Play Behaviors in Children during the COVID-19 Pandemic: A Review of the Literature

Play is a key factor for children’s healthy psychological, emotional, social, and cognitive development. During the COVID-19 pandemic, it has been postulated that children’s play was affected, not only regarding the time children spent playing but also in terms of the qualitative characteristics of play. The aim of this review was to investigate how children’s play has changed during the COVID-19 pandemic. A review was conducted in the PubMed, Google Scholar, EMBASE, SCOPUS, ERIC, PsycInfo, and JSTOR databases up to 6 December 2020. Furthermore, references of eligible studies as well as of relevant articles were searched using a snowballing technique. The search retrieved 17 eligible studies, conducted in Europe and North America. In general, outdoor play was reduced during the pandemic; on the other hand, there was an increase in indoor play and in videogames-screen time. COVID-19 was present in children’s pretend play. Children’s play was a key contributor to children’s mood and wellbeing. Furthermore, teachers were especially concerned about how children’s play was affected during the lockdown measures. There is evidence that children’s play habits were affected during the COVID-19 pandemic; further research is required, especially cross-culturally oriented.


Introduction
Play is a constitutional right for children, in accordance with the Convention on the Rights of the Child (Article 31), which highlights the "right to rest and leisure, to engage in play and recreational activities appropriate to the age of the child and to participate freely in cultural life and the arts" [1]. According to Eberle [2], "play is a roomy subject, broad in human experience, rich and various over time and place, and accommodating pursuits as diverse as peekaboo and party banter, sandlot baseball and contract bridge, scuba diving and Scrabble". In fact, play is considered a universal, intrinsic activity in children, present in every civilization, despite cultural differences [3]. The importance of play in children's social, emotional, and mental health has been argued by many specialists.
Play can be divided into three stages: embodiment, projection, and role play, collectively referred to as EPR [4]. The first one includes activities that are experienced through body (e.g., messy play, hopping, jumping); in the second stage, children use different media to express themselves (e.g., paper, colors, clay), while in the latter stage, children develop characters and stories through verbal and non-verbal means. Usually, the three stages of EPR are completed by the age of 7 years [5]. Different types of play could also be used regarding the means and manners (e.g., constructive play, fantasy play [5]), allowing children
Articles that examined play behaviors and play in general in children during the COVID-19 outbreak were considered eligible. Considering play, indoor activities such as videogaming, playing board games, role playing, etc. and outdoor activities such as biking, free play, sports, etc. were eligible. As far as study design is concerned, case reports, cohort studies, cross-sectional studies, case series, and case-control studies were included. Studies evaluating reports from parents were also deemed eligible, in order to describe a comprehensive picture of children's behaviors. Studies written in English, Spanish, and French were chosen, and there was no gender restriction.
Two authors (A.K. and A.S.) working independently from one another in pairs performed the selection of studies. Data from eligible studies were extracted, including name of first author, region/country where the survey was conducted, language, study period, study design, sample size, age range, selection of sample, ascertainment and/or association with the COVID-19 epidemic, outcomes and methods/questionnaires used for measurements, statistical analysis, and main findings.

Quality Assessment
The Newcastle Ottawa Scale for Cross-sectional Studies [20] and Newcastle Ottawa Scale for Cohort Studies [21] (Appendix A, Tables A1 and A2) were used to evaluate the risk of bias in eligible studies. The quality assessment was performed by two independent researchers (A.K. and A.S.).

Selection of Studies
Seventeen studies on the topic were identified. Among them, six studies were conducted in America (four in Canada [22][23][24][25], one in the USA [26], and one in Mexico [27]) and 11 were performed in Europe (five in Spain [28][29][30][31][32], two in Portugal [33,34], two in Ireland [35,36], one in the UK [37], and one in Poland [38]). Four of them had overlapping samples, but they have been included in Table 1 in the "overlapping studies" section" as they offered additional information regarding the issue examined in this paper. The majority of studies were cross-sectional (n = 14), and only three were cohort studies (Table 1). A total of 10,313 parents with one or more children 0-17 years old, 2159 children 0-13 years old who were represented by their parents (not specified if one or both parents participated in the research or how many children each parent had), 726 children and adolescents who reported for themselves, and 307 primary teachers reporting on children's play behaviors during the COVID-19 pandemic were gathered (Table 1. The data of cases where parents reported for their children and specific demographic data for their children were provided (e.g., sex percentage, mean age) are included in Table 1. Respondents were electronically invited through various social media platforms (e.g., Facebook, Twitter) and university-based emailing lists of students, faculty, and staff.
Online self-report questionnaire 90% of children during the early-COVID-19 period chose free play/unstructured activity (e.g., running around, tag) and 55% went for a walk; 10.4% of children participated in team sports training sessions or practice through remote or streaming services, 28.9% participated in activity classes or lessons (e.g., martial arts, dance, yoga) through remote or streaming services, and 2.4% participated in remote or streaming classes or sessions provided by a health club or gym. Older children (age 9-13) vs. younger children (ages 5-8) were more than five times as likely to participate in team sports training session or practice through remote or streaming services (OR = 5. 40  9.30% of male participants and 3.70% of female participants (4.30% 8-12 years old, and 10.70% 13-17 years old) did not practice any sport or carry out any physical activity during the confinement measures. 21.50% of male participants and 13.40% of female participants (14.10% 8-12 years old, and 14.10% 13-17 years old) did not practice any hobby during the confinement measures.
Furthermore, playing (both online gaming and conventional games) was the second most important factor (after family) for children and adolescents' happiness (22.77% boys <12 years old, 26.09% girls <12 years old, 16.65 male adolescents (13-17), 25.86% female adolescents (13)(14)(15)(16)(17)). 23.77% of the participants liked the fact that they had more free time to play at home. For families with childcare needs, parental anxiety was associated with higher total hands-on play (F(3142) = 14.01, p < 0.001), combined hands-on play (F(285) = 6.82, p = 0.011), and combined screen time (F(282) = 6.25, p = 0.014). Families without childcare needs indicated parenting stress was associated with lower total hands-on play (F(3212) = 7.95, p < 0.005) and combined hands-on play (F(2110) = 5.67, p = 0.019), and higher supervised screen time (F(3138) = 6.14, p = 0.014). Boys and girls did not differ in the %PA in any of the age groups; children with an outdoor space and who had other children in the household were significantly more active (p < 0.001); children from families with all adults working from home showed lower levels of %PA; and being younger, having a big outdoor space, having other children in the household, and having at least one adult not working from home were significant positive predictors of children's %PA, explaining 21% of the overall variance.

Outdoor and Indoor Play
Children's outdoor play was affected during the COVID-19 pandemic restrictions, with outdoor activities being restricted in regions with more severe measures compared to areas with looser confinement measures [22,30,34]. More specifically, a Canadian study revealed that children and adolescents (5-11 years) only reduced their time spent walking or biking by 47.3%, whereas only 27.7% increase it [23]. In addition, 63.8% of Canadian children participating in the aforementioned study decreased their outdoor physical activity or their engagement with outdoor sports and 47.5% reduced their time in outdoor playing. By contrast, an increase of 31.2% in indoor physical activity or engagement with indoor sports, and an increase of 61.0% in time spent playing inside were noted [23]. On the other hand, 80% of children in an Irish study went for a walk near their neighborhood at least once a week, while 1/3 walked on a daily basis [36].
Primary school children were more likely to spend time outdoors instead of using screens as leisure time (expect during the morning hours due to mandatory attendance of online classes) than their secondary school counterparts [37]. During lockdown, the majority of children aged 5-8 years (97.4%) and 9-13 years (80.6%) preferred free play and/or unstructured physical activity (e.g., running around or other active games) [26].
Decline in time spent on both outdoor and indoor physical activity (walking and biking) and both indoor and outdoor play in children were inversely associated with parental age [24]. Thus, children of older parents spent less time playing. This decline was also positively associated with parents' encouragement toward physical activity [24], with parents' support and participation, with household type (detached or not)-with the exception of indoor play [24,33]-and with there being at least one adult free from work [33]. Physical activity was also positively associated with the existence of more than one child in the house and negatively associated with parents working from home [33].
A study on Spanish children revealed that 40.1% practiced some kind of physical activity at home, including dancing and sports, almost every day, 22.2% various times a day, whereas 37% of them never practiced any kind of physical activity or did so only a few times per week [29]. On the other hand, reading books and stories was a more unpopular option for children (25.6% did not read any books, 32.6% read only a few times, and 29.7% read books almost every day, while only 12.1% did so multiple times a day), although sufficient access to books and board games at home was reported [29].
During the lockdown measures, children's free play (under 12 years old) was negatively associated with the number of television and videogame devices at home and with time spent on smartphones, tablets, or videogame devices per day [31]. Children in Spain watched television for 80.38 min per day, played videogames for 18.78 min per day, used smart phones for 14.58 min per day and tablets 28.47 min per day [31]. Furthermore, children under 5 years old watched television for 65.33 min per day, used tablets for 17.10 min per day and mobile phones for 8.34 min per day [32]. Both mothers and fathers in the UK spent twice as much time on active childcare during the COVID-19 pandemic (including playing games) versus 2014-2015 (35), while indoor play was positively associated with parental discouragement of children using screens [24].

The Types of Play
During lockdown, a Mexican study examined the changes in children's play behaviors during the COVID-19 pandemic [27]; according to their parents' observations, 21.7% of children were more engaged with active games, 18.4% with board games, 16.4% with videogames, and 11.7% preferred manipulative games with toys (games using objects to explore a concrete idea), while an increase in violent games compared to before COVID-19 was noted (10.5%). Moreover, 9.4% of parents reported that their children liked role playing, 8.6% played creative types of games, 8.2% engaged in various recreational activities, and 5.7% in exploratory games. The majority of these were fantasy games (49.5%), while 1.1% were skills games and 8% educational games, with 19.5% of them representing the current situation (i.e., pandemic-focused games) and 18.5% of them being games focusing on helping others or showing solidarity in general. More than one third of children (35.6%) preferred to play with adults and 35.2% alone, while only 28.9% preferred to play with other children [27].
The emotional state of children was affected by the lack of social play during COVID-19 lockdown; the majority missed their friends (90%) or playing with other children in general (87%), while approximately one third of them (34%) included COVID-19 as part of their play [36]. Playing with family members was associated with stronger bonds within the family and improvement in children's mood [38]. In fact, according to Martinez et al. [29], playing (both videogaming and conventional play) was the second most important factor that contributed to children's happiness (right after family). Furthermore, screen time included not only videogames or social media roaming [30,34], but also different types of physical activity (e.g., team sports, yoga, martial arts, gym sessions), offered through streaming services (in countries such as the USA, where this feature was offered), with older children (9-13) engaging five times more frequently in remote team sports activities than their younger counterparts (OR = 5.40, 95% CI 1.70-17.15) [26].
Parents were also concerned about their children's play behaviors. More specifically, parents who needed childcare for their children experienced anxiety regarding hands-on play and screen time [25], while a Spanish study showed that having parents of foreign origin was negatively associated with physical activity time [30].
Teachers' role in enhancing play among children was important as well [35]. The majority of teachers encouraged parents to engage in playful activities during lockdown. During online learning, 68.8% of them used educational games and other activities, while 87% were eager to use play as a mediator in face-to-face learning after returning to the classroom.
According to this review, a decrease in play behaviors was noted in outdoor activities, due to confinement measures across countries [22,29,30,33]. Similar findings were provided by Graber et al. describing that children's access to play was limited during periods of quarantine (e.g., hospitalization, refugee camp), but not providing a significant change in children's play behaviors overall [41]. Indeed, most studies concluded that children decreased the time spent on physical activity and mostly on outdoor activities. In most countries, restrictive measures prohibited or at least discouraged parents from using playgrounds or outdoor sports; thus, outdoor activities were limited among both boys and girls [23]. Those findings represent a challenge in light of the guidelines of the World Health Organization, which defines that children and adolescents aged 5-17 years old should exercise, in moderate to high intensity, at least 60 min daily, mainly through aerobic exercises [42]. Overall, outdoor play connects children with nature and make them more active and curious, while also boosting their immune system and regulating their sleep routines [43,44].
During lockdown, children spent their time on various indoor activities. According to this review, children often chose videogames using a television, PC, tablet, or smartphone, while reading books and playing board games were not so popular [29,31]. Studies during the ongoing COVID-19 pandemic noted that there was an increase in screen time among children, not only for educational purposes, but also for leisure activities [45]. The American Pediatric Association proposed that children's time in front of screens should be determined by their age, providing parents with a useful guide [46].
Although there were limitations in activities, both indoor and outdoor, children never gave up their imagination. They chose different types of play activities, including their siblings or parents in them whenever they were available, leading to stronger bonds and improving their mood [27,28,34,38]. Additionally, the importance of play among children emerged as a stress coping mechanism [40]. In general, children engaging in play and related activities also present with better social skills, enhanced cognitive function, reduced anxiety, and fewer depressive symptoms [47,48]. It is, however, important to underline the fact that social play has been limited during the pandemic, and children shared that they missed their friends [36]. Since the COVID-19 outbreak and the measures taken by each country is an unprecedented situation, we do not know yet the impact that it may have on children's and adolescents' peer bonding, or whether children and adolescents have discovered other means and coping mechanisms (e.g., video calls with their friends).
Commenting on the external validity of this review, all studies were conducted in countries with high-income economies-with the exception of the study by Torres Gonzalez et al. [27], which was conducted in an upper-middle-income country (Mexico); studies were performed in Europe and America; there were no eligible studies from countries with a different socioeconomic background and culture (e.g., from African or Asian countries). Moreover, a lack of investigation around associations with the sociocultural background of the families was noted.