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272 NATURE THERAPY
explored possible evolutionary advantages of ADHD, given its current
existence (Williams and Taylor 2006). To appreciate this, it is important
to consider the context and societal norms that have also evolved
through time. In the past, humans were nomad hunters and gatherers,
learning through experience without the pressures or structure of modern education. Some propose that those with ADHD tendencies may
have freely sought ways to adapt to challenges, even if it meant exploring different places to survive. Although today’s education system is
more regimented, there may be value in providing individualized support, especially for children who may not succeed in that setting. This
brings in the potential for nature and outdoor therapy to provide an alternative learning space as an adjunct to the traditional classroom setting.
According to attention restoration theory (Kaplan 1995), attention
fatigue should be restored to regain optimal functioning, and nature
therapy is one way to provide this restoration (Kaplan and Kaplan
1989). This is broken down into voluntary and involuntary forms of attention (Hartig et al. 1991). Daily activities require voluntary attention,
with competing stimuli or thoughts that must be inhibited to get certain
tasks done. In contrast, involuntary attention is driven by interest, curiosity, and fascination. One such medium would be exposure to natural
environments, which invites attention and focus that may be less mentally demanding. Some propose that removing oneself from a setting of
voluntary attention and focusing on a new environment necessitating
involuntary attention may ultimately allow the restoration process to
occur (Kaplan and Talbot 1983).
Data are limited on how exactly nature exposure affects attention
(Ohly et al. 2016). One review suggested that there may be differences
between the effects of real environments and those of virtual exposure
(Stevenson et al. 2018). However, as explored in previous chapters, na-
ture therapy is a broad term that can target virtually any of the human
senses. Whether it be through auditory or visual stimulation or full immersion in a natural environment, nature therapy has been shown to
have the potential for positive effects (Gamble et al. 2014; Zhang et al.
2017). One study found that attentional functioning in children with severe ADHD improved during and after activities in greener spaces, as
observed by parents (Taylor et al. 2001). The findings further support
exploring how these effects can be used in various settings such as
home and school so that children with ADHD can benefit from enhanced attention and complete tasks more efficiently. However, in 2002
the U.S. Food and Drug Administration approved stimulants to treat
ADHD, which may have placed a greater emphasis on pharmacological
treatment than on nature therapy. The recent global coronavirus disease
The Outdoor Classroom 273
2019 (COVID-19) pandemic, which brought about extended periods of
isolation, inevitably reintroduced the value of open, green spaces (Davies and Sanesi 2022).
Although emotional dysregulation is not included in the DSM-5
(American Psychiatric Association 2013) diagnostic criteria for ADHD,
studies have shown that youths with an ADHD diagnosis are at higher
risk for developing depression later in life (Seymour et al. 2012). Adult
ADHD is often comorbid with depressive disorder, anxiety disorder,
and substance use. Thus, early interventions to promote mood stability
could improve outcomes longitudinally. As the sources of stress increase through adolescence, the time and value placed on outdoor excursions decrease. Outdoor field trips and recess time are replaced with
study hall periods, standardized testing, and online assignments. Technology is constantly advancing, and the evolution of daily living is
thought to further disconnect people from natural unstructured play.
Some studies have shown that children with ADHD have greater difficulty maintaining behavioral control in an industrialized environment
than in a green space (van den Berg and van den Berg 2011).
Although proving a correlation between nature therapy and improving mental health is challenging, researchers, clinicians, and educators continue to explore ways in which to do so. Increasing numbers
of studies are exploring the effects of outdoor educational programs,
which encompass teaching, learning, or experiencing in an outdoor setting, beyond the classroom. Active, experiential, guided learning can
improve the physical, psychological, and social aspects of education
(Quinn and Russo 2022). A survey of undergraduate students found
that early nature exposure can increase engagement in wellness initiatives in higher-level education (Sachs et al. 2020). This is further evidence that engaging youths in nature-based activities and learning can
have long-lasting benefits. Especially in an age of urbanization and
technological advancement, the outdoors can be a source of relief. Thus,
creatively applying nature as a medium for learning and growth from
an early age may establish long-term benefits and continued engagement with nature as a beneficial tool (Table 12–2).
The discussion does not end with children and adolescents but extends to include the family and community. The concept of multifamily
therapy has been studied and used for schizophrenia, relapse prevention, and vocational and social skill rehabilitation, with an emphasis
placed on the family and community network (Stuart and Schlosser
2009). A study done in Hong Kong suggested that multifamily therapy
can also be applied to families with children who have ADHD (Ma et
al. 2019). In this study, children were able to display creativity and risk-
274 NATURE THERAPY
Table 12– 2. Ideas to implement nature in the educational
setting
Connectivity with
Educational approach
others
Learning environment
Nature-based field
trips
Nature-based homework
assignments
Nature-based classroom
design
Encouragement of
exploration,
fascination, and
curiosity through
nature
Group-based nature
activities
Family-based nature
activities
Meditation and
mindfulness in the
outdoors
Classrooms with
windows
Dorm room windows
facing nature
Early introduction of
nature as source of
wellness
taking behaviors in the natural environment, leading to a shift in the
parents’ perception of their behaviors. The green space was a change in
environment and an opportunity for the families to engage in a different, more enriching way. Children who participated in this study reported narrative themes of positive time with family, safe space,
entertainment, and enhanced communication with parents.
OLDER ADULTS
Aging Population and Demographics
The world’s population is aging. A 2022 report from the Department of
Economic and Social Affairs of the United Nations, Population Division, predicted that the proportion of people age 65 years and older in
the United States will increase from 9.7% of the global population in
2022 to 16.4% by 2050. In the United States and Europe, the population
age 65 years and older was 18.7% in 2022 and is predicted to increase to
26.9% by 2050 (United Nations Department of Economic and Social Affairs, Population Division 2022). South Korea is predicted to have an
even greater jump, from a 15.7% geriatric population in 2020 to 40.1%
in 2050, with 16.1% of South Korean adults being 80 years or older (Statistics Korea 2021). Aging can lead to cognitive and functional decline,
and a significant portion of the population is going through this change
at this time (Detweiler et al. 2012).
The Outdoor Classroom 275
According to the 2020 Profile of Older Americans (Figure 12–1), 61% of
older adults lived in the community with their partners, 27% lived alone
in the community, and a small number lived in nursing homes. Furthermore, 1% of people between ages 65 and 74, 2% of people between ages
75 and 84, and 8% of people older than 85 lived in nursing homes. In 2019,
51% of people age 65 and older lived in nine U.S. states: California, Florida, Texas, New York, Pennsylvania, Ohio, Illinois, Michigan, and North
Carolina. Older adults are dispersed in terms of geography and living
arrangements (Administration for Community Living 2021).
Urbanization
Another factor that plays a key role in changes in overall population health,
especially for older adults, is urbanization. Urbanization refers to population growth and increase in population density. The process results in increased traffic, air and noise pollution, and heat island effects and loss of
opengreenand blue spaces (Kabisch et al. 2017; see Chapter 8, “The Wet
Outdoors”). These changes have negative health effects on people of all
ages but especially older adults. For instance, outdoor air pollutants have
been associated with increased hospitalizations due to respiratory complaints, such as chronic obstructive pulmonary disease, asthma, and pneumonia, with higher risks in older adults than in the rest of the population
(Simoni et al. 2015). Urbanization is also associated with lower levels of
physical activity, particularly for low- and middle-income households
(Boakye et al. 2023). Sedentary lifestyles are a risk factor for long-term illness such as diabetes, obesity, and depression. This affects the vulnerable
populations more, which includes older adults (Kabisch et al. 2017).
Physical Activity and Aging
Physical activity helps with the process of healthy aging. Urbanization
often results in difficulty finding the appropriate environment for
physical activity. Takano et al. (2002) conducted a study to determine
whether walkable green spaces affect the longevity of older adults in
cities. The study analyzed the 5-year survival of 2,211 senior citizens with
respect to residential environmental characteristics. The physical environments near residences were characterized as having spaces for
strolling, tree-lined streets, more hours of sunlight, and less noise from
automobiles and factories. The results showed that walkable green
streets and spaces near residences were significantly associated with increased 5-year survival of senior citizens, irrespective of age, sex, marital
status, attitude toward community, and socioeconomic status. This study
was conducted between 1992 and 1997 and published in 2002. Even at
276 NATURE THERAPY
0
20
40
60
80
100
1900
3.1
20602040201920001980196019401920
25.5
94.7
80.8
54.1
35
16.2
9
4.9
Figure 12–1. Number of U.S. persons age 65 years and older,
1900–2060 (numbers in millions).
Increments in years are uneven. Lighter bars (2040 and 2060) indicate projections.
Source. Reprinted from Administration for Community Living: 2020 Profile of Older Americans. May 2021. Available at: https://acl.gov/sites/default/files/Profile%20of%20OA/
2020ProfileOlderAmericans_RevisedFinal.pdf.
that time, evidence indicated that nature therapy can improve the health
of the aging population, and the study called for changes in urban planning policy for the better health of residents (Takano et al. 2002).
Inactivity in Long-Term-Care Facilities
Physical activity by older adults has been associated with decreased
functional decline, lower risk of obesity and hypertension, and decreased risk of falls. High levels of inactivity can also lead to higher levels of depression and anxiety (Leung et al. 2017). Thus, physical activity
should be an essential part of older adults’ routines, but this population
is one of the least physically active parts of society (Cvecka et al. 2015).
Many older adults are moving into assisted living and nursing homes.
These facilities provide older adults with more care than they would
typically receive if they lived in the general community. Assisted living
homes, as compared with nursing homes, provide tenants with more
independent living and self-directed care. However, the level of physical and cognitive impairment in assisted living residents is still greater
than in older adults living in the community. A study by Leung et al.
(2017) screened 114 residents from assisted living facilities across British
Columbia for daily levels of physical activity. The study showed that
residents spent 87% of their awake hours in sedentary behavior. The increased sedentary time was associated with significantly worse scores
on the Modified Falls Efficacy Scale and Timed Up and Go scale. The
The Outdoor Classroom 277
Timed Up and Go scale is used to assess physical function, and the
Modified Falls Efficacy Scale measures the confidence of participants to
partake in activities without falling. This study indicated that older
adults in care facilities have more sedentary lifestyles, and this can affect their health status (Leung et al. 2017).
Evidently, the general population is aging at a rapid rate. This, combined with external factors, such as urbanization and the reduction in
overall physical activity, puts the aging population at risk for significant
cognitive and physical health problems. As discussed in previous chapters of this book, evidence suggests that exposure to natural environments
can improve overall human health and well-being at all ages. Therefore,
it is certainly worthwhile to explore nature therapy to better the physical,
emotional, and cognitive health specifically in the aging population.
Possible Benefits of
Nature Therapy for Older Adults
Agricultural activity, which is a form of horticultural therapy, is part of
many psychiatric hospital settings because of the well-established
mental health benefits of such activity (Detweiler et al. 2012). Similarly,
horticultural therapy has been shown to have positive effects on older
adults by increasing positive affect and decreasing anger (Chan et al.
2017). Another way to incorporate nature into the lives of older adults
is through therapeutic gardens. Therapeutic gardens provide sensory
stimulation and a safe environment for exercise and spending time in
assisted living facilities and nursing homes. These gardens stimulate
the senses by including various plants to promote visual, tactile, and olfactory stimulation; leaves to produce sound when ruffling in the wind;
and trees to provide color and shade. They can also include vegetables
and herbs that residents can harvest themselves. Studies have shown
overall health benefits from nature therapy, including pain reduction,
improved attention, and stress reduction. It is thought that these positive effects can extend specifically to older adults (Detweiler et al. 2012).
Dementia
Nature therapy has been studied in older patients with dementia. A
2018 article in the American Journal of Medicine defined dementia as “any
decline in cognition that is significant enough to interfere with independent, daily functioning” (Gale et al. 2018, p. 1161). The root cause of the
onset of dementia can be neurological, psychiatric, or secondary to
other medical conditions. Dementia is more common in older adults,
with the leading causes being neurocognitive disorders such asAlzhei-
278 NATURE THERAPY
mer’s disease and dementia with Lewy bodies (Gale et al. 2018). In 2010,
4.4 million American adults had dementia, which included 14.7% of
adults older than 70 years. The total population with dementia is expected to triple by 2050 if no advancements are made in the prevention
and treatment of the disease. The treatment and care of patients with
dementia would benefit from more attention, given the lack of diseasemodifying treatments. However, interventions affect different aspects
of dementia, and these therapies combined can make a substantial difference in the quality of life for patients (Tisher and Salardini 2019). Behavior therapy is at the forefront of dementia treatment, with the aim of
extinguishing difficult learned behaviors. However, only a few studies
support the efficacy of this type of therapy, and this form of treatment
must be tailored to specific behaviors (Douglas et al. 2004). This certainly leaves room for investigation into other forms of nonpharmacological therapies for dementia, especially those that can be used more
broadly and in group settings, such as nature therapy.
Depression is a risk factor for developing Alzheimer’s disease, a
form of dementia that is most common in the older population. Rates of
mood disorders are high in patients with dementia; 50% of patients
with diagnosed Alzheimer’s disease also have diagnosed depression.
Mood disorders and dementia both affect attention, memory, motivation, processing speed, and organization. Thus, mood disorders in patients who have dementia can significantly affect their quality of life.
Medications such as selective serotonin reuptake inhibitors and talking
therapy are used to treat depression in dementia (Tisher and Salardini
2019). However, nature therapy also has been shown to improve mood
in patients with dementia. A 2017 study by White et al. assessed changes
in mood of residents in a dementia facility in the United Kingdom with
mid- to late-stage dementia after being exposed to a nature garden
(White et al. 2018). The outdoor areas of the facility had been renovated
to encourage activity, by including various plants such as fruit trees and
vegetable beds. Qualitative data on the outdoor experiences of residents
were collected in 2012 from primary caregivers and activity coordinators. The study showed that significant improvement in mood occurred
with exposure to nature. This association was not linear, with 80–90 minutes of exposure leading to maximal benefits (White et al. 2018). This is
simply one study showing the benefit of nature therapy for mood improvement in dementia. These results should prompt more studies to
be done on this topic, especially in multiple settings, such as the residential home, and with various forms of nature therapy (Table 12–3).
Sleep deprivation is also a risk factor for dementia, especially Alzheimer’s disease. Sleep deprivation also leads to delirium and affects
The Outdoor Classroom 279
Table 12– 3. Ideas to implement nature therapy in dementia
facilities
Intervention Benefits
Addition of wander gardens to facility Decreased inappropriate behaviors
and improved mood (Detweiler et
al. 2008)
Increase in time spent outdoors and
addition of courtyards
Implementation of community-based
horticultural program
Improved sleep (Calkins et al. 2007)
Decreased agitation, increased time
spent engaging in activity (
2020
), and improved sleep (Lee and
Kim 2008)
Lu et al.
cognition, particularly in patients with dementia (Tisher and Salardini
2019). Sleep disturbance and behavioral symptoms are two primary
burdens on caregivers that lead to the institutionalization of patients
(Phillips and Diwan 2003). Current treatment for sleep disorders in dementia is the same as in older adults without dementia, including maintaining sleep hygiene, assessing comorbidities, and taking medications
such as high-risk sedative-hypnotics and neuroleptics (Tisher and Salardini 2019). However, studies have shown that nature therapy can influence sleep in patients with dementia. Astudy by Lee and Kim in 2008
examined gardening as a physical activity in institutionalized patients
with dementia. The study included 23 institutionalized patients with
dementia and sleep disturbances or agitation. The subjects selected
their own plants and grew them for 28 days, tending to them twice a
day, in the morning and afternoon. The study found that indoor gardening led to significant increases in nocturnal sleep time efficacy, decreases in awakening after sleep onset, and decreases in nap times. In
the same study, Lee and Kim (2008) also found that agitation was significantly decreased, and cognition was significantly improved in patients with dementia after exposure to indoor gardening. This study
suggested that nature therapy is associated with improvement in several facets of dementia that affect quality of life, and this tool should be
used as an adjunct in the treatment of the disease (Lee and Kim 2008).
Clinical Translation: Case Example
A therapeutic high school arranged a field trip to a state park. The park’s
interpretive staff taught the students about the local ecosystems and led a
hike over a short trail. When they returned to the visitor center, they learned
280 NATURE THERAPY
how to make collage art from fallen leaves. The students provided positive
feedback about the trip and requested more such experiences.
Students are enrolled in both classrooms and group therapy as part
of their daily schedule. The social skills group leader decided to take inspiration from the student feedback and arranged an outing for the
group that week.
Students were brought to a local park down the block from the school.
They were encouraged to forage for fallen plant materials on the ground to
use in collaging back at the school. They were given strict guidelines on
weeds that were permissible to pick and instructed to avoid disrupting
other park vegetation. They were encouraged to share their observations as
part of the social skills component while foraging. The students expressed
surprise and wonder at the number and variety of leaves and flowers in the
park. They reported that they had not looked that closely at the ground before, despite walking past the park to get to school every day.
Although many of the students in the group had a history of poor
frustration tolerance and low threshold for emotional dysregulation,
they showed resilience in the face of the activity’s minor discomforts.
From tolerating soiled hands sticky with sap to recoiling in disgust from
insects in the vicinity, the students encouraged one another to persevere.
The students practiced reframing their negative automatic thoughts.
For example, the group leader modeled enthusiasm for observing insect
behavior in its natural habitat. The students learned that the insects they
initially feared were not dangerous and could be intrinsically rewarding
to see. With the group’s support, they cautiously overcame their initial
repulsion.
The group leaders began a group discussion in which each student
explained how they picked the various elements of their collection. The
discussion encouraged curiosity and allowed the students to demonstrate mastery by sharing their acquired knowledge of the natural world.
The group session ended with a return to the classroom and the students assembling collage artwork from their trimmings. While working
on their art, they informally continued the discussion about their natural discoveries, their reignited excitement about the natural world, and
their plans to explore the outdoors in their own backyards.
CONCLUSION
Nature therapy provides benefits to physical and mental health, especially in special vulnerable populations, children, and older adults. Nature therapy has been shown to have a positive effect on conditions
such as autism, ADHD, and dementia. This supports the idea that nature therapy should be implemented in places such as schools, assisted
living facilities, and nursing homes, and there are several ways to incorporate nature into these settings. It would certainly be worthwhile to do
further research on how nature therapy can affect other illnesses in
these special populations.
The Outdoor Classroom 281
KEY POINTS
• Nature therapy has the potential to provide cognitive,
mental, and physical benefits in children with autism
spectrum disorder and ADHD.
• According to attention restoration theory, attention fatigue should be restored to regain optimal functioning,
and nature therapy is one way to provide this restoration.
• Involving caregivers and family members in the nature
therapy interventions can be beneficial for children and
adolescents and their families.
• The rapidly aging population combined with urbanization, as well as the reduction in overall physical activity,
puts older adults at risk for significant cognitive and
physical health concerns.
• Nature therapy has been shown to provide therapeutic
effects in older adults with dementia, and this form of
treatment should be further explored for other conditions that affect older adults.
QUESTIONS
1. Which of the following best describes the versatility of a therapeutic
garden specifically for children with autism spectrum disorder?
A. Open space for large groups to congregate.
B. Plants with finely textured leaves.
C. An audible speaker for constant communication.
D. Easily accessible laptops to research nature-based concepts.
E. Limited space to ensure constant supervision.
Correct answer: B. Plants with finely textured leaves.
The use of therapeutic gardens has been explored and studied for
children with autism spectrum disorder, specifically catering to
their individual needs. Color schemes, contrasting shades, and
various textures in nature are examples of ways to provide either
stimulating or calming effects. Of the choices available, plants
with finely textured leaves (B) are the best option. The therapeutic garden should not be designed for the purpose of congregating large groups (A). Access to electronic devices should be
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