Kenneth R Ginsburg And The Committee On Communications And The Committee On Psyc

Kenneth R. Ginsburg 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.

  • children
  • adolescents
  • play
  • parents
  • resilience
  • mental health
  • college
  • schedules


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 briefly 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.


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 fit 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


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  information, 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  “overscheduled” 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 activities.45–47,51,52

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 lifestyle.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.


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 difficult 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.


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 profit 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 find 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,  overscheduling may lead to less emotionally competent, well-buffered  children.


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


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 excessive  stressors in their lives. 

  • 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, fit 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 finest  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 firm 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 playgroups 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 underresourced  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 benefits 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 benefits 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


Karen Smith


  • All  clinical reports from the American Academy of Pediatrics automatically  expire 5 years after publication unless reaffirmed, revised, or retired  at or before that time.
  • The  guidance in this report does not indicate an exclusive course of  treatment or serve as a standard of medical care. Variations, taking  into account individual circumstances, may be appropriate.
  • ↵*  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.


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