Abstract
Despite the known benefits of play for child development, 1 disparities in play exist, particularly among under-resourced children.2,3 This lack of access to play may exacerbate existing disparities in developmental outcomes. Indeed, the populations of children experiencing the great barriers to play are often those at higher risk of developmental concerns, including children belonging to racialized minorities and those who speak languages other than English, are uninsured, and come from low-income families.4,5
For timely identification of developmental concerns, the American Academy of Pediatrics (AAP) recommends pediatric healthcare providers screen for developmental milestones at least 5 times before the age of 3 years. 6 Developmental screening is a brief method to identify developmental progress and is important for early detection of developmental delays. 7 Pediatric healthcare providers are at the forefront of conducting developmental screeners and disseminating relevant information and referrals to support healthy growth. They also have the potential to serve a critical role in educating caregivers on the importance of play in enhancing executive functioning, emotional intelligence, and social skills. 8 Thus, interventions aimed at promoting play during routine pediatric visits could be a medium to disseminate the importance of play to improve developmental outcomes, particularly among under-resourced children.
One such program, Prescription for Play (P4P), is administered by pediatric healthcare providers during routine 18- to 36-month well-child checks (WCCs). During the visit, providers educate caregivers on the benefits of play for socioemotional and physical development and offer a P4P kit and educational materials to support play experiences. To understand the effectiveness of P4P, it is important to explore whether it influences the developmental health of children. In line with recommendations to use validated developmental screening tools, 7 this study prospectively explored differences in developmental concerns among a population of largely under-resourced children who received P4P versus those who did not using the Parents’ Evaluation of Developmental Status (PEDS) screening tool. The PEDS is designed for children of ages 0 to 8 years and asks caregivers to report concerns on different developmental domains. 9 It was hypothesized that children exposed to P4P would be less likely to have developmental concerns at their subsequent WCC than those who did not receive P4P.
Methods
Program Overview
Prescription for Play is a freely available social impact program of The LEGO® Group (https://www.rx4play.org), designed for healthcare providers seeing 18- to 36-month-old patients for WCCs. Prescription for Play offers a virtual hub to healthcare teams, which includes program resources and trainings, implementation toolkits, continuing medical education credits, technical assistance, educational content, and program support. Prescription for Play further provides participating clinics with play kits containing age-appropriate LEGO DUPLO® bricks and related educational materials to engage caregivers on the benefits of play. Participating providers are instructed to model play using the play kit in real time while educating caregivers on the role of play in child development. In line with AAP recommendations, 8 providers are encouraged to give caregivers a “prescription” to play daily with their child. At subsequent visits, providers are advised to continue conversations on the importance of play, with the goal of building caregivers’ capacity to dedicate time each day to play with their children.
Procedure
Data were derived from the Community Health Center, Inc. (CHCI), the largest Federally Qualified Health Center (FQHC) located in Connecticut, which primarily serves uninsured and underserved populations and has been implementing P4P since June 2021. Data were extracted from the electronic health record (EHR) for all 18- to 36-month WCCs from August 2021 through July 2023. The CHCI Institutional Review Board approved the study.
Measures
P4P participation
Patients were dichotomized according to whether they received P4P or not as documented in their EHR.
Parents’ Evaluation of Developmental Status
The PEDS questionnaire is a 10-item, self-report measure eliciting caregivers’ concerns about their child’s developmental health across 6 domains: language, motor skills, behavior, self-help, school, and social skills. 9 To understand the prospective impact of P4P on developmental outcomes, the PEDS score from the WCC occurring after the visit in which P4P was implemented was selected for use among patients who received the intervention. For patients who did not receive P4P, the subsequent time point in which the PEDs score was available after the first WCC documented during the study period was included. Parents’ Evaluation of Developmental Status scores were dichotomized as either indicating concerns or being normal.
Demographics
Patient age, gender, race/ethnicity, language, and insurance provider were extracted from the EHR to describe the sample. Given disparities in developmental concerns across each of these demographic factors, these variables were further considered as covariates.4,5
Analysis
Pearson’s χ2 tests and Fisher’s exact tests compared demographic characteristics and PEDS scores between patients who did and did not participate in P4P. A sensitivity analysis was conducted using Fisher’s exact tests to determine the differences in baseline PEDS scores and subsequent PEDS scores between patients who did and did not participate in P4P. Multivariable logistic regression was then used to estimate the effects of participation in P4P on subsequent PEDS scores, controlling for sociodemographic effects. Data were analyzed using SPSS Version 27 (IBM, Armonk, NY).
Results
Data were extracted for 3176 patients who completed 18- to 36-month WCC during the timeframe assessed. Of these, 2715 (85.5%) patients were excluded for missing or incomplete data, leaving an analytic sample of 461. Of the analytic sample, 59.0% (n = 272) participated in P4P, and 41.0% (n = 189) did not. Demographic characteristics are shown in Table 1. Bivariate analyses showed that patients who received P4P were less likely to have reported their ethnicity and less likely to have concerns on the PEDS than those who did not receive P4P.
Sample Characteristics of Pediatric Patients Who Did and Did Not Participate in the P4P Program.
Unreported data in the χ2 column, denoted by “–” indicate variables for which Fisher’s exact tests were estimated, and coefficients are thus not available.
Abbreviation: P4P, Prescription for Play.
Asian, Native Hawaiian or Other Pacific Islander, Other, State Prohibited, Undetermined.
Only a subset of patients (n = 199; 43.2%) had a PEDS score recorded at both an initial and subsequent time point. A Fisher’s exact test showed no statistical difference (P = .87) in baseline PEDS scores on subsequent PEDS scores between those who participated in P4P (n = 113) and those who did not (n = 86). As such, baseline PEDS scores were not included in the final multivariable logistic regression model.
Table 2 displays the results from the multivariable logistic regression exploring differences in developmental concerns by participation in P4P, controlling for demographics. Due to small cell sizes, gender and insurance provider details were excluded. 10 The odds of having developmental concerns were lower among patients who received P4P than among those who did not (odds ratio [OR] = .64, 95% CI [.42, .98], P = .04). Patients who declined or did not report race were more likely to have developmental concerns than those identifying as Black or African American (OR = 2.57, 95% CI [1.05, 6.28], P = .03). Spanish-speakers were less likely to have developmental concerns than English-speakers (OR = .52, 95% CI [.31, .85], P = .01).
Odds Ratios and 95% Confidence Intervals From a Multivariable Logistic Regression Model Predicting the Likelihood of Having Developmental Concerns.
Gender and insurance provider were excluded from the model due to small cell sizes.
Abbreviation: P4P, Prescription for Play.
Asian, Native Hawaiian or Other Pacific Islander, Other, State Prohibited, Undetermined.
Discussion
This study is the first to prospectively examine developmental concerns in children after participating in P4P. Data suggest that participation in P4P may protect against developmental concerns, which is consistent with literature showing that play promotes positive developmental outcomes.2,3,11 Although this study evaluated a developmental screener and is not able to provide specific details on developmental outcomes, it may be that the guidance caregivers receive about play as part of P4P translates to increased play at home and care settings, thereby promoting more favorable developmental outcomes. However, future work is needed to replicate and expand upon these findings to more comprehensively understand whether and how P4P impacts child development. Regardless, this study supports research indicating that play is a fundamental part of healthy development8,12 and provides initial support for the potential benefits of prescribing play in WCCs during the first 3 years of life as is recommended by the AAP. 8
This study further identifies variation in developmental concerns between different language speakers. Namely, Spanish-speaking caregivers were shown to be less likely to report developmental concerns for their children than English-speaking caregivers, which may relate to a tendency for Spanish-speakers to report more on needs related to food and other resources during WCCs than child development. 13 Results further show that patients who did not report their race had higher odds of reporting developmental concerns than those identifying as Black or African American. Although the cause of this disparity is unclear without additional information, this finding highlights limitations that often arise from the EHR with regard to high rates of missing and unreported data. 14
There are several limitations worth noting. The study sample is from a relatively large FQHC in Connecticut; thus, these findings may not be reflective of non-FQHC settings. In addition, most children did not have data on gender, race, and ethnicity, and a majority (85.5%) of the sample was excluded for missing or incomplete data, which makes it challenging to draw conclusions regarding these outcomes in the full sample of children receiving care. Moreover, although healthcare teams implementing the P4P program get access to an online virtual hub, which includes program resources and trainings, we were unable to monitor program compliance as part of this retrospective EHR analysis. Lastly, the study used only one developmental screener assessed over a short period of time, which does not allow for conclusions on the impact of P4P on longer-term developmental outcomes.
Despite these limitations, this study highlights the potential for P4P to reduce developmental concerns among underserved communities. Future research should continue to explore the role of play-promotion during WCCs in addressing developmental delays among underserved populations.
Author Contributions
Footnotes
Authors’ Note
All authors of this manuscript acknowledge receiving funding through a grant from The LEGO® Group. However, The LEGO® Group was not involved in the design of this research study nor the collection, analysis, or interpretation of the data described herein. The LEGO® Group had no influence on the writing of this manuscript. The contents of this manuscript are solely the responsibility of the authors and do not necessarily reflect the views of The LEGO® Group.
Availability of Data and Materials
Due to privacy and ethical restrictions, data are not available.
Ethical Approval
This work was approved by the Community Health Center, Inc. Institutional Review Board.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a grant from the LEGO® Group.
