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262 NATURE THERAPY
3. The most desired outcome in psychiatric nature activism is
A. Personal satisfaction.
B. Increased availability of nature therapy.
C. New collegial relationships.
D. Better reputation of psychiatry.
E. Record-setting mountain climbing.
Correct answer: B. Increased availability of nature therapy.
Given that our foremost ethical value is the needs and care of the
patient, increased availability of nature therapy (B) is the best
answer, although all the other answers, except possibly (E), have
some value too.
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12
The Outdoor Classroom
In this chapter,
Grace S. Ro, M.D.
Leia Chemmacheril, M.D., M.B.A.
Earth and sky, woods and fields, lakes and rivers, the mountain and the sea, are excellent schoolmasters, and teach some
of us more than we can ever learn from books.
—John Lubbock (1894, p. 70), 1st Baron Avebury
ting for the child and adolescent population and how such interventions are relevant to their mental and physical health and wellness. The
concept of a classroom also can be applied to later stages in life—
namely, the geriatric population—less so as a structured environment
to learn basic concepts but rather to restore and maintain mental health
in the context of aging and medical comorbidities.
we explore nature therapy in the classroom set-
267
268 NATURE THERAPY
CHILDREN AND ADOLESCENTS
The American Academy of Pediatrics has clinical reports on the value
of unstructured play and recommends at least 60 minutes of daily physical activity (Lobelo et al. 2020; Yogman et al. 2018). From outdoor recess
to visits to the park to walks to the grocery store, the outdoors can be a
versatile environment for physical activity and exploration. Studies
have shown that several positive outcomes are associated with physical
activity, such as strength building, decreased cardiovascular risk factors, and improved cognition (Landry and Driscoll 2012). Inconclusive
evidence indicates a significant difference in the outcomes of physical
activity in nature and physical activity indoors (Lahart et al. 2019).
However, it is worth exploring and placing more emphasis on the specific setting and therapeutic effects that nature and the outdoors can
have from an early age. Outdoor, “green” exposure also has had positive effects on mental health and self-regulation (Beute and de Kort
2014; Christian et al. 2015; Raney et al. 2019). For example, forest bathing by South Korean elementary school students has been explored as a
form of nature therapy, with a significant improvement in self-esteem
and a significant decrease in depressive symptoms (Bang et al. 2018).
The Centers for Disease Control and Prevention has published resources for educators to encourage outdoor play because it can be a powerful tool not only for children to learn but also for caregivers to observe
childhood development through social, emotional, and cognitive milestones. Free, unstructured play is essential for brain development in
children because they can learn to interact with others, explore, resolve
conflicts, and use their imaginations while being physically active. Several studies have aimed to explore the potential correlation between
nature exposure and its positive effects, but research is limited on the effects in the child and adolescent population (Weeland et al. 2019). The
literature also varies in how nature therapy or exposure is defined,
which presents challenges in comparing various studies and outcomes.
Many schools include outdoor recess, gym class, and field trips as
part of a child’s educational experience. The available outdoor exposure may depend on the setting of various school districts, from more
to less urban, which may offer different levels of outdoor opportunities
and exposure (Kellert 2002). This brings into question the disparities in
childhood experiences, education, and development, because limited
access to safe green spaces may reduce the potential for nature therapy’s positive effects. One study found that increased green space reduces the risk of behaviors associated with conduct disorders at age
The Outdoor Classroom 269
7 years and reduces the risk of behaviors associated with mood disorders such as anxiety and depression at age 12 years (Madzia et al. 2019).
Other studies have reported lower incidence rates of mood disorders
such as depression and anxiety in adults living in urban areas with
more green space availability (Astell-Burt et al. 2014; White et al. 2013).
Further studies are needed to explore the correlation between increasing green spaces and enhanced mental health and behaviors.
Autism Spectrum Disorder and
Nature Therapy
About 1 in 36 children has autism spectrum disorder, with 3.1 times more
boys affected than girls (Maenner et al. 2023; Shaw et al. 2023). Risk factors include genetic predisposition, prenatal risks including maternal age
and metabolic conditions, in utero risks, and other potential causes for
neurodevelopmental injury (Mandy and Lai 2016). Children with autism spectrum disorder have deficits in engaging in social interactions,
language delays, and sensitivity to changes in their environment. They
can also present with repetitive actions or rituals, limited attention, restricted interests, or rigid routines. Other medical conditions such as
motor abnormalities, seizures, and sleep disorders often co-occur with
autism spectrum disorder (Lai et al. 2014). Often, these children can
show impairments in social play behaviors, which can ultimately affect
their ability to build relationships with their peers (Tanner et al. 2015).
Nature therapy can be used as a powerful tool to provide diversity
in structure, sensation, and experience. It has the potential to provide
cognitive, mental, and physical benefits in children with autism spectrum disorder (Barakat et al. 2019; Table 12–1). Therapeutic gardens
have been explored and studied for children with autism spectrum disorder, given the versatility in their design to cater to people who may be
over- or understimulated. For example, a monochromatic color scheme
can have a calming effect, whereas vivid, contrasting shades can have a
stimulating effect. Smooth leaves and finely textured plants could be relieving, whereas coarse bark and coarsely textured walkways could be
more captivating. It is important to consider that autism spectrum disorder may present differently; for example, one child may be hypersensitive to overstimulation, and another may be hyposensitive, which may
result in opposing effects of the same stimulus. Nevertheless, the flexibility and creativity in designing a therapeutic garden are endless. More
research should be done to explore the efficacy of these types of interventions, with hopes of designing a replicable curriculum for widespread use by youths who may benefit from it.
270 NATURE THERAPY
Table 12– 1. Benefits of outdoor learning
Cognitive benefits Mental benefits Physical benefits
Creativity, observation Stress reduction Coordination, balance
Collaboration, imagination Positive emotions
Intrapersonal skills Concentration
Learning, curiosity Privacy, intimacy
Source. Adapted from Barakat et al. 2019.
Although nature can be a powerful tool for children with autism
spectrum disorder, important barriers and caveats must be considered.
Safety is a major concern that was reported by caregivers of children
with autism spectrum disorder, because they may be easily distracted
(Ayvazoglu et al. 2015). A higher incidence of injuries is also seen in
those with autism spectrum disorder because of common co-occurring
medical conditions such as seizures and visual impairment, so appropriate preventive interventions should be explored and established
(Jain et al. 2014). Other factors to consider are associated behaviors, core
symptoms of autism spectrum disorder, and unintentional injuries resulting from inadequate supervision (Lee et al. 2008). Thus, further
studies to explore risk factors for potential harm and necessary support
are crucial for nature therapy models to be beneficial, feasible, and safe.
This information also may encourage caregivers to support and implement interventions such as therapeutic gardens.
Nature therapy also has been explored in youths with disabilities. A
day school for children with special needs in Israel explored the use of
nature as a vessel for improved communication, teamwork, and selfesteem (Berger 2006). This was inspired by the observation that classic
psychotherapeutic interventions may be less efficacious for those with
lower IQ and abstract skills (Butz et al. 2000; Nezu and Nezu 1994).
Berger (2006) found that nature served as a space that was ever changing yet provided an opportunity to encourage flexibility in responding
and adapting to these changes. Direct experiential interactions with nature allowed for the progression of fear and alienation into familiarity,
belonging, and caring. This study suggested that nature can be a powerful vessel to use for those who rely on fewer verbal and cognitive cues.
ADHD and Nature Therapy
In the classroom setting, young students are constantly stimulated by
their peers, teachers, and environment. Children are expected to main-
The Outdoor Classroom 271
tain directed attention to focus on tasks and remain engaged in the
learning process. However, such high levels of stimulation can lead to a
phenomenon called cognitive fatigue. This has been conceptualized as
an inability to maintain optimal performance over an acute period
(Holtzer et al. 2011). Although cognitive fatigue may be a result of excessive stimulation, some people experience fatigue more readily or
have reduced productivity, resulting in suboptimal outcomes.
ADHD is a neurodevelopmental disorder that is becoming increasingly common, with significant effects on children’s learning, mood,
and interpersonal relationships (Wolraich et al. 2019). Symptoms of inattention, hyperactivity, and impulsivity must be present in at least two
social settings (e.g., home, school, church) for at least 6 months before
age 12 years (American Psychiatric Association 2013). The neurobiology of ADHD is not fully understood; however, structural differences
in various brain regions have been proposed (Tripp and Wickens 2009).
When dysfunctional, the frontal lobe, which includes the motor cortex,
can result in disinhibited motor activity and disturbed attention (Niedermeyer and Naidu 1997). The anterior cingulate cortex has associated
mesolimbic dopamine circuitry, which may be deficient in ADHD, resulting in motivational deficits and behavioral dysfunction (Silvetti et
al. 2013).
Early diagnosis and treatment are thought to prevent worsening
symptoms and comorbid conditions in adulthood (Magnus et al. 2021).
Medications (stimulants, nonstimulants) are more effective when provided in combination with therapy and environmental modification
strategies (Brown et al. 2018). Stimulants such as methylphenidate and
amphetamine increase the availability of norepinephrine and dopamine in the prefrontal cortex. Nonstimulants such as atomoxetine target
the same neurotransmitters but without abuse potential (Brown et al.
2018). Although pharmacological agents can reduce distractibility, improve sustained attention, and reduce impulsivity, ways to augment
these effects can be explored through nature therapy. Medications approved for ADHD, though effective for many, can have side effects such
as mood changes, personality changes, and decreased appetite (Charach
and Fernandez 2013). The stigmatization of ADHD diagnosis and treatment can also reduce adherence to pharmacological interventions
(Mueller et al. 2012). Although the medications have been shown to increase academic productivity, the evidence that they improve long-term
social and academic outcomes is limited (Hinshaw 1994). Thus, alternative supplemental treatment modalities continue to be explored.
From a genetic perspective, ADHD has been associated with the allele of the DRD4 gene (Tovo-Rodrigues et al. 2013). Researchers have
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