Play is a vital and necessary component of typical child development (Singer, Golinkoff, & Hirsh- Pasek, 2006). A recent clinical report from the American Academy of Pediatrics strengthens the Academy’s previous position on play, and even encourages pediatricians to write a “prescription for play” at every well-child visit during the first 2 years of life (Yogman et al., 2018). In this report, Yogman and colleagues (2018) emphasize how developmentally-appropriate play fosters a multitude of healthy child development outcomes, mitigates toxic stress, and builds social-emotional resilience, and assert that “in the presence of childhood adversity, play becomes even more important” (p. 1). Researchers have recently studied how fantastical play might serve as a platform for children to develop and practice certain cognitive, emotional, and social skills (Thibodeau, Gilpin, Brown, & Meyer, 2016). Given these connections, fantastical play might serve as a useful addition to a child life specialist’s toolkit.

Fantastical Play and Imaginary Companions in Childhood

Research indicates that engaging in pretend or fantastical play has been related to a variety of cognitive, social, and emotional benefits (Copple & Bredekamp, 2009; Hirsh- Pasek, Golinkoff, Berk, & Singer, 2009; Thibodeau et al., 2016; Tomlinson, 2009). Recently, researchers have focused on the special benefits seen in children who prefer fantasy-oriented play over reality-oriented play (Pierucci, O’Brien, McInnis, Gilpin, & Barber, 2014; Thibodeau et al., 2016). Children who prefer more fantasy-oriented play
frequently engage in both representational play (i.e., pretend play that involves everyday experiences, like pretending to be a doctor) and fantastical play (i.e., pretend play that involves unrealistic or impossible experiences, like pretending to be a superhero or creating an imaginary companion) and prefer games, toys, and media that involve fantastical elements (e.g., Dr. Seuss or Harry Potter books; Pierucci et al., 2014; Sharon & Woolley, 2004; Singer & Singer, 1990; Taylor, 1999). Importantly, recent work has documented how children who participate in more fantastical pretend play demonstrate better emotion regulation skills than their peers (Gilpin, Brown, & Pierucci, 2015), and researchers argue that a child’s imagination serves as a safe environment that allows and encourages children to display and practice a variety of emotions, ultimately helping them develop control and mastery (Bretherton, 1989; Hoffman & Russ, 2012).

A specific type of fantastical play, the creation of an imaginary companion, is known to be a healthy and common form of pretend play in early childhood (Taylor, 1999). Although frequency estimates vary across the literature, approximately one-third to one-half of children—and possibly more— between the ages of 3 and 12 create imaginary companions, with the preschool years serving as the high season (Pearson et al., 2001; Singer & Singer, 1990; Taylor, 1999). Such companions can serve a myriad of functions, and these functions often depend upon the special needs of their child creators (Hoff, 2005; Nagera, 1969; Taylor, 1999; Taylor, Shawber, & Mannering, 2009). Although two of the most important functions of imaginary companions appear to be fun and companionship (Taylor, 1999), other research has indicated that they also function to assist in self-regulation, enhance self-esteem and life quality, and serve as a safe environment in which to practice various social scenarios (e.g., practicing how to make up with a real friend; Hoff, 2005). Research has documented various positive traits that are often associated with having an imaginary companion, such as increased emotional understanding (Lindeke & Kavanaugh, 2007), cooperativeness with peers and adults (Singer & Singer, 1990), and perspective-taking skills (Taylor & Carlson, 1997). Children who have an imaginary companion are rated as more outgoing (Roby & Kidd, 2008), and by their parents, as better communicators with adults (Manosevitz, Prentice, & Wilson, 1973). Although some might be worried about imaginary worlds and their inhabitants serving as a form of dissociation, the results of studies on imaginary companions and psychopathology have indicated that imaginary companions can serve an adaptive purpose and assist in coping with psychopathology and various life traumas (e.g., childhood abuse; Klausen & Passman, 2007).

There are several hypothesized reasons as to why fantasy-oriented play helps children. One, this type of play allows children to engage in focused and often complex tasks that are unlike those they encounter in their everyday experiences, particularly because they allow children to engage in counterfactual or "would-be" thinking...

Although no causal link has been established between imaginary companions and these positive traits, relevant experimental work has addressed the causality and directionality of the relationship between fantastical pretend play and higher-order skills called executive functions (e.g., working memory, inhibitory control, cognitive flexibility; Thibodeau et al., 2016). In this study, preschool-aged children were randomly assigned to one of three conditions: fantastical pretend play intervention, non-imaginative play intervention, or business-as-usual control. In the fantastical pretend play intervention, research assistants worked with small groups of children to come up with and act out various fantastical scripts (e.g., going to the moon and interacting with space creatures). Results indicated that those children in the fantastical pretend play intervention condition demonstrated an improvement in executive functions, whereas children in the other conditions did not. Additionally, data on intervention engagement revealed that those children in the fantastical pretend play intervention who were highly engaged in the play and who were highly fantastical exhibited the greatest gains in executive functions.

Other relevant experimental work has found causal links between dramatic pretend play games and social and emotional abilities (Goldstein & Lerner, 2018). In this study, 4-year-old children were randomly assigned to one of three conditions: a dramatic pretend play games intervention and two control conditions, block building and reading stories. In the dramatic pretend play games intervention, research assistants led children through common improvisational exercises designed for preschool-aged children that included a variety of pretend play activities (e.g., dressing up, making a birthday cake, becoming a statue and being posed by classmates). Results indicated that only those children participating in the dramatic pretend play games intervention had improved emotional control (e.g., how well they could calm their own distress in the face of others’ distress, how often they reported being overwhelmed by emotions). Thus, participating in the dramatic pretend play games intervention caused children to become better at controlling their emotions.

Although these two studies (Goldstein & Lerner, 2018; Thibodeau et al., 2016) are two of the only recently published experimental studies on the effects of pretend play on developmental outcomes, this work is encouraging and supports long-held theory. There are several hypothesized reasons as to why fantasy-oriented play helps children. One, this type of play allows children to engage in focused and often complex tasks that are unlike those they encounter in their everyday experiences, particularly because they allow children to engage in counterfactual or “would-be” thinking (Bretherton, 1989; Gopnik & Walker, 2013; Vygotsky, 1967). Two, it provides children a myriad of ways to practice identifying, managing, and expressing emotions, which ultimately helps them develop control and mastery (Bretherton, 1989). And three, a child’s imagination is a safe environment that permits, and often encourages, creative expression of a variety of emotions and provides many opportunities for learning more about themselves and others (Hoffman & Russ, 2012).

Incorporating Fantastical Play and Imaginary Companions into Child Life Intervention

A population that could potentially be greatly served by engagement with imaginary companions—and increased involvement in fantastical pretend play in general—is children with chronic illnesses who spend a great deal of time in the hospital. Research has demonstrated that chronic illness may affect the quality of children’s interactions with others, especially peers. For example, children who are frequently hospitalized might have limited social experiences due to reduced time with peers, physical limitations, or altered appearances and abilities (Drotar, 1981). Additionally, research has also indicated that children are aware of the frequency of their classmates’ absences from school and that children who miss a lot of school are often less preferred as playmates because they are seen as unreliable (Graetz & Shute, 1994).

Child life specialists could potentially use fantasy-oriented play—specifically imaginary companions—as a tool to help children cope with their illness and the often scary and confusing medical procedures associated with it, as well as to improve quality of life in the hospital. Imaginary companions can be used to start conversations, particularly those that might be uncomfortable, and help illuminate what a child is thinking or worrying over. A child might not want to talk about how they are feeling, but they might not mind explaining how their companion is feeling instead, allowing the specialist to pick up on certain thematic clues. This process is similar to what child life specialists already do when they engage in medical play with children using puppets, dolls, or stuffed animals as pretend patients (McCue, 1988). Through medical play, children often reveal the misconceptions and fears they have about medical procedures, allowing an opportunity for the specialist to clear up confusion and alleviate fears (Burns Nader & Hernandez-Reif, 2016). Imaginary companions can also help make transitions and difficult routines easier. For example, the companion can help talk through unfamiliar situations and processes before they happen. Finally, imaginary companions can help inspire creativity and help child life specialists build rapport and establish bonds with the patients in their care.

As one example of this process, specialists could encourage patients to use an existing companion or a personified transitional object (e.g., teddy bear), or to create their own companion who could help them through their time spent at the hospital. Although the authors are currently investigating ways to systematize the creation process, it will be open-ended and likely unique to each child. After dedicating time to developing and elaborating the companion together—with the specialist providing appropriate scaffolding, while still allowing the child autonomy in directing the overall creation—the specialist could incorporate the companion into various role-playing scenarios that allow the child to work through aspects of their hospital stay that they find concerning. Other organizations have already caught on to this idea. The Pediatric Brain Tumor Foundation (www.curethekids.org) has created an “Imaginary Friend Society” website (www.imaginaryfriendsociety.com), which hosts an animated film series that uses imaginary companions to help give kids confidence and courage as they navigate their cancer diagnoses. Additionally, children are encouraged to donate drawings of their own imaginary companions, and the foundation not only publishes them in a gallery on the website, but also turns them into motivational posters, coloring books, and journals.

Important Considerations and Next Steps

There are several important considerations to keep in mind when implementing the creation and utilization of an imaginary companion with a child. First and foremost, the specialist should rely on sound professional judgment and discussion with the patient’s parents if there is ever any concern over the activity or its direction. Second, the main focus of the activity should be child-directed. If it is not child directed, children are not exercising their cognitive skills to the same extent and their interest will likely wane. And finally, the specialist should provide scaffolding that encourages positive engagement, highly imaginative play, and emotional expression.

Currently, the authors are working to develop a consistent methodology for child life specialists to implement in a variety of healthcare settings to support children through the process of creating their own imaginary friend. The methodology, designed as a series of fun activities, creates opportunities for a child life specialist to build rapport with a child while facilitating the creative process. Engaging in fantastical play interventions, such as creating an imaginary companion, has the potential to improve coping by providing the child with the various cognitive, social, and emotional benefits afforded by fantastical play as well as to improve quality of life by providing a meaningful play opportunity that can serve as a fun distraction from a stressful environment.