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A Potential Natural Treatment for Attention-Deficit/Hyperactivity Disorder: Evidence From a National Study

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We examined the impact of relatively "green" or natural settings on attention-deficit/hyperactivity disorder (ADHD) symptoms across diverse subpopulations of children. Parents nationwide rated the aftereffects of 49 common after-school and weekend activities on children's symptoms. Aftereffects were compared for activities conducted in green outdoor settings versus those conducted in both built outdoor and indoor settings. In this national, nonprobability sample, green outdoor activities reduced symptoms significantly more than did activities conducted in other settings, even when activities were matched across settings. Findings were consistent across age, gender, and income groups; community types; geographic regions; and diagnoses. Green outdoor settings appear to reduce ADHD symptoms in children across a wide range of individual, residential, and case characteristics.
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American Journal of Public Health | September 2004, Vol 94, No. 91580 | Research and Practice | Peer Reviewed | Kuo and Faber Taylor
RESEARCH AND PRACTICE
Objectives. We examined the impact of relatively “green” or natural settings
on attention-deficit/hyperactivity disorder (ADHD) symptoms across diverse sub-
populations of children.
Methods. Parents nationwide rated the aftereffects of 49 common after-school
and weekend activities on children’s symptoms. Aftereffects were compared for
activities conducted in green outdoor settings versus those conducted in both
built outdoor and indoor settings.
Results. In this national, nonprobability sample, green outdoor activities re-
duced symptoms significantly more than did activities conducted in other set-
tings, even when activities were matched across settings. Findings were consis-
tent across age, gender, and income groups; community types; geographic
regions; and diagnoses.
Conclusions. Green outdoor settings appear to reduce ADHD symptoms in
children across a wide range of individual, residential, and case characteristics.
(Am J Public Health. 2004;94:1580–1586)
A Potential Natural Treatment for Attention-Deficit/Hyperactivity
Disorder: Evidence From a National Study
| Frances E. Kuo, PhD, and Andrea Faber Taylor, PhD
pensive, nonstigmatizing, and free of side
effects.
NATURE AND ADHD “SYMPTOMS”
IN NON-ADHD POPULATIONS
Substantial research conducted among non-
ADHD populations has shown that “symp-
toms” of ADHD—inattention and impulsivity—
are reduced after exposure to natural views
and settings. Environmental psychologist
Stephen Kaplan has proposed that tasks and
situations that require one to deliberately di-
rect attention or inhibit unwanted stimuli,
thoughts, or impulses draw on a shared
mechanism that is subject to fatigue.
9,10
After
prolonged or intense use of this mechanism,
fatigue sets in, and it becomes increasingly
difficult to pay attention and inhibit impulses;
that is, the behavior and performance of indi-
viduals without ADHD temporarily take on
many of the characteristic patterns of ADHD.
Indeed, the symptoms of ADHD and “at-
tention fatigue” so closely mirror each other
that the Attention Deficit Disorders Evalua-
tion Scale has been used as a measure of at-
tention fatigue.
11
However, unlike ADHD, at-
tention fatigue is proposed to be a temporary
condition; when the deliberate attention
mechanism has an opportunity to rest, fatigue
dissipates and behavior and performance im-
prove. According to Kaplan, natural environ-
ments assist in recovery from attention fa-
tigue, in part because they engage the mind
effortlessly,
12–15
providing a respite from hav-
ing to deliberately direct attention.
9,10
Thus,
the sense of rejuvenation commonly experi-
enced after spending time in natural settings
may in part reflect a systematic restorative
effect on directed attention.
Studies involving a variety of measures,
treatments, populations, and research de-
signs have produced evidence of enhanced
attention after exposure to natural views and
settings. “Nature” experienced in a wide vari-
ety of forms—including wilderness backpack-
ing, gardening, viewing slides of nature,
restoring prairie ecosystems, and simply hav-
ing trees and grass outside one’s apartment
building—has been linked to superior atten-
tion, effectiveness, and effectiveness-related
outcomes.
11 , 16–21
The use of experimental de-
signs and statistical tests for mediation in
some studies has helped address questions
of cause and effect, and the persistence of
positive findings across diverse research de-
signs suggests that the effect of nature on
inattention is robust.
Attention-deficit/hyperactivity disorder
(ADHD) is the most common neurobehav-
ioral disorder of childhood.
1
It manifests as an
unusually high and chronic level of inatten-
tion, impulsivity/hyperactivity, or both, and it
may affect more than 2 million school-aged
children.
2
Recent statistics indicate that,
among children aged 6 to 11 years, the inci-
dence of ADHD is approximately 7%.
3
ADHD exacts a substantial toll on afflicted in-
dividuals and often persists into adulthood.
According to the Centers for Disease Control
and Prevention: “if untreated, a person with
ADHD will struggle with impairments in cru-
cial areas of life, including relationships with
peers and family members, and performance
at school or work.”
2(p1)
Unfortunately, current ADHD treatments
fall far short of ideal, offering only limited re-
lief from symptoms and often involving seri-
ous side effects.
4–7
The Centers for Disease
Control and Prevention has labeled ADHD
“a serious public health problem,”
8
citing “the
large estimated prevalence of the disorder;
the significant impairment in the areas of
school performance and socialization; the
chronicity of the disorder; the limited effec-
tiveness of current interventions to attend to
all the impairments associated with ADHD;
and the inability to demonstrate that interven-
tion provides substantial benefits for long-
term outcomes.”
8(p1)
In this article, we report the results of 1 in
a series of studies exploring a possible new
treatment for ADHD. The findings outlined
here, taken in the context of previous re-
search, suggest that common after-school
and weekend activities conducted in rela-
tively natural outdoor environments may be
widely effective in reducing ADHD symp-
toms. If controlled experiments and clinical
trials bear out this potential, such natural
treatments promise to supplement current
approaches to managing ADHD, with the
advantages of being widely accessible, inex-
September 2004, Vol 94, No. 9 | American Journal of Public Health Kuo and Faber Taylor | Peer Reviewed | Research and Practice | 1581
RESEARCH AND PRACTICE
In addition, there is evidence to suggest
that nature can be helpful in addressing the
impulsivity/hyperactivity axis of ADHD.
11 , 2 1 ,22
Notably, 1 study revealed direct evidence of
superior performance on objective tests of im-
pulse control in a sample of urban public
housing children randomly assigned to archi-
tecturally identical apartment buildings with
relatively green views versus relatively bar-
ren views.
21
NATURE AND ADHD
The finding that exposure to nature re-
duces “symptoms” among individuals without
ADHD raises the possibility that nature might
similarly affect individuals with ADHD. Rela-
tive to individuals without ADHD, we might
expect individuals with ADHD to be equally,
if not more, vulnerable to attention fatigue. If
so, persons with ADHD might benefit from
attention restoration as well. Moreover, there
are hints in the neuroscience literature that
attention fatigue and ADHD are linked to the
same underlying mechanism. In non-ADHD
populations, the right prefrontal cortex has
been implicated in both the capacity to delib-
erately direct attention and the presence of
attention fatigue. A number of studies have
produced evidence of a right frontal–cortical
locus of attention control,
23,24
and another
has shown that the right prefrontal cortex is
subject to fatigue after sustained demands on
directed attention.
25
Correspondingly, the right prefrontal cor-
tex has been implicated in ADHD. The right
prefrontal cortex has been found to be
smaller and less active among children with
ADHD than among same-aged peers,
26–29
and severity of ADHD symptoms has been
shown to be proportional to degree of asym-
metry between left and right prefrontal cor-
tex regional cerebral blood flow.
30
Thus, it
may be that attention fatigue and ADHD
represent different problems in the same un-
derlying mechanism.
Two studies to date have examined the
impacts of exposure to nature among indi-
viduals with ADHD. Both focused on chil-
dren aged 7 to 12 years who had been pro-
fessionally diagnosed with ADHD. In the
first study,
31
96 parents rated a variety of
leisure activities with respect to whether
their child’s symptoms were better than,
worse than, or the same as usual after en-
gaging in those activities. Parents also rated
the general severity of their child’s symp-
toms and provided information on the
“greenness” of the child’s typical play set-
tings. Results indicated that symptoms were
better than usual after activities in relatively
green settings. Moreover, the aftereffects of
activities taking place in green outdoor set-
tings were better than those of activities tak-
ing place either indoors or in relatively built
outdoor settings, and the greener a child’s
typical play settings, the less severe his or
her general symptoms.
Thus, both cross-sectional and longitudinal
data linked greenness of children’s activity
settings to milder symptoms. Furthermore,
the influence of green outdoor activities could
not be attributed to general effects stemming
from being outdoors or to social setting, amount
of physical activity, type of activity, prefer-
ence for nature, or timing of medication.
Nonetheless, the correlational nature of these
data precluded strong conclusions regarding
the causal role of nature in reducing attention
deficit symptoms.
A controlled field experiment (A. Faber
Taylor and F.E. Kuo, unpublished data, 2004)
was conducted to address the issue of causal-
ity. In this study, children with ADHD com-
pleted guided walks, while unmedicated, in
each of 3 settings differing in the extent to
which natural or urban elements predomi-
nated. The 20-minute walks were counterbal-
anced for order and controlled for day of
week, time of day, walking guide, and walking
pace. Routes were chosen to involve roughly
equivalent levels of noise and pedestrian den-
sity. As a means of ensuring some degree of
attentional fatigue, 15 minutes of puzzle-like
tasks were administered to children before
each walk.
After each walk, a single evaluator, un-
aware of condition assignments, administered
objective measures of attention. Children’s
performance on these measures was signifi-
cantly better after walking in the greenest
setting than after walking in either of the
other 2 settings. Because the research design
compared the same child across settings, it
controlled for individual factors such as age,
gender, socioeconomic status, and case char-
acteristics (e.g., comorbidity, general severity
of symptoms).
These studies, both focusing on largely
urban, midwestern samples of children aged
7 to 12 years, provide the first evidence to
suggest that exposure to nature reduces
ADHD symptoms but leave open the ques-
tion of whether such effects are widely gen-
eralizable. To explore whether these effects
might hold for a wider range of ages, commu-
nity sizes, and geographic regions, we con-
ducted a national, Internet-based study: the Na-
tional Activity Settings and Attention-Deficit/
Hyperactivity Disorder Study.
METHODS
Sampling and Response
Recruitment. Parents and legal guardians of
children with ADHD were recruited via ad-
vertisements placed in major US newspapers
and via the Web site of Children and Adults
with Attention-Deficit/Hyperactivity Disor-
der (http://www.chadd.org), the largest na-
tional, nonprofit organization in the United
States serving individuals with ADHD. Infor-
mation on the study was posted on the Inter-
net from September 15 to October 31,
2000. Potential participants were invited to
take part in “a national study on how differ-
ent activities affect children’s ADHD symp-
toms.” Two incentives were offered: a list of
recommendations for coping with ADHD
based on the study’s findings and the chance
to win a gift certificate.
Response and final sample. In the 47 days
during which the study was posted, the Web
site received 1053 unique hits. Access to the
questionnaire itself was restricted to individu-
als whose responses to screening questions
met the sampling criteria, according to which
respondents had to be parents or legal
guardians of children aged 5 to 18 years who
had been formally diagnosed with ADHD by
a physician, psychologist, or psychiatrist. Ap-
proximately 30% (n= 315) of visitors did not
meet the sampling criteria, most frequently
because the child had not been professionally
diagnosed. Of the qualified visitors, 71.5%
(n= 528) went on to fill out at least a portion
of the 20- to 30-minute survey; of these indi-
viduals, 9.6% (n= 71) did not respond to the
portion of the survey reported here. Five sur-
American Journal of Public Health | September 2004, Vol 94, No. 91582 | Research and Practice | Peer Reviewed | Kuo and Faber Taylor
RESEARCH AND PRACTICE
TABLE 1—Individual, Residential, and
Case Characteristics: National Activity
Settings and Attention-Deficit/
Hyperactivity Disorder Study
Characteristic No. (%)
Gender
Female 84 (20.69)
Male 322 (79.31)
Age, y
5–6 38 (8.80)
7–9 162 (37.50)
10–13 174 (40.28)
14–18 58 (13.43)
Household income, $
<10000 9 (2.36)
10 000–24 999 34 (8.92)
25 000–49 999 112 (29.40)
50 000–74 999 106 (27.28)
75 000 120 (31.5)
Community type
Large city 54 (13.88)
Suburb 155 (39.85)
Medium town
a
62 (15.94)
Small town 56 (14.40)
Rural 62 (15.94)
Region
Northeast 106 (29.44)
South 78 (21.67)
West 82 (22.78)
Midwest 94 (26.11)
Diagnosed with hyperactivity
No 99 (24.38)
Yes 307 (75.62)
Case severity
Very mild 4 (0.99)
Mild 34 (8.40)
Average 119 (29.38)
Severe 176 (43.46)
Very severe 72 (17.78)
Comorbid condition
Conduct disorder 18 (3.98
b
)
Learning disorders 131 (28.98
b
)
Oppositional defiant disorder 78 (17.26
b
)
None 128 (28.32
b
)
a
Defined as a town with a population between 15 000
and 100 000.
b
Percentage of total sample (n = 452) who responded
yes. Not all respondents indicated comorbidity status,
and some respondents reported more than 1 comorbid
condition.
veys were unusable owing to computer error.
The analyses reported here were based on
452 surveys, including 6 from the Spanish
version of the questionnaire. Table 1 presents
the distribution of individual, environmental,
and case characteristics in the final sample.
Measurement
Assessing activity setting effects on ADHD
symptoms. Parents rated the aftereffects of
common after-school and weekend activities
on their child’s ADHD symptoms. Instruc-
tions specifically mentioned 4 symptoms se-
lected from the official ADHD
32
diagnostic
criteria to be easily observable by parents:
difficulty in remaining focused on unappeal-
ing tasks, difficulty in completing tasks, diffi-
culty in listening and following directions,
and difficulty in resisting distractions. For
each activity in a given physical and social
context, parents were asked to indicate
whether that activity generally resulted in
their child’s symptoms being “much worse
than usual,” “worse than usual,” “same as
usual,” “better than usual,” or “much better
than usual” for the hour or so after the activ-
ity. In the case of activities in which the child
rarely engaged, parents were instructed to se-
lect “don’t know.”
Parents rated each of 49 survey items rep-
resenting the broad range of activities, physi-
cal settings, and social contexts children expe-
rience outside of school. Of these 49 items,
many examined aftereffects of the same activ-
ity across different physical and social con-
texts. For example, “reading” might take place
indoors, in a relatively green outdoor setting,
or in a built outdoor setting; moreover, it
might take place alone, in a pair, or in a
group of 3 or more (for the purposes of this
survey reading alone or in a pair were
grouped together). The survey defined a
green outdoor setting as any “mostly natural
area—a park, a farm, or just a green backyard
or neighborhood space.” Built outdoor set-
tings were defined as “mostly human-made—
parking lots, downtown areas, or just a neigh-
borhood space that doesn’t have much
greenery.”
Other information. Parents provided infor-
mation about their child, including the child’s
residential surroundings and case characteris-
tics. As a means of assessing whether partici-
pants had salient beliefs regarding the effects
of green environments on ADHD symptoms,
participants were asked to nominate any ac-
tivities that stood out to them as having par-
ticularly positive effects on their child’s ADHD
symptoms and to provide any guesses as to
the reason for those effects.
Analysis
In all analyses, rated aftereffects were re-
coded onto a numeric scale with the follow-
ing values: 20, 10,0,10, and 20; “same
as usual” was coded 0, improved symptoms
were coded positively, and worsened symp-
toms were coded negatively. Three series of
analyses were conducted. First, to examine
whether activities conducted in different
physical and social settings were, on average,
rated as resulting in either better symptoms
or worse than usual symptoms, we con-
ducted a series of 1-sample t tests comparing
rated aftereffects with the “same as usual”
value of 0.
Second, to compare the aftereffects of
green outdoor activities with those of activi-
ties conducted in other settings, we conducted
2 series of 2 × 2 (Physical Setting × Social
Context) repeated measures analyses of vari-
ance (ANOVAs). Green outdoor activities
were compared with both indoor activities
and built outdoor activities for the sample as
a whole and for each of 28 subsamples. The
analyses controlled for effects of social con-
text and for differences between children
(e.g., gender, income, diagnosis). However, be-
cause there was not complete overlap of ac-
tivities across settings, these analyses did not
control for differences in the types of activi-
ties taking place in each setting (e.g., televi-
sion viewing occurs indoors but not in other
settings).
Finally, a pair of 2 × 2 repeated measures
ANOVAs addressed whether any advantages
associated with green outdoor activities might
owe to the activities themselves rather than
the settings. These ANOVAs examined the
effects of physical setting and social context
on the aftereffects of matched activities (e.g.,
reading indoors vs reading in a green outdoor
setting). There were 5 activities rated in both
green outdoor and built outdoor settings and
6 activities rated in both green outdoor and
indoor settings.
September 2004, Vol 94, No. 9 | American Journal of Public Health Kuo and Faber Taylor | Peer Reviewed | Research and Practice | 1583
RESEARCH AND PRACTICE
TABLE 2—Symptom Reduction Differences: Activities Conducted in “Green” Outdoor
Settings Versus Other Settings
Green Outdoors vs Built Outdoors Green Outdoors vs Indoors
Mean Mean
Characteristic F df P Difference F df P Difference
Gender
Female 7.7 72 .001 1.16 22.3 77 .0001 2.59
Male 19.5 294 .0001 1.32 128.5 302 .0001 3.56
Age, y
5–6 9.6 31 .001 2.55 13.6 31 .001 3.16
7–9 4.2 130 .05 0.94 59.3 141 .0001 3.70
10–13 11.5 149 .001 1.31 63.7 162 .0001 3.36
14–18 3.5 49 .07 1.31 26.3 53 .0001 3.40
Income, $
<25000 8.1 39 .01 1.76 13.1 39 .001 3.18
25 000–49 999 3.0 99 .09 1.00 28.7 102 .0001 2.69
50 000–74 999 12.3 98 .001 1.57 69.3 102 .0001 4.34
75 000 9.6 107 .01 1.34 42.3 113 .0001 3.40
Community type
Large city 4.1 49 .05 1.14 13.8 50 .001 3.01
Suburb 11.1 140 .001 1.47 53.2 144 .0001 3.27
Medium town 4.9 58 .05 1.43 26.8 60 .0001 3.71
Small town 4.4 48 .05 1.32 33.9 52 .0001 3.81
Rural 4.1 55 .05 1.26 23.6 57 .0001 3.45
Region
Northeast 7.7 91 .01 1.49 45.0 95 .0001 4.07
South 5.1 70 .05 1.48 25.8 72 .0001 3.34
West 14.4 77 .001 1.69 32.0 79 .0001 3.25
Midwest 4.1 85 .05 1.06 37.7 91 .0001 3.27
Diagnosed with hyperactivity
No 12.2 82 .001 1.51 50.7 91 .0001 3.93
Yes 15.8 279 .0001 1.22 101.1 283 .0001 3.20
Case severity
Very mild or mild 13.1 231 .001 1.23 78.2 234 .0001 3.14
Average 11.9 99 .001 1.44 52.1 109 .0001 3.76
Severe 11.0 163 .001 1.40 68.1 163 .0001 3.53
Very severe 2.2 67 .14 0.83 12.7 70 .001 2.23
Comorbid condition
None 11.6 112 .001 1.59 55.5 118 .0001 3.33
Learning disorders 5.3 119 .05 1.05 37.0 123 .0001 3.08
Oppositional defiant disorder 1.0 72 .33 0.58 36.8 73 .0001 3.34
Total sample 27.0 376 .0001 1.31 165.3 403 .0001 3.43
RESULTS
Do Green Outdoor Activities Reduce
Symptoms?
One-sample t tests indicated that green out-
door activities significantly reduced symptoms;
specifically, aftereffects of green outdoor activ-
ities were assigned ratings significantly greater
than 0 whether those activities were conducted
alone/in pairs (t
430
=16.91, P < .0001) or in
larger groups (t
408
=3.77, P = .0002). By con-
trast, built outdoor activities were judged to
reduce symptoms when conducted alone/in
pairs (t
398
=11.65, P< .0001) but not when
conducted in larger groups (t
380
=0.82, P =
.41). Similarly, indoor activities significantly
reduced symptoms when conducted alone/in
pairs (t
446
=6.56, P < .0001) but significantly
exacerbated symptoms when conducted in
larger groups (t
438
=6.68, P<.0001). Thus,
only in green outdoor settings did activities re-
duce symptoms regardless of social context.
Are Green Activities Better Than
Activities Conducted in Other Settings?
Table 2 provides the results of 2 × 2 re-
peated measures ANOVAs examining the ad-
vantage of green outdoor activities over built
outdoor and indoor activities, respectively,
while controlling for social context. Before we
examine the main effects of physical settings
on symptoms, a brief overview of the other ef-
fects tested in these analyses is in order. Con-
sistent with parent reports and previous re-
search, activities conducted alone or in a dyad
had reliably better effects on symptoms than
did group activities. There were significant in-
teractions between social context and physical
setting in the case of 2 of the analyses de-
picted in Table 2; simple effects tests con-
firmed that the main effects of physical setting
held for each of the social contexts separately.
For the sample as a whole, ratings indi-
cated that green outdoor activities reduced
symptoms significantly more than did either
built outdoor activities or indoor activities.
The findings for specific subsamples echoed
these results with remarkable consistency; in
each of 56 analyses, green outdoor activities
received more positive ratings than did activi-
ties taking place in other settings, and this dif-
ference was significant or marginally signifi-
cant in 54 of the 56 analyses. These findings
suggest that green outdoor activities are bene-
ficial in reducing ADHD symptoms among
both boys and girls; children in the 5- to 6-year,
7- to 10-year, 11- to 13-year, and 14- to 18-
year age groups; and children from 4 sepa-
rate household income brackets (ranging from
less than $25000 to $75 000 or more per
year). The advantage for green outdoor activi-
ties was observed among children living in
different regions of the United States and
among children living in a range of settings,
from rural to large city environments.
In addition, the advantage for green out-
door activities held among both children with
American Journal of Public Health | September 2004, Vol 94, No. 91584 | Research and Practice | Peer Reviewed | Kuo and Faber Taylor
RESEARCH AND PRACTICE
hyperactivity (i.e., those diagnosed with
ADHD) and children without hyperactivity
(i.e., those diagnosed with attention-deficit dis-
order); among children with relatively mild,
average, and severe symptoms; among chil-
dren without comorbid conditions; and among
children with both ADHD and learning disor-
ders. In 2 groups—children with “very severe”
symptoms and children with both ADHD and
oppositional defiant disorder—green outdoor
activities were significantly more helpful than
indoor activities but not more helpful than
built outdoor activities (P=.14, P< .33).
Are Green Settings Better After Control
for Activity Type?
A 2 × 2 (Physical Setting × Social Context)
repeated measures ANOVA indicated that the
same activities reduced symptoms significantly
more when they were conducted in green set-
tings than when they were conducted in in-
door settings or in built outdoor settings
(F
13 7 5
=32.1, P < .0001, and F
1386
=21.9,
P< .0001, respectively).
Beliefs About Nature and ADHD
Of the 339 reasons parents gave as to why
an activity might reduce their child’s ADHD
symptoms, only 2 could be construed as re-
ferring to green outdoor settings: “fresh air”
and “ability to be outside in light, open
spaces.” None of the responses referred di-
rectly to nature or green space.
DISCUSSION
Overall, our findings indicate that exposure
to ordinary natural settings in the course of
common after-school and weekend activities
may be widely effective in reducing attention
deficit symptoms in children. Analyses of the
sample as a whole indicated that green out-
door activities resulted in reduced children’s
symptoms and had more positive aftereffects
on symptoms than did activities conducted in
other settings. Moreover, the advantage of
green outdoor activities over other activities
was consistent for children across a wide
range of individual, residential, and case
characteristics.
Some of the specific findings of this study
are worth noting in that they argue against
potential alternative explanations for the
green advantage. Consistent with previous re-
search, comparisons of matched activities in
different physical settings suggested that the
benefits of green outdoor activities cannot be
wholly attributed to differences in the activi-
ties themselves (A. Faber Taylor and F.E.
Kuo, unpublished data, 2004).
31
Similarly,
comparisons of green outdoor activities with
built outdoor activities argued against the
green advantage being solely attributable to
qualities shared by outdoor settings, such as
freedom of movement and changing or novel
patterns of stimulation (A. Faber Taylor and
F. E. Kuo, unpublished data, 2004).
31
Along
the same lines, the finding of a green advan-
tage among children with attention-deficit dis-
order (who are not hyperactive) suggests that
the salutary effects of green settings on
ADHD cannot be solely attributed to the op-
portunity to “burn off” hyperactive impulses.
Furthermore, it is worth noting that a green
advantage was found among children who
lived in communities of different sizes, lived in
different regions of the United States, and were
at different household income levels; thus, the
benefits of exposure to relatively green settings
seemed to hold despite what must have been
wide variation in the specific “green outdoor,”
“built outdoor,” and “indoor” settings available
to children in these different subpopulations.
In addition, the finding of a green advantage
among rural children suggests that the benefits
of green spaces cannot be solely a function of
the relative novelty of such spaces in the larger
context of urban surroundings. Finally, the ad-
vantages of green outdoor activities over other
activities did not appear to be an artifact of
parents’ folk theories regarding the value of
such activities (A. Faber Taylor and F.E. Kuo,
unpublished data, 2004).
31
A number of avenues for future research
seem worth pursuing to address the limita-
tions of the current study. One limitation of
our study was the possibility of systematic
error in parents’ perceptions of different set-
tings, leading to an illusion that children’s
symptoms are better after exposure to some
settings than to others.
Another limitation is that, although we
found setting differences even when compar-
ing the same activity across different settings,
the same activity may take on slightly—but
systematically—different characteristics when
conducted in different settings, and the differ-
ences attributed here to different settings may
actually reflect differences in activity character-
istics. If so, we would expect the green advan-
tage to disappear when tested with objective
performance measures after carefully matched
activities. In fact, however, the green advan-
tage remained in tests conducted under these
conditions. In our recent field experiment (A.
Faber Taylor and F.E. Kuo, unpublished data,
2004), ADHD children did indeed perform re-
liably better on an objective test of concentra-
tion after exposure to a relatively natural
urban setting than after carefully matched ex-
posures to less natural urban settings.
Thus, it appears that the green advantage
found in parents’ ratings reflects a systematic
phenomenon that is objectively measurable
and not easily attributable to activity charac-
teristics. Nonetheless, perhaps the highest fu-
ture priority is for additional controlled ex-
periments involving the use of objective
performance measures to further verify and
quantify the impacts of natural settings on
ADHD. Dose–response parametric variations
will reveal the extent to which green activi-
ties make a difference, for how long, and
under what conditions.
Future research also would be useful to
confirm and extend the apparent generality
of the current findings. At present, it is un-
clear whether the few marginally significant
and nonsignificant differences observed in
this study reflect systematic or random varia-
tion; for example, do children with both op-
positional defiant disorder and ADHD really
benefit no more from green outdoor settings
than from built outdoor settings?
Along the same lines, it is not certain
whether the benefits of nature extend to sub-
populations underrepresented in this study,
such as children from households with annual
incomes of less than $10000, children with
relatively mild symptoms (as judged by their
parents), and children of different ethnic back-
grounds. It should be noted that, in a previous
general population study involving African
American children from households with an-
nual incomes below $10000, children living in
relatively “green” apartment buildings exhib-
ited superior attention and impulse control.
21
These findings suggest that neither low house-
hold income nor African American ethnicity
September 2004, Vol 94, No. 9 | American Journal of Public Health Kuo and Faber Taylor | Peer Reviewed | Research and Practice | 1585
RESEARCH AND PRACTICE
preclude children from experiencing the
restorative effects of nature. Moreover, the fact
that similar effects have been found among
both children from the general population
11 , 2 1
and children with relatively severe ADHD
symptoms provides reason to hope that the
benefits of nature will extend to ADHD chil-
dren with relatively mild symptoms.
Another fruitful avenue for future studies
may be to extend current theory and research
on attention fatigue and restoration to investi-
gation of ADHD. Is the distinction between
deliberately directed and involuntary atten-
tion
9
helpful in conceptualizing ADHD? Does
ADHD confer any additional vulnerability to
attention fatigue? Do environmental factors
that appear to induce attention fatigue in the
general population—noise, crowding, and
need for vigilance
33–37
—exacerbate ADHD
symptoms? The consistent findings of poorer
ratings for activities conducted in larger as
opposed to smaller groups are in accord with
this expectation (A. Faber Taylor and F.E. Kuo,
unpublished data, 2004).
31
This line of research has exciting implica-
tions for the management of ADHD. If clini-
cal trials and additional research confirm the
value of exposure to nature for ameliorating
ADHD, daily doses of “green time” might
supplement medications and behavioral ap-
proaches to ADHD. These “doses” might take
a variety of forms: choosing a greener route
for the walk to school, doing class work or
homework at a window with a relatively
green view, or playing in a green yard or ball
field at recess and after school.
While medications are effective for most
children with ADHD, they are ineffective
for some, and other children cannot tolerate
them. In the case of children for whom
medication is tolerable and effective, expo-
sure to green settings as part of their daily
routine might augment the medication’s ef-
fects, offering more complete relief of symp-
toms and helping children function more ef-
fectively both at school and at home. In
addition, a green dose or series of green
doses might conceivably reduce the need
for medication by 1 dose per day, allowing
growing children to recover their appetites
in time for dinner and get a good night’s
sleep. Finally, among those children for
whom medication is not an option, a regular
regime of green views and green time out-
doors might offer the only relief from symp-
toms available.
About the Authors
Frances E. Kuo is with the Department of Natural Re-
sources and Environmental Sciences and the Department
of Psychology, University of Illinois at Urbana-Champaign.
Andrea Faber Taylor is with the Department of Natural
Resources and Environmental Sciences, University of Illi-
nois at Urbana-Champaign.
Requests for reprints should be sent to Frances E. Kuo,
PhD, Human Environment Research Laboratory, Univer-
sity of Illinois at Urbana-Champaign, 1103 S Dorner Dr,
Urbana, IL 61801 (e-mail: fekuo@uiuc.edu).
This article was accepted July 30, 2003.
Contributors
F. E. Kuo conceived the study, cosupervised the analysis,
and wrote the article. A. Faber Taylor cosupervised the
analysis, assisted with design of measures and data col-
lection, and reviewed drafts of the article. Both authors
helped to conceptualize ideas and interpret findings.
Acknowledgments
We are grateful to the National Urban and Commu-
nity Forestry Advisory Council, the US Forest Ser-
vice, and the US Department of Agriculture’s Coop-
erative State Research, Education, and Extension
Service (grant 00-DG-11244225-354) for their sup-
port of this research. Some of the findings described
here were presented at the 2002 International Con-
ference of the Environmental Design Research Asso-
ciation in Philadelphia, Pa.
We are grateful to Ali Banihashem, Christine Carr,
Catherine Do, Lindsey Hammond, Pam Leiter, Ellen
Steele, Patrick Sullivan, and Johanna Weber for their
contributions to survey preparation and data analysis.
Human Participant Protection
No protocol approval was needed for this study.
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This clinical practice guideline provides recommendations for the assessment and diagnosis of school-aged children with attention-deficit/hyperactivity disorder (ADHD). This guideline, the first of 2 sets of guidelines to provide recommendations on this condition, is intended for use by primary care clinicians working in primary care settings. The second set of guidelines will address the issue of treatment of children with ADHD. The Committee on Quality Improvement of the American Academy of Pediatrics selected a committee composed of pediatricians and other experts in the fields of neurology, psychology, child psychiatry, development, and education, as well as experts from epidemiology and pediatric practice. In addition, this panel consists of experts in education and family practice. The panel worked with Technical Resources International, Washington, DC, under the auspices of the Agency for Healthcare Research and Quality, to develop the evidence base of literature on this topic. The resulting evidence report was used to formulate recommendations for evaluation of the child with ADHD. Major issues contained within the guideline address child and family assessment; school assessment, including the use of various rating scales; and conditions seen frequently among children with ADHD. Information is also included on the use of current diagnostic coding strategies. The deliberations of the committee were informed by a systematic review of evidence about prevalence, coexisting conditions, and diagnostic tests. Committee decisions were made by consensus where definitive evidence was not available. The committee report underwent review by sections of the American Academy of Pediatrics and external organizations before approval by the Board of Directors. The guideline contains the following recommendations for diagnosis of ADHD: 1) in a child 6 to 12 years old who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems, primary care clinicians should initiate an evaluation for ADHD; 2) the diagnosis of ADHD requires that a child meet Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria; 3) the assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms, and degree of functional impairment; 4) the assessment of ADHD requires evidence directly obtained from the classroom teacher (or other school professional) regarding the core symptoms of ADHD, duration of symptoms, degree of functional impairment, and associated conditions; 5) evaluation of the child with ADHD should include assessment for associated (coexisting) conditions; and 6) other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD but may be used for the assessment of other coexisting conditions (eg, learning disabilities and mental retardation). This clinical practice guideline is not intended as a sole source of guidance in the evaluation of children with ADHD. Rather, it is designed to assist primary care clinicians by providing a framework for diagnostic decisionmaking. It is not intended to replace clinical judgment or to establish a protocol for all children with this condition and may not provide the only appropriate approach to this problem.
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