Benefits of Pediatric Outdoor Therapy
Obesity is a global pandemic affecting more than 2.1 billion people, including 47% of children. In the United States alone, approximately one-third of children and adolescents are classified as obese or overweight and costing an estimate of $147 billion to $210 billion per year (smith). Obesity is a chronic disease that consists of your body mass index (BMI) being greater than 30kg/m2, or for children being in the 95th or great percentile (Porter et al). It is a result of an imbalance of caloric intake and energy expenditure. Inadequate physical activity is associated with increased morbidity and mortality, including cancer, cardiovascular disease, disability, diabetes mellitus (DM), hypertension, osteoarthritis, gallbladder disease, sleep apnea, asthma and stroke (Wolfenden et al, smith, McCurdy). The primary causes of obesity in children are lack of physical activity/lack of sports participation, increased screen time and gaming, and inadequate diet. Olshansky et al, cautioned that today’s children may be the first generation at risk of a shorter lifespan than their parents due to an increase in sedentary indoor lifestyles. For adults, the American College of Sports Medicine recommends that 150 to 250 minutes of moderate intensity exercise per week is needed to prevent weight gain when accompanied by a proper diet. The amount and intensity changes as children develop. For children 6 years and older, it is recommended to obtain at least 60 minutes per day. Technology has made it significantly easier to be less active in our daily tasks. According to Hu, et al, for every 2-hour increment of watching television is associated with a 23% increase in obesity. Tester et al, found that 27.1% of children who were severely obese had four or more hours of screen time compared to 14.7% of children with normal weight. In the study by Ansari, et al, approximately 37 minutes per day of outdoor play at Head Start was associated with a decrease in children’s BMI scores; showing the importance of how early in age we can implement preventive measures to overcome the obesity challenge worldwide. Studies like this can give insight on considering establishing guidelines that encourage more outdoor time. In contrast, the study by Driediger, et al, in which they explored the effect of four 30-minute outdoor unstructured play sessions showed no significant difference between groups of preschoolers that participated in moderate to vigorous physical activity versus light physical activity, total physical activity and sedentary time. Yet, in their discussion, they still concluded that having multiple daily opportunities for outdoor play had positive impacts on children’s health.
As physical therapists, we can play a significant role in educating children and families in appropriate physical activity. According to the research by Herrington and Brussoni, children are more physically active when outside. Vanderloo et al, compared the physical activity level of both indoor and outdoor of preschoolers and found that participants engaged in 0.54 min/h of moderate to vigorous exercise and 14.42 min/h of total physical activity indoors compared to 5.03 min/h of moderate to vigorous exercise and 31.68 min/h of total physical activity outdoors with boys demonstrating a greater amount of moderate to vigorous exercise outdoors versus girls. This was also observed in a similar study by Tandon et al. Children are natural explorers and utilizing the outdoors is an excellent way to integrate therapy with minimal equipment by implementing balance challenges, sensory integration techniques, and functional tasks that help develop large muscle groups. The Academy of Pediatrics recommends a wide variety of activities that are unstructured and fun, promoting spontaneity, and ensuring children maintain a sense of play.
Two psychologists, James J. Gibson and spouse Eleanor J. Gibson, are known for their work in a “scribble” experiment with children in which the participants were to correctly recognize the drawing identical to the initial one shown to them and summarized that their performance improved because their perception was enhanced from repeated trials. They furthered their research discussion on perceptual learning and the interaction between perception and action, the relationship between the organism and the environment, and the role of active exploration. This led to the introduction of the term affordance, a quality or characteristic of the environment that provides an individual to act (Rahlin). Affordances have been a foundation for designing and studying outdoor play. In a study done comparing a traditional playground to a nature-based playground, it was summarized that children spend a longer duration of time in play on a nature-based playground. A traditional playground could be an affordance for children who are highly physically competent; however, it could also be too challenging for children who are lowly physically competent. A nature-based playground with many loose parts such as blocks, pails, balls offers more affordances for a child who is less physically competent and still allows for participation with others to help them gradually develop and master skills.
Outdoor play can lead to a higher risk of injury or even death amongst children due to the variability of the environment, lack of safety measures, and lack of education on safety measures. According to data from the US National Electronic Injury Surveillance System, nonfatal injuries that occur outdoors include 70% falls, 39% fractures, 8.5% traumatic brain injuries (TBI). With injuries being the leading cause of death in children, Parkin and Howard performed a review of systematic reviews available on effectiveness of protective measures and approaches to the environment and legislature for four common outdoor play activities including bicycling, snowboarding or skiing, playgrounds and walking. The authors summarized that healthcare providers caring for children have a leading role in injury prevention through family counseling/education, advocacy and research. Playground, a place meant for entertainment and fun, is one of the most dangerous locations for a child because of inadequate marking, inappropriate surface materials, insufficient or lack of guardrails, and are often unattended or well supervised. Other risks that raise parental concerns include allergies, pollution, insect-borne diseases, skin cancer. In the cross-sectional study by Tandon, et al, 36% of 1900 preschoolers cared for in a home-based childcare setting did not go outside at least once a day to enjoy a walk or play with either their parent(s) or the childcare provider. According to Herrington and Brussoni’s research, risk-taking in play is important for children’s health and development. By utilizing outdoor play in physical therapy, we can teach children safe play behaviors, help them learn about their own potential, navigate the environments safely, and educate the parents; ultimately, in the parameters of a real-life scenario with the influences and challenges of the environment. Best practice guidelines recommend going outside for outdoor play 2-3 times a day totaling 60-90 minutes.
Although there are risks to outdoor play, there are also many benefits and are considered to be essential to healthy development. Benefits include brain development, social-emotional skills, physical motor development, health improvements, cognitive and academic skills, mental health, vitamin D levels, resiliency of a child, and in some studies vision problems such as myopia (Mackenzie et al, Tandon et al, Ngo et al, McCurdy). Furthermore, risky play can help develop risk-management strategies and aid in negotiating decisions about substance use, relationship and sexual behavior later in life (Brussoni et al). Many diagnoses including cancer can have a detrimental effect on our psychosocial wellbeing and interfere with getting to be a kid. Children with disabilities who are at risk of lower rates of participation and engagement which contributes to behavioral and emotional disorders and reduced physical and mental wellbeing that can lead to lifelong health concerns. A review by Neville, et al, shows the effects of specialized summer camps created for children and youth with cancer. Camps are in the outdoor setting that allow kids to escape from physical and mental stressors of reintegrating back into the daily lives of school, home, and the hospital. Some common qualitative themes included increased positive attributes (sociability, perseverance, confidence), increased respite (finding the right balance), improved quality of interactions with parents, improved health-related quality of life and reductions in depression. A similar controlled study by Zachor, et al mimics these results in outdoor adventure programs for children with autism spectrum disorder (ASD) and found the children who attended the outdoor program showed a mild reduction in ASD symptoms and increase in both verbal and nonverbal communication and social reciprocal behaviors important to interpersonal communication; whereas, the control group resulted in more pronounced restricted and repetitive behaviors commonly seen in children with ASD. These camps and programs provided a place of healing both physically and mentally, a play of acceptance, and an overall sense of community.
Outdoor therapy opens the doors to creativity and can be used in adjunct with other therapeutic approaches. Kern et al, performed a study on embedding music therapy into outdoor play for children with ASD in an inclusive community-based childcare program, which resulted in improved peer interactions and meaningful play. Large undefined spaces and lack of structured play can be challenging and overstimulating for a child with ASD and by adding a positive stimulus such as music, children with autism are able to interact with their peers. As community-based programs are becoming more inclusive and accepting, children with disabilities are now able to receive realistic learning experiences and can learn from peer models. Many studies have demonstrated the following benefits of adding music in physical therapy including: improvement in behavioral issues (tantrums, crying), increased cadence in gait for those with neurological disorders, increased engagement and participation. Another opportunistic adjunct to outdoor therapy is imaginative play and suspending reality. Njelesani et al, observed 100 children in three public outdoor spaces including a public park, a residential road, and a local market in the Ugandan town of Mbarara. In their findings, they concluded that the children engage in three different types of occupation: play, work and nothing in particular. Of the play, the majority of it was creative or active play. Creative play involved using their imagination and coming up with new ways of using materials and toys (a doll made of grass, pushing tires down the road with sticks). Active play was gross motor skills such as climbing trees, kicking balls, swimming, and hard work tasks like pushing each other in boxes. Work occupation involved household chores, caring for younger children, or selling goods at the market. Nothing in periarticular involved waiting or just “handing out”. Outdoor therapy can capitalize on both creative and active play described in the study by Njelesani et al.
As play is the dominant occupation of a child, it is important to assess a child in activities they want to participate in, who they want to do it with, how frequently, and how much they enjoy it. This is done through several outcome measures that look at children’s activities and participation levels including the Kid Play Profile (KiPP), the Pediatric Activity Card Sort (PACS), the Children’s Assessment of Participation and Enjoyment and Preferences for Activities for Children (CAPE/PAC), and the Children’s Leisure Assessment Scale (CLASS). In the review by Brown and Thyer, there were a number of significantly correlated constructs between the CAPE/PAC and the CLASS giving preliminary evidence of convergent validity.
Richard Louv was one of the first to bring attention to alienation of children from the natural world and coined the term “Nature Deficit Disorder” (NDD). He suggested embracing nature in our thinking and fostering opportunities for children in everyday activities such as walks. Barriers to outdoor play including reduced access to a safe neighborhood or playground exist in areas of lower socioeconomic status and are a major obstacle in the implementation of outdoor play. Recurring barriers in literature include families not having time in their schedules, risk aversions of the parents, lack of training, financial resources, and technology temptations. Another obstacle is over populated residential areas that don’t have green space available. Brussoni et al, conducted a randomized controlled trial in which they developed a digital tool and in-person Risk-reframing (RR) workshop in hopes to reframe parents’ perceptions of the risks their children take while at play. Risky play was divided into six categories including, play at speed, play with heights, play with tools, play near dangerous elements, venturing out without adults, and rough and tumble play. McCurdy et al, discussed the concept of “green” schools that give an option to children who have barriers to outdoor play. “Green” schools offer a diversity of environmental aspects such as trees, gardens, and nature trails that give a natural environment to children and help engage them in physical activity, as well as encourage imagination. A study within the McCurdy article found that groups living in nature-based areas had the lowest level of all-cause mortality and mortality due to circulatory disease.
In the midst of the global COVID-19 pandemic, therapists began to implement telehealth for the primary source of providing care in the midst of social distancing protocols. However, some therapists embraced the great outdoors and brought to life the phrase “bringing the inside out”. It has helped reverse the declining trend of outdoor play. According to an article in Psychology Today, time spent outdoors increased from 10.47 hours per week to 14.52 during the initial quarantine and the current average of 11.82 is still higher than before the pandemic began. Even before the pandemic, studies in adult pain management showed that hospital stays were nature scene murals and nature sound machines improve patient reported pain.
In Texas, there are several wilderness therapy programs including BlueFire Wilderness Therapy, Trails Momentum, and Wildernew that help young adults facing issues such as anxiety, depression, addiction, low self-worth, low self-confidence, eating disorders, and relationship difficulties. Their therapists know the healing powers of escaping normal life and the unhealthy stimuli and diving into nature.
Nutrition, physical activity, child behavior, socio-economic status and environmental factors clearly influence childhood obesity rates and many of which fall under physical therapist’s scope of practice to address. Physical therapists can provide education on nutrition and diet to both the child and their parent(s) by adhering to the Pediatric Nutrition Handbook or A Parent’s Guide to Childhood Obesity: A Road Map to Health by the American Academy of Pediatrics (AAP). They directly play a role in physical activity and helping to develop those gross motor skills. If physical activity doesn’t change their behavior alone, physical therapists can help with evaluating other causes of behavior issues such as sleep or communication frustration and can assist in the referral process to other specialties like speech language pathologists or Applied Behavior Analysis therapy. By providing pro bono or free health screenings throughout the community and school systems, physical therapists can help combat the barriers of socio-economic status. As trends of obesity continue to go upward, we have a duty as healthcare professionals to combat the battle. As stated by McCurdy et al, health care providers “cannot manage the intricacies of childhood obesity on their own”. Emphasizing and raising awareness of outdoor play for parents, implementing outdoor therapy as an adjunct to traditional therapy, and advocating for better policies on the federal level is crucial in prevention and the decline of the childhood obesity trend. Further studies are necessary to explore the feasibility and ideal prescription of outdoor time. Interventions should be scientifically based, age-appropriate and individualized. Encouragement of more outdoor time has been started by the Children and Nature Initiative, which works with pediatric health care providers to educate families on parks and natural environments that are easily accessible.
References
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