Artigos

Introduction
The idea of play is deeply rooted in human culture, life, and it plays an important role in human development. Playing can be defined as “a transaction between the individual and the environment that is intrinsically motivated, internally controlled, and free from many of the constraints of objective reality and skills related to framing (giving and responding to cues)”1. It has a wide range of benefits for children, including improved language skills and better physical development. The activity of playing can manifest in various ways, such as engaging in physical play, imaginative play, and playing with conventional toys and shape sorters2.
In addition to playing, another crucial developmental stimulus is the practice shared book reading, which involves reading to or with the child. This practice has been found to bring benefits to several areas of child development, particularly language. It can be done individually or in groups and is suitable for both literate and non-literate children3.
While shared playing and reading are often cited as positive stimuli for child development in the first 2 years of life, the literature has largely focused on their facilitation or stimulation of language development. This is due to increased interaction and communication between parents and children4. Some studies have reported positive associations between shared playing/reading and socio-emotional factors5, academic skills6, and vocabulary and sustained attention skills7. However, to the best of our knowledge, no studies have used instruments that simultaneously gather information on cognitive, language, motor, and socio-emotional domains. Exploring the association between shared playing/reading and other domains of child development beyond language could provide valuable insights for discussing of individual or collective interventions aimed at enhancing early childhood development. This could ultimately have a positive impact on the child’s long-term outcomes.
Our objective is to fill this gap by evaluating the association between parental/family interaction, specifically shared playing/reading, and child development at 2 years of age.
Materials and Methods
This study uses data from Iracema-COVID, a cohort study that follows mothers and their children born between July and August 2020, in the city of Fortaleza, the capital of the state of Ceará, in northeastern Brazil. Recruitment was conducted using the Live Birth Information System (Sistema de Informações sobre Nascidos Vivos - SINASC), which identified and contacted by phone mothers who gave birth in public hospitals and reside in Fortaleza. Data collection was conducted by interviewers at the participants' homes. The cohort design has been previously described in detail elsewhere 8–10. We conducted a cross-sectional analysis of 317 dyads (mothers and children) using data from the fourth wave of Iracema-COVID, when the children were 2 years old. We excluded 11 children with neurological disorders reported by their mothers, from the analysis. Information on daily playing/reading between the child and the family, collected through the following question: "Every day, do you or someone else in your family usually play, read, or talk only with the child?", was exposure variable. This question allowed for a "Yes" or "No" response.
The outcome Child development is the outcome of the analysis and was assessed using the Caregiver Reported Early Development Instrument (CREDI), a tool designed for population-level use, and comparable across cultures. It collects data on child development across five domains: cognitive, language, motor, socio-emotional, and overall 11. The long version of the instrument, consisting of 117 questions, was utilized in this study. It has been translated and validated for use in Brazil12, and here we utilized the long version of 117 questions. The scores for each domain were calculated using to an algorithm provided by the developers of CREDI (https://credi.shinyapps.io/Scoring_App/). The results are presented and analyzed as age-adjusted z-scores, assuming a normal distribution, and categorized as follows <-2SD; -2?SD?-1; -0.99?SD?0.99; 1?SD?2; and >2SD.
To adjust the models, two variables related to psychosocial stimulation were selected to adjust the models because they were believed to be associated with the exposure and outcome 13. These variables were: a) the presence of books, newspapers, and magazines in the home, and b) ownership of children's books with pictures. In addition, the following self-reported variables were used in the analysis including the child’s sex (male/female), prematurity (Yes/No); child attendance at daycare (Yes/No), maternal education (in years), mother's skin color (white, yellow, black/brown, other); mother living with a partner (Yes/No), income (monthly family minimum wage: <1; 1-2; 3 or more), whether the mother has other children <6 years old (Yes/No), whether the mother receives help with child care (Yes/No), whether the mother receives government cash transfer (Yes/No), whether the mother has private health insurance (Yes/No), and maternal common mental disorders (Self-Reported Questionnaire (SRQ20): negative: <8; positive: 8 or more).
The study conducted a descriptive analysis using means, standard deviations, raw and relative frequencies. The distribution of CREDI scores according to shared play/reading was described using the Kernel density estimator. Bivariate analyses were performed using the chi-squared and Kruskal-Wallis tests. Crude and adjusted linear regression models were run for each of the CREDI domains to determine the association between shared play/reading between family members and children and better child development. All covariates that showed statistical significance at the 0.05 to 0.20 level in the crude bivariate analysis were included in the adjusted model. Final covariates included in the multivariable model were selected using a backward stepwise approach. All models were adjusted for variables related to the availability of magazines/newspapers and children's books at home. The analyses were performed using Stata v.11.
Results
Out of the 306 children studied, 285 (93.11%) engaged in daily reading/playing activities with their parents or relatives. About half were male, 10.46% were born prematurely, and 22.08% were attending kindergarten. The mean CREDI z-scores by domain were -0.33 for cognition, -0.54 for language, -0.45 for motor skills, -0.32 for socio-emotional, and -0.45 for the overall. The mothers’ mean age was 26.18 years and their mean years of education was of 10.67 at the time of the interview. Additionally, 83.01% of the participants self-identified as having black or brown skin color, 75.81% lived with a partner, 53.19% reported a monthly income between 1 and 2 minimum wages, and 63.07% received cash transfer assistance. (Tables 1 and 2).
The Kernel distribution of the CREDI scores disaggregated by shared playing/reading status indicates that results for children who were exposed to shared playing/reading had better results in all CREDI domains (Figure 1).
Tables 3 and 4 show a significant difference in the CREDI domains, with better outcomes (higher scores) for children who participated in shared playing/reading activities with parents or family members. Furthermore, a crude analysis, stratified for each of the CREDI domains revealed a statistically significant association between the child’s sex and all of the CREDI domains, with girls achieving higher scores. Maternal age was also positively associated with higher scores in language, socio-emotional, and overall CREDI domains. Higher maternal education was associated with better cognition results, the presence of a partner in the household was associated with better scores in the cognition, motor, socio-emotional, and overall domains. Adjusted regression analyses showed that engaging in playing/reading activities with parents or family members contributed to improved child development across all domains measured by the CREDI (Tables 3 and 4).
Discussion
This study investigated the relationship between shared play and reading activities among children and their parents or relatives, and child development. The results indicate that shared play and reading activities may improve cognitive, language, motor, socio-emotional, and overall development in 2-year-old children.
The literature consistently reports that exposure to conversation14, shared book reading15, and playing2 are factors that contribute to greater language development in children. This might be because this activity stimulates an increase in the density and myelination of the fibers that compose the brain’s white matter, which enhances language skills16. Our results support these findings and demonstrate a positive association between language development and playing/reading.
However, engaging in play can offer benefits in other aspects such as social and emotional behavior, cognition17, and physical skills18. In many mammals, the neocortex, which is responsible for functions such as sensory perception, emotion, and cognition, is more frequently activated during play time19. Additionally, among primates, a study with primates showed that games involving locomotion results in a greater development of motor skills 20. These data can support the hypothesis that motor skills can be influenced by games in humans as well. Assuming that humans have similar processes, we would anticipate higher scores in the CREDI cognitive and motor domains in children who experienced a shared play/reading situation, as shown by our results.
Play, especially social play, has been found to promotes the activation of areas of the human brain associated with social processing and empathy, particularly the posterior superior temporal sulcus 21. This area is involved in perceiving social cues and understanding and empathizing with others. This suggests that engaging in play with others, particularly with parents and relatives, may have positively impact the socio-emotional development of children.
Our results suggest the benefits of implementing programs and policies to promote shared reading between children and parents or family members can have numerous benefits. Such programs can help to foster positive relationships between children and their caregivers, promote early literacy skills, and support cognitive development. Fortunately, experiences taking place in the home22 are already being reported worldwide, with government support23 or initiated by foundations and non-governmental organizations24, and are considered to be cost-effective, as they can be implemented relatively easily and can have a significant impact on children's development.
From a global perspective, the information in this study can contribute to achieving one of the goals of the United Nations 2030 Agenda for Sustainable Development, to "ensure that all girls and boys have access to quality early childhood development, care, and preprimary education so that they are ready for primary education"25. By taking action to promote shared reading and invest in quality early childhood development programs, we can help to ensure that all children have the opportunity to reach their full potential and contribute to a more sustainable and equitable future. In addition, from a national perspective, article 3 of the Child and Adolescent Statute provides the following statement "Art. 3. Children and adolescents enjoy all the fundamental rights inherent to the human person, without prejudice to the full protection provided by this law, which guarantees them, by law or by other means, all the opportunities and facilities to ensure their physical, mental, moral, spiritual and social development, in conditions of freedom and dignity."26. The text of the legal provision emphasizes the importance of promoting the adequate proper development of children, which can also be encouraged through the discussion of the data presented here.
The strength of this study lies in the use of a standardized instrument to measure child development. Therefore, it facilitates the assessment of the benefits of shared playing/reading on various domains of development beyond language. This study also has some limitations. The exposure variable was self-reported by the mother rather than directly observed, which may result in an overestimation of parental behavior. Also, the question that generated the shared play/reading variable includes “talking” only with the child. This could have overestimated the frequency of the exposure variable, however, talking is a fundamental part of the language development stimulation and would likely be included on the playing/ reading activities. Considering the novelty of the proposal presented in this article, it was not possible to find research in the literature that analyzed the association between shared reading and playing and early development through CREDI. It should also be mentioned that CREDI does not provide for any type of adjustment for cases of prematurity. Even though the data analyzed here did not show differences based on this variable, this procedure could be considered and discussed in future research. This may be a secondary limitation of this study, as the discussion cannot be developed in dialogue with papers using the same approach. Since the sample for this research was not specifically designed for the purpose of this article, we have subgroups with few or no representatives in the analyses. Therefore, conducting research with larger and more representative samples would be recommended to confirm our findings. Furthermore, in future studies, it would be important to collect information about reading, playing, and conversations shared with the family separately. Thus, the association of each type of stimulus could be studied individually.
Conclusion
The practice of playing/reading shared between parents/relatives and children was positively associated not only with better language development in 2-year-old children, but also with better cognitive, motor, socio-emotional, and overall development scores. Therefore, we recommend raising awareness and promoting programs that encourage playing/reading.

?
References
1. Bundy AC, Nelson L, Metzger M, et al. Validity and Reliability of a Test of Playfulness. The Occupational Therapy Journal of Research 2001; 21: 276–292.
2. Yogman M, Garner A, Hutchinson J, et al. The Power of Play: A Pediatric Role in Enhancing Development in Young Children. Pediatrics; 142. Epub ahead of print 1 September 2018. DOI: 10.1542/peds.2018-2058.
3. Lingwood J, Lampropoulou S, de Bezenac C, et al. Children’s engagement and caregivers’ use of language-boosting strategies during shared book reading: A mixed methods approach. J Child Lang 2022; 1–23.
4. Clemens LF, Kegel CAT. Unique contribution of shared book reading on adult-child language interaction. J Child Lang 2021; 48: 373–386.
5. Feigin VL, Brainin M, Norrving B, et al. World Stroke Organization (WSO): Global Stroke Fact Sheet 2022. International Journal of Stroke 2022; 17: 18–29.
6. Shahaeian A, Wang C, Tucker-Drob E, et al. Early Shared Reading, Socioeconomic Status, and Children’s Cognitive and School Competencies: Six Years of Longitudinal Evidence. Scientific Studies of Reading 2018; 22: 485–502.
7. Vally Z, Murray L, Tomlinson M, et al. The impact of dialogic book-sharing training on infant language and attention: a randomized controlled trial in a deprived South African community. Journal of Child Psychology and Psychiatry 2015; 56: 865–873.
8. Castro MC, Farías-Antúnez S, Araújo DABS, et al. Cohort profile: maternal and child health and parenting practices during the COVID-19 pandemic in Ceará, Brazil: birth cohort study (Iracema-COVID). BMJ Open 2022; 12: e060824.
9. Correia LL, Machado MMT, Araújo DABS, et al. Primary Health Care during the COVID-19 pandemic in Fortaleza, Brazil: associated factors and pattern of use by mothers and children up to 18 months of age. Revista Brasileira de Epidemiologia; 25. Epub ahead of print 2022. DOI: 10.1590/1980-549720220036.
10. Farías-Antúnez S, Machado MMT, Correia LL, et al. Food insecurity among families with infants born during the COVID-19 pandemic in Fortaleza, Northeast Brazil. J Health Popul Nutr 2023; 42: 14.
11. McCoy DC, Waldman M, CREDI Field Team, et al. Measuring early childhood development at a global scale: Evidence from the Caregiver-Reported Early Development Instruments. Early Child Res Q 2018; 45: 58–68.
12. Altafim ERP, McCoy DC, Brentani A, et al. Measuring early childhood development in Brazil: validation of the Caregiver Reported Early Development Instruments (CREDI). J Pediatr (Rio J) 2020; 96: 66–75.
13. Strouse GA, Nyhout A, Ganea PA. The Role of Book Features in Young Children’s Transfer of Information from Picture Books to Real-World Contexts. Front Psychol; 9. Epub ahead of print 6 February 2018. DOI: 10.3389/fpsyg.2018.00050.
14. Romeo RR, Leonard JA, Robinson ST, et al. Beyond the 30-Million-Word Gap: Children’s Conversational Exposure Is Associated With Language-Related Brain Function. Psychol Sci 2018; 29: 700–710.
15. Demir?Lira ÖE, Applebaum LR, Goldin?Meadow S, et al. Parents’ early book reading to children: Relation to children’s later language and literacy outcomes controlling for other parent language input. Dev Sci; 22. Epub ahead of print 15 May 2019. DOI: 10.1111/desc.12764.
16. Davison KE, Zuk J, Mullin LJ, et al. Examining Shared Reading and White Matter Organization in Kindergarten in Relation to Subsequent Language and Reading Abilities: A Longitudinal Investigation. J Cogn Neurosci 2023; 35: 259–275.
17. Robinson EL, StGeorge J, Freeman EE. A Systematic Review of Father–Child Play Interactions and the Impacts on Child Development. Children 2021; 8: 389.
18. Nijhof SL, Vinkers CH, van Geelen SM, et al. Healthy play, better coping: The importance of play for the development of children in health and disease. Neurosci Biobehav Rev 2018; 95: 421–429.
19. Wang S, Aamodt S. Play, stress, and the learning brain. Cerebrum 2012; 2012: 12.
20. Berghänel A, Schülke O, Ostner J. Locomotor play drives motor skill acquisition at the expense of growth: A life history trade-off. Sci Adv; 1. Epub ahead of print 7 August 2015. DOI: 10.1126/sciadv.1500451.
21. Hashmi S, Vanderwert RE, Price HA, et al. Exploring the Benefits of Doll Play Through Neuroscience. Front Hum Neurosci; 14. Epub ahead of print 1 October 2020. DOI: 10.3389/fnhum.2020.560176.
22. LuCiD IC for L and CD. Supporting families with shared reading activity in the home, https://www.lucid.ac.uk/resources/for-practitioners/supporting-families-with-shared-reading-activity-in-the-home/ (2023, accessed 6 June 2023).
23. Biddulph Education. Early Reading Together® programme, https://www.readingtogether.net.nz/early-reading-together.html (2023, accessed 6 June 2023).
24. Read to Me Project, https://readtomeproject.org/ (2023, accessed 6 June 2023).
25. United Nations. 2030 Sustainable Development Goals, https://www.un.org/sustainabledevelopment/development-agenda/ (2015, accessed 16 February 2023).
26. Brasil CC. Lei no 8.069, de 13 de julho de 1990, https://www.planalto.gov.br/ccivil_03/leis/l8069.htm (1990, accessed 4 June 2023).