My brother used to punch me every time a Volkswagen Beetle drove by. The rules of the game were simple: the first one to spot the Beetle got to call out “Punch Buggy” followed by the car color (you know, to verify authenticity, no cheap shots allowed) and throw the punch. Since my brother was older and taller, and could see out of the back window of the car more easily, the game should have been re-named Little Sister Sore Arm (the acronym of which, if spelled backward, must have been what my little sister self thought of my brother during this game). I don’t know how that game evolved, or why it had to be a Volkswagen Beetle specifically, but years later, the automative maker Volkswagen is still captivating consumer thought and play by asking an important question: can we influence people to make more positive choices by making them more fun? They used this concept to encourage people to drive more environmentally conscious cars, and propelled that idea into their “Fun Theory.” They host a competition to utilize fun ways to encourage positive outcomes (www.thefuntheory.com). This has important implications for health, as our population has become increasingly sedentary, and making positive choices like walking up stairs instead of taking an escalator can seem difficult to achieve. Check out this short video for this Fun Theory winner’s creative solution, and their remarkable results showing a 66% increase in healthy behavior:
I also think it has far reaching implications about play and fun in health care beyond the cardiovascular benefits. Why is fun important? Why do we play? And should we be paying attention to these questions in our health care encounters and assessment of patient outcomes? The basic questions about play have driven the careers of numerous researchers interested in its science. In fact, there is a National Institute for Play, headed by Dr. Stuart Brown, a psychologist who first became interested in the importance of play on human behavior when he was studying an unlikely patient population: particularly aggressive murderers. Dr. Brown found that a consistent feature of the young men he studied was a lack of opportunity to play when young. In the several decades of research since then, including studies in both animal behavior and human development, the mysteries of play and why it is so important to optimal development are still being investigated. The study of play actually goes back thousands of years. In Plato’s The Republic, Socrates is quoted as saying “our children from their earliest years must take part in all the more lawful forms of play, for if they are not surrounded by such an atmosphere they can never grow up to be well conducted and virtuous citizens.”
What is known is that play helps develop motor skills, cognitive skills, and skills for social interaction. The benefits of play are numerous and represent an important way that both human and animal species learn. Kittens pounce, puppies play-fight, even birds get in the action. In my home state of Maine for instance, common ravens have been reliably observed “sledding” in the snow, sliding down snow banks or snow covered roof tops and then flying back up to slide down again. At the beach, the gulls, who usually fly over rocks and drop their clams to crack them open to eat them, sometimes seem to “play with their food” and drop their clams only to swoop down and catch them mid-air before they hit the ground, and then sail up again to repeat their game. Beyond solo play, there is also highly choreographed group play across a spectrum of animals from chimps to crocodiles. Animals playing together exhibit specific “signal patterns” that signify play, such as the “curtsey” of wolves and dogs before a play-fight (or what ethologist Marc Bekoff calls the “play bow”) to alert others that the behavior is “all in fun.”
What happens if we are not given the opportunity to play? Are there deleterious effects, as Dr. Brown surmised in studying his criminal population? Dr. Sergio Pellis, a neuroscientist, has done experiments in rats suggesting a relationship between play and brain development. In rats reared in an environment devoid of their normal “play” opportunities, they found this experimental group had more immature brains than control rats. The neuroscientist Jaak Panksepp has spent his career studying brain development and play, and has found that unstructured play is crucial for proper brain development and socialization. He developed a surgical rat model of ADHD, and observed that the brain disinhibition in the experimental rats resulted in more rough-and-tumble play and aggression compared to controls, and he drew parallels to the hyperactivity seen in children diagnosed with ADHD. Further, he found that providing these experimental rats with one more hour per day of play to, as I see it, “get their wiggles out,” resulted in return to normal levels of activity. While the ADHD community has not specifically embraced play therapy as the solution to ADHD, it certainly has sparked discussions. There is also a body of literature on exercise and movement on managing ADHD symptoms, and play therapy as a means to tackle depression and anxiety symptoms.
“The absence of play is not work, it is depression.” -Brian Sutton-Smith, developmental psychologist and play theorist
So why is this concept of play so important to the central question of this Collective Well blog, are we in health care providing an environment to empower children with chronic health conditions to reach their potential, and are we measuring that full potential when we look at outcomes? This question has bothered me for a very long time. So much of childhood play is now organized rather than free-form, and opportunities need to be crafted as they are not always readily available. I have seen many of my patients be excluded from recreational play or sport activities due to real or perceived limitations in their health or stamina. But there is another lesson there, beyond the fitness aspects. I remember one little boy, a patient of mine who was 9 years old, who did not have many friends. But he did have one friend, a best friend. They hung out all school year, and I could see my little patient blossom. Then in the spring, this friend decided to sign up for Little League baseball. My patient did not. Now once upon a time, as the mother of 3 boys, I spent many an hour in the Little League bleachers, and I could have predicted exactly what happened. In the dugout, the boys make plans to go out for ice cream after the game. On the sidelines, the parents make plans to grab a bite to eat together after. Sleep-overs are arranged, bonds are formed. And by the very nature of the fact that my patient was not present while these plans were being made, he was excluded. From all of it. And within 3 weeks, he lost his friend simply because of lack of proximity, and began a downward spiral that culminated in severe depression by adolescence.
The cardiovascular benefits of active play and recreation are clear, as are the social and cognitive benefits. Providing more opportunities for free-form fun would be very beneficial. There is a tremendous push now in medicine to encourage children to be active, and there are some wonderful opportunities for inclusivity for patients with disabilities. But more can be done to include those with chronic conditions who may not have physical or cognitive disabilities, such as those with diabetes or asthma or congenital heart disease for instance, to enjoy the benefits of group play. For if they are unwittingly left out, then what are the consequences? And I really believe that even small opportunities, such as the one hour a day play for Pellis’ rats, can have sustaining effects for a large return-on-investment for our patients. That was the driving force behind my starting a camp for kids with heart conditions, for instance. More on that later.
I think all of our patients need to be able to freely experience the joy of play, the rules of the game with their peers, and the ability to explore in a safe and unhindered way. If children are allowed this exploration, they will find bonds with their peers, develop a sense of self, and develop the means to get their “ring-in-the-hand moment” where they find out they are capable.
I still am not sure I understand the evolutionary purpose of the game of Punch Buggy, but I know it passed the time in the car back in the day, and it strengthened my observational skills as to this day I can spot a Volkswagen Beetle across lanes of traffic. Although perhaps there is an evolutionary advantage, as maybe this little distraction or amusement makes me less likely to have road rage as I maneuver my car in amongst one of the biggest human behavior experiments of all time, otherwise known as morning commuter traffic into Boston. I also still have to hand it to Volkswagen, as when I arrived at the parking garage the other morning after surviving another perilous trip into Beantown, I parked next to a Volkswagen Beetle. It has been updated since my childhood with a curvier new look and it was painted a vibrant yellow color. And it was sporting big false eyelashes on the headlights.
Long live fun.