–14 As they master their world, play helps children develop new competencies that lead to enhanced confidence and the resiliency they will need to face future challenges.7,10,15 Undirected play allows children to learn how to work in groups, to share, to negotiate, to resolve conflicts, and to learn self-advocacy skills.7,10,11,16 When play is allowed to be child driven, children practice decision-making skills, move at their own pace, discover their own areas of interest, and ultimately engage fully in the passions they wish to pursue.7,10,11 Ideally, much of play involves adults, but when play is controlled by adults, children acquiesce to adult rules and concerns and lose some of the benefits play offers them, particularly in developing creativity, leadership, and group skills.17 In contrast to passive entertainment, play builds active, healthy bodies. In fact, it has been suggested that encouraging unstructured play may be an exceptional way to increase physical activity levels in children, which is one important strategy in the resolution of the obesity epidemic.18,19 Perhaps above all, play is a simple joy that is a cherished part of childhood.
Children’s developmental trajectory is critically mediated by appropriate, affective relationships with loving and consistent caregivers as they relate to children through play.4 When parents observe their children in play or join with them in child-driven play, they are given a unique opportunity to see the world from their child’s vantage point as the child navigates a world perfectly created just to his or her needs. (The word “parent” is used in this report to represent the wide range of adult caregivers who raise children.) The interactions that occur through play tell children that parents are fully paying attention to them and help to build enduring relationships.6,13,14,20,21 Parents who have the opportunity to glimpse into their children’s world learn to communicate more effectively with their children and are given another setting to offer gentle, nurturing guidance. Less verbal children may be able to express their views, experiences, and even frustrations through play, allowing their parents an opportunity to gain a fuller understanding of their perspective. Quite simply, play offers parents a wonderful opportunity to engage fully with their children.
Play is integral to the academic environment. It ensures that the school setting attends to the social and emotional development of children as well as their cognitive development. It has been shown to help children adjust to the school setting and even to enhance children’s learning readiness, learning behaviors, and problem-solving skills.22–32 Social-emotional learning is best integrated with academic learning; it is concerning if some of the forces that enhance children’s ability to learn are elevated at the expense of others. Play and unscheduled time that allow for peer interactions are important components of social-emotional learning.33,34
REDUCED CHILD-DRIVEN PLAY AND THE POTENTIAL REPERCUSSIONS
Despite the numerous benefits derived from play for both children and parents, time for free play has been markedly reduced for some children. This trend has even affected kindergarten children, who have had free play reduced in their schedules to make room for more academics. A 1989 survey taken by the National Association of Elementary School Principals found that 96% of surveyed school systems had at least 1 recess period. Another survey a decade later found that only 70% of even kindergarten classrooms had a recess period.35,36
Currently, many schoolchildren are given less free time and fewer physical outlets at school; many school districts responded to the No Child Left Behind Act of 200137 by reducing time committed to recess, the creative arts, and even physical education in an effort to focus on reading and mathematics.38,39 This change may have implications on children’s ability to store new in-formation, because children’s cognitive capacity is enhanced by a clear-cut and significant change in activity.35,40 A change in academic instruction or class topic does not offer this clear-cut change in cognitive effort and certainly does not offer a physical release. Even a formal structured physical education class may not offer the same benefit as free-play recess.35,41 Reduced time for physical activity may be contributing to the discordant academic abilities between boys and girls, because schools that promote sedentary styles of learning become a more difficult environment for boys to navigate successfully.42,43
Some children are given less time for free exploratory play as they are hurried to adapt into adult roles and prepare for their future at earlier ages.44–46 Parents are receiving carefully marketed messages that good parents expose their children to every opportunity to excel, buy a plethora of enrichment tools, and ensure their children participate in a wide variety of activities.45,47 Children are exposed to enrichment videos and computer programs from early infancy as well as specialized books and toys designed to ensure that they are well-rounded and adequately stimulated for excelled development. Specialized gyms and enrichment programs designed for children exist in many communities, and there is an abundance of after-school enrichment activities. These tools and programs are heavily marketed, and many parents have grown to believe that they are a requirement of good parenting and a necessity for appropriate development. As a result, much of parent-child time is spent arranging special activities or transporting children between those activities. In addition to time, considerable family financial resources are being invested to ensure that the children have what are marketed as the “very best” opportunities.33,34,47–49
It is clear that organized activities have a developmental benefit for children, especially in contrast to completely unsupervised time.2 Some research substantiates that for most children, benefits increase with higher levels of participation.2 In addition, it has been suggested that because this lifestyle is associated with middle-class families, it may have a benefit in maintaining social class or in creating upward mobility.50 It is less clear, however, at what point a young person may be “over scheduled” to their developmental detriment or emotional distress. Free child-driven play known to benefit children is decreased, and the downtime that allows parents and children some of the most productive time for interaction is at a premium when schedules become highly packed with adult-supervised or adult-driven
It is left to parents to judge appropriate levels of involvement, but many parents seem to feel as though they are running on a treadmill to keep up yet dare not slow their pace for fear their children will fall behind. In addition, some worry they will not be acting as proper parents if they do not participate in this hurried life style.45–47,51,52
Although most highly scheduled children are thriving,2 some are reacting to the associated pressures with anxiety and other signs of increased stress.45,46,53 In this regard, highly scheduled children have less time for free, child-driven, creative play,45,46,47,54 which offers benefits that may be protective against the effects of pressure and stress.45,54 There is evidence that childhood and adolescent depression is on the rise through the college years.55–60 Although there are certainly many factors involved, and a direct link between the early pressure-filled intense preparation for a high-achieving adulthood and these mental health concerns cannot be made on the basis of current research, it is important that we consider the possibility of this linkage. We can be certain that in some families, the protective influences of both play and high-quality family time are negatively affected by the current trends toward highly scheduling children.
As trusted child advocates, pediatric health professionals are ideally suited to help parents consider the appropriate balance between preparing for the future and living fully in the present through play, child-centered organized activities, and rich parent-child interaction. It is likely that the balance that needs to be achieved will be different for every child on the basis of the child’s academic needs, temperament, environment, and the family’s needs. Because there are so many forces that influence the trend toward focusing on future preparation, it is important that parents have a medical home that can reinforce the importance of some of the basic, tried-and-true aspects of child rearing.
FACTORS THAT HAVE CHANGED THE ROUTINE OF CHILDHOOD
There may be as many explanations for the current trends as there are families, but several key factors that have led to decreased free play should be considered.
1. There are more families with a single head of household or 2 working parents and fewer multigenerational households in which grandparents and extended family members can watch the children. Therefore, fewer families have available adult supervision in the home during the workday, which makes it necessary for children to be in child care or other settings in which they can be monitored by adults throughout the day.61 Organized after-school activities and academic enrichment opportunities offer valuable alternatives to children who might otherwise be left with minimal or no adult supervision.
2. Many parents have learned how to become increasingly efficient in balancing work and home schedules. They wish to make the most effective use of limited time with their children and believe that facilitating their children to have every opportunity is the best use of that time. Some may use some of the standards of efficiency and productivity they have mastered at work to judge their own effectiveness as parents; this is sometimes referred to as the professionalization of parenthood.51 This phenomenon may create guilt in parents who find it diffcult to balance competing demands after a taxing workday. Parents who understand that high-interaction, at-home activities (eg, reading or playing with children) present opportunities for highly effective parenting may feel less stress than those who feel compelled to arrange out-of-home opportunities.
3. Parents receive messages from a variety of sources stating that good parents actively build every skill and aptitude their child might need from the earliest ages. They are deluged in parenting magazines and in the media with a wide range of enrichment tools and activities that tout their ability to produce super-achieving children. They read about parents who go to extreme efforts, at great personal sacrifice, to make sure their children participate in a variety of athletic and artistic opportunities. They hear other parents in the neighborhood talk about their overburdened schedules and recognize it is the culture and even expectation of parents.51,52
4. The college-admissions process has become much more rigorous in recent years, largely because of a baby boom hitting the college years. Parents receive the message that if their children are not well prepared, well balanced, and high-achieving, they will not get a desired spot in higher education. Even parents who wish to take a lower-key approach to child rearing fear slowing down when they perceive everyone else is on the fast track.62,63 Children are encouraged to build a college resume through both academic excellence and a wide variety of activities and volunteer efforts starting at younger ages. In some cases, parents feel pressured to help their child build a strong resume.
5. In response to the increasingly rigorous college-admissions process, many secondary schools are judged by the rates in which their students are accepted by the most prestigious centers of higher learning. Partly in response to this, many students have been encouraged to carry increasingly rigorous academic schedules, including multiple advanced-placement courses. In addition, many students are taking preparation courses for standardized entrance examinations. These students are left with less free time because of the home preparatory time needed for their classes.
6. The pressure for admission to select schools begins for some families long before college. Selection for private preschool programs can even be competitive, and parents may need to consider how best to “package” their preschoolers.
7. There is a national trend to focus on the academic fundamentals of reading and arithmetic. This trend, spearheaded by the No Child Left Behind Act of 2001, is a reaction to the unacceptable educational performance of America’s children in some educational settings. One of the practical effects of the trend is decreased time left during the school day for other academic subjects, as well as recess, creative arts, and physical education.38,39 This trend may have implications for the social and emotional development of children and adolescents.33 In addition, many after-school child care programs prioritize an extension of academics and homework completion over organized play, free play, and physical activity.64
8. The decrease in free play can also be explained by children being passively entertained through television or computer/video games. In sharp contrast to the health benefits of active, creative play and the known developmental benefits of an appropriate level of organized activities, there is ample evidence that this passive entertainment is not protective and, in fact, has some harmful effects.65–68
9. In many communities, children cannot play safely outside of the home unless they are under close adult supervision and protection. This is particularly true in areas that are unsafe because of increased violence or other environmental dangers.
WHY IS IT A PROBLEM?
It would be wrong to assume that the current trends are a problem for all children; some excel with a highly driven schedule. Because we need skilled young people to be well prepared to be tomorrow’s leaders, we must recognize the advantages to the increased exposures and enriched academics some of our children are receiving. In fact, many of our children, particularly those in poverty, should receive more enrichment activities. But even children who are benefiting from this enrichment still need some free unscheduled time for creative growth, self-reflection, and decompression and would pro.t from the unique developmental benefits of child-driven play.
However, for some children, this hurried lifestyle is a source of stress and anxiety and may even contribute to depression.45,46 Increased pressure to achieve is likely to manifest in school avoidance and somatic symptoms.69–72 The challenge for society, schools, and parents is to strike the balance that allows all children to reach their potential without pushing them beyond their personal comfort limits and while allowing them personal free playtime.
It appears that the increased pressures of adolescence have left some young people less equipped to manage the transition toward the college years. Many student health services and counseling centers on college campuses have not been able to keep pace with the increased need for mental health services, and surveys have substantiated this need by reporting an increase in depression and anxiety among college students.57–59 A survey by the American College Health Association reported that 61% of college students had feelings of hopelessness during the previous academic year, 45% felt so depressed they had trouble functioning, and 9% suffered suicidal ideation.57 Several studies have linked feelings of anxiety and depression with that of perfectionism and an overly critical self-evaluation.72–77 Other studies have linked this perfectionism with highly critical parents who instill pressures to excel.78–82 Perfectionism is challenging to the individual and has a broader effect on society because it may stifle creativity and unencumbered thinking.83 There are no longitudinal studies that directly link intense preparation for adulthood during childhood to this rise in mental health needs, and there certainly are other causes, but some experts believe today’s pressured lifestyle is an important contributor.46,84
Children may also have received an unintended message from this hurried, intense preparation for adulthood. They may have learned that the end-point goal— the best school or the best job—must be reached at all costs. High schools, colleges, and universities throughout the country are reporting that more students may be cheating to achieve the desired end result of a superior grade.85,86 Despite grade inflation over the last decades, many teachers report increased stress in students when they achieve less-than-perfect scores.87–89 This competitive era may be producing a minority of young people so intensely worried about the appearance of high achievement that they will forsake core values such as fairness and honesty for the sake of acquiring good grades.
Some families whose children are highly scheduled may also suffer. Adults who may already be burdened by work responsibilities and maintaining a household and themselves sacrificing their downtime because they need to arrange activities and transport children between appointments.45–47 In addition, because of the pressures they feel to meet every one of the needs they perceive (or are told) their child requires to excel, they may feel inadequate and ultimately have less personal satisfaction in parenting.51,52 Most importantly, parents lose the opportunity for perhaps the highest-quality time with their children. Some of the best interactions occur during downtime—just talking, preparing meals together, and working on a hobby or art project, playing sports together, or being fully immersed in child-centered play.
As parents prepare their children for the future, they cannot know precisely which skills each will need for the workforce. With added anxiety over their inability to adequately predict the future, they become susceptible to the promises of success and full preparation offered by all of the special enrichment programs and vulnerable to the belief that if their children are at least exposed to everything, they will have the best chance to be prepared. Although no one can be sure what skills will be needed, certain character traits will produce children capable of navigating an increasingly complex world as they grow older. These traits include confidence, competence or the ability to master the environment, and a deep-seated connectedness to and caring about others that create the love, safety, and security that children need to thrive. In addition, to be resilient—to remain optimistic and be able to rebound from adversity— young people need the essential character traits of honesty, generosity, decency, tenacity, and compassion. Children are most likely to gain all of these essential traits of resiliency within a home in which parents and children have time to be together and to look to each other for positive support and unconditional love.90–95 Many families are successfully navigating a wide variety of commitments without sacrificing high-quality parent-child time,2 but some families’ ability to maintain essential parent-child time may be compromised by this hurried lifestyle. In these families, over scheduling may lead to less emotionally competent, well-buffered children.
WHAT ARE THE SOLUTIONS?
Because there are at least several causes for the decreased amount of child-directed play, there is no single position that child advocates should take. For example, in the case of a child who is economically disadvantaged and does not reside in a safe neighborhood, it may be unwise to simply propose more child-centered play. Although parents can be encouraged to optimize conditions for this kind of play in the home, there must be broad societal responses that address poverty, social inequities, and violence before we can advise parents to allow unsupervised play. In addition, for children in poverty, enhanced child care services, early community-based education (eg, Head Start), increased academic programming, more enrichment activities, and greater opportunities for community-based adult-supervised activities are warranted. Some of the needed solutions for this group of disadvantaged children remain beyond the scope of this article and are raised here to emphasize that the suggestions offered here need to be individualized; one size does not fit all.
For all children, however, advocates need to promote the implementation of those strategies known to promote healthy youth development and resiliency. Some of those strategies are community based, and others are school based, but many reside within the family. They are rooted in the deep connection that develops when parents engage with their children.92,93,95 Play remains an ideal venue for parents to engage fully, and child professionals must reinforce the value of this play. Some play must remain entirely child driven, with parents either not present or as passive observers, because play builds some of the individual assets children need to develop and remain resilient.
Parents need to feel supported to not passively accept the media and advertising messages that suggest there are more valuable means of promoting success and happiness in children than the tried, trusted, and traditional methods of play and family togetherness. Purveyors of these special programs should be encouraged to produce long-term evidence that define how their products/strategies produce more successful children. In parallel, we would encourage independent researchers to evaluate both the benefits and problems associated with these enrichment tools. Researchers should also continue to explore the type and quantity of activities that are likely to be enriching for children with different needs.
Colleges are seeing a generation of students who appear to be manifesting increased signs of depression, anxiety, perfectionism, and stress. They should clarify their messages about the type of students they seek in the face of widespread folklore that they seek only super-achieving students. Colleges certainly seek a physically and emotionally healthy student body with the character traits that support learning. Colleges could reduce the stress levels of young people and their parents if they offered clear, more realistic expectations about the type of students they seek and helped families to understand that there is a match for each reasonably prepared student. In addition, colleges should address the myth that desirable students are those who excel in every area. In the adult world, people rarely excel in more than 1 or 2 areas, while well-balanced individuals enjoy several others. Colleges should recognize the possibility that when children believe that they must excel in all areas to gain admission, they might respond to those perceived and unrealistic expectations with stress and anxiety.62,63
ADVICE FOR PEDIATRICIANS*
In the midst of so many conflicting messages about what parents should do to prepare their child for what is perceived to be an increasingly complicated, competitive world, pediatricians have a natural role to serve as caring, objective child professionals with whom parents can discuss their approach to child rearing and reflect on their own desires for their children. Because pediatricians have a unique and important role in promoting the physical, emotional, and social well-being of children and adolescents, it is important that they promote strategies that will support children to be resilient and to reduce stressors in their lives.
* This guidance is offered by the American Academy of Pediatrics and, therefore, is targeted to pediatricians. Other health professionals who serve children and adolescents, including other physicians, pediatric and family nurse practitioners, and physician assistants, are welcome to consider incorporating these guidelines into practice.
•Pediatricians can promote free play as a healthy, essential part of childhood. They should recommend that all children are afforded ample, unscheduled, independent nonscreen time to be creative, to reflect, and to decompress. They should emphasize that although parents can certainly monitor play for safety, a large proportion of play should be child driven rather than adult directed.
•Pediatricians should emphasize the advantages of active play and discourage parents from the overuse of passive entertainment (eg, television and computer games).
•Pediatricians should emphasize that active child-centered play is a time-tested way of producing healthy, .t young bodies.
•Pediatricians should emphasize the benefits of “true toys” such as blocks and dolls, with which children use their imagination fully, over passive toys that require limited imagination.
•Pediatricians can educate families regarding the protective assets and increased resiliency developed through free play and some unscheduled time.
•Pediatricians can reinforce that parents who share unscheduled spontaneous time with their children and who play with their children are being wonderfully supportive, nurturing, and productive.
•Pediatricians can discuss that, although very well intentioned, arranging the .nest opportunities for their children may not be parents’ best opportunity for influence and that shuttling their children between numerous activities may not be the best quality time. Children will be poised for success, basking in the knowledge that their parents absolutely and unconditionally love them. This love and attention is best demonstrated when parents serve as role models and family members make time to cherish one another: time to be together, to listen, and to talk, nothing more and nothing less. Pediatricians can remind parents that the most valuable and useful character traits that will prepare their children for success arise not from extracurricular or academic commitments but from a .rm grounding in parental love, role modeling, and guidance.
•Pediatricians should be a stable force, reminding parents that the cornerstones of parenting—listening, caring, and guiding through effective and developmentally appropriate discipline—and sharing pleasurable time together are the true predictors of childhood, and they serve as a springboard toward a happy, successful adulthood.
•Pediatricians should help parents evaluate the claims made by marketers and advertisers about the products or interventions designed to produce super-children.
•Pediatricians should emphasize the proven benefits of reading to their children, even at very early ages.
•Pediatricians can be available to parents as sounding boards to help parents evaluate the specific needs of their child in terms of promoting resiliency, developing confidence and competence, and ultimately enhancing that child’s trajectory toward a successful future.
•Pediatricians can support parents to organize play-groups beginning at an early preschool age of approximately 2.5 to 3 years, when many children move from parallel play to cooperative play in the process of socialization.
•Pediatricians can advocate for developing “safe spaces” in under resourced neighborhoods, perhaps by opening school, library, or community facilities to be used by children and their parents after school hours and on weekends.
•Pediatricians can educate themselves about appropriate resources in their own community that foster play and healthy child development and have this information available to share with parents.
•Pediatricians should support children having an academic schedule that is appropriately challenging and extracurricular exposures that offer appropriate balance. What is appropriate has to be determined individually for each child on the basis of their unique needs, skills, and temperament, not on the basis of what may be overly pressurized or competitive community standards or a perceived need to gain college admissions.
•Pediatricians should encourage parents to allow children to explore a variety of interests in a balanced way without feeling pressured to excel in each area. Pediatricians should encourage parents to avoid conveying the unrealistic expectation that each young person needs to excel in multiple areas to be considered successful or prepared to compete in the world. In parallel, they should promote balance in those youth who are strongly encouraged to become expert in only 1 area (eg, a particular sport or musical instrument) to the detriment of having the opportunity to explore other areas of interest.
•As parents choose child care and early education programs for their children, pediatricians can reinforce the importance of choosing settings that offer more than “academic preparedness.” They should be guided to also pay attention to whether the settings attend to the social and emotional developmental needs of the children.
•Pediatricians can join with other child professionals and parents to advocate for educational settings that promote optimal academic, cognitive, physical, social, and emotional development for children and youth.
•Pediatricians should assess their patients for the manifestations of stress, anxiety, and depression in family-centered interviews for children and privately conducted interviews with adolescents.
• Because stress often manifests with physical sensations, pediatricians should be highly sensitized to stress as an underlying cause of somatic illness.
• Pediatricians should refer to appropriate mental health professionals when children or their parents show signs of excessive stress, anxiety, or depression.
Play is a cherished part of childhood that offers children important developmental bene.ts and parents the opportunity to fully engage with their children. However, multiple forces are interacting to effectively reduce many children’s ability to reap the bene.ts of play. As we strive to create the optimal developmental milieu for children, it remains imperative that play be included along with academic and social-enrichment opportunities and that safe environments be made available to all children. Additional research is needed to explore the appropriate balance of play, academic enrichment, and organized activities for children with different temperaments and social, emotional, intellectual, and environmental needs.
COMMITTEE ON COMMUNICATIONS, 2006–2007
Donald L. Shifrin, MD, Chairperson Daniel D. Broughton, MD Benard P. Dreyer, MD Kenneth R. Ginsburg, MD Regina M. Milteer, MD Deborah A. Mulligan, MD Kathleen G. Nelson, MD
Tanya R. Altmann, MD Media Resource Team
Michael Brody, MD American Academy of Child and Adolescent Psychiatry
Michelle L. Shuffett, MD Media Resource Team Brian Wilcox, PhD American Psychological Association
Carolyn Kolbaba Veronica L. Noland Marjorie Tharp
COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, 2006–2007
William L. Coleman, MD, Chairperson Marian F. Earls, MD Edward Goldson, MD Cheryl L. Hausman, MD Benjamin S. Siegel, MD Thomas J. Sullivan, MD
J. Lane Tanner, MD
Ronald T. Brown, PhD Society of Pediatric Psychology Mary Jo Kupst, Phd, MD Society of Pediatric Psychology Sally E. A. Longstaffe, MD Canadian Paediatric Society Janet Mims, MS, CPNP National Association of Pediatric Nurse Practitioners
Frances J. Wren American Academy of Child and Adolescent Psychiatry
George J. Cohen, MD
Note: all references appear in the pdf of the full article, see top of page