Grow Outside! Keynote address to the American Academy of Pediatrics National Conference

Adapted excerpts from Richard Louv’s plenary keynote address to the American Academy of Pediatrics National Conference, Oct. 2, 2010 in San Francisco. On Oct. 1, Louv made similar remarks at the UCSF Conference, Children First: Promoting Ecological Health for the Whole Child.

More than three decades ago, when Dr. Mary Brown’s children were growing up in Bend, Oregon (she describes it as a city at the base of the Cascade Mountains with a world class fly-fishing river running through it and where the sun shines over 300 days a year), it never occurred to her that much of her practice as a pediatrician would one day be so focused on childhood obesity and depression.

These maladies, as she described them in an e-mail to me a few days ago, are the ones that happen when kids move inside and interact with their video games and computers instead of outside playing with each other and using their imaginations. She continued, Just this week I saw a teenager who attempted suicide, who had no friends, no activities and no ideas about how to change her life. Her life had been moving from place to place with nothing but a computer for a friend. A month, ago I saw a 13-year-old boy who weighed over 300 pounds who told me if he didn’t have his video games he would have no reason to live. She added, Last weekend it was 75 degrees and sunny and I went for a long walk though several neighborhoods that were safe, with open spaces and endless opportunities for outdoor activities and I was not able to find one child outside looking for lizards, butterflies or playing with other kids.

The disconnect with the outdoors, especially the natural world, is, she says, one of the core reasons for so many of the physical and mental problems that have changed the practice of pediatrics over the last 20 years.

Dr. Brown, a member of the board of directors of the American Academy of Pediatrics, believes that pediatricians can play a vital role in the movement to reconnect children to nature, because they so often see the symptoms of what I’ve called nature-deficit disorder. I introduced that term in Last Child in the Woods. In that book and since, I emphasize that nature-deficit disorder is a societal disorder, and in no way a medical diagnosis — though perhaps someday it should be. Rather, the term gives us a way to consider the price children, and all of us, pay for our growing alienation from the natural world. That disconnect is, many of us believe, a partial explanation for what pediatricians now call the millennial morbidities, which include increases in childhood depression and asthma; a rise in vitamin D deficiency which can cause rickets and lead to osteoporosis; and growing incidences of type-2 diabetes among children – an increase so significant (type 2 now accounts for up to half of the new cases of childhood diabetes) that the term adult-onset diabetes is no longer used.

As Dr. Brown points out, for many pediatricians, the strategic pediatric priorities have changed from infectious disease, immunizations and car seats and helmets to mental health, obesity and early brain development, all of which could be changed by re-connecting our kids to the wonder of nature.

A few years ago, after the publication of Last Child, I suggested a pediatrics Grow Outside! campaign. The idea, as I described it in the updated edition in 2008, was that pediatricians and other health professionals could be powerful voices for that reconnection, by offering prescriptions to go outside, along with posters, pamphlets, and personal persuasion. What some of us had in mind was an effort modeled on the national physical fitness campaign launched by President John F. Kennedy. Since then, we’ve seen some wonderful progress — the First Lady’s campaign, Let’s Move (and its recently added subset, Let’s Move Outside) against child obesity. A number of new campaigns, which I’ll describe a bit later, are enlisting health care providers to encourage independent or close-to-independent play in the natural world.

Along with educators, conservationists, business people and many others, pediatricians are already helping to lead this movement. Pediatricians and other pediatric health providers are particularly effective at this because of  their special, trusted voice. I’m here today to ask you to raise that voice. Please understand what we are not requesting: We are not asking you to consider the nature prescription as a replacement for traditional evidence-based approaches; when appropriate, it should be considered complimentary to traditional therapies. While correlative evidence is rolling in, we still lack sufficient, rigorous longitudinal research. This disparity does not necessarily reflect the relative importance of nature-based therapy versus other modalities, but rather where the funding for research comes from. Nonetheless, the correlative evidence does tend to point in a single, common-sense direction: Getting children outside can be good for their health, and getting them outside in nature may well offer special benefits.

Here is a sample of what the research suggests, and what pediatrics professionals can do:

• Contact with the natural world appears to significantly reduce symptoms of attention deficit disorder in children as young as five.

• Nearby nature, and even a view of nature from a bedroom window, can reduce stress in children

• Older children who spent more time outside were generally more physically active and had a lower prevalence of overweight than children who spent less time outside. (Less is known about the impact on very young children.)

• Children in greener neighborhoods appear to have lower body weight changes.

• Spending time outdoors may help prevent myopia.

• Play in natural environments is associated with young children’s improved motor abilities and increased creativity.

• Access to nature nurtures self-discipline and self-confidence among children, including children with disabilities.

• Natural environments, such as parks, foster recovery from mental fatigue and may help children learn.

• Green exercise may offer added benefits when compared to equal exertion in indoor gyms.

• In hospitals, clinics and medical offices, incorporate nature into the design to help children, and their families, reduce stress and heal.

• The concept of play, including play in nature, is more compelling and inviting to most adult caregivers, parents and guardians than exercise.

An additional benefit of nature experience has received scant attention, yet it is one of the most stirring: family bonding. Research has not looked specifically at a link between outdoor experience and quality of parent-child attachment, and certainly parents can be sensitive and responsive to their babies and young children indoors or out, says Martha Farrell Erickson, Ph.D., a developmental psychologist and a past children’s health advisor to the White House. But, in many ways, the natural world seems to invite and facilitate parent-child connection and sensitive interactions. What better way to escape the constant, interrupting beeping of modern life, and actually have a chance to spend concentrated time with your child, than with a walk in the woods?

How pediatricians, nurses and other pediatric health professionals can help

In 2009, Janet Ady of the U.S. Fish and Wildlife Service stood before a crowd of grassroots leaders gathered by the Children & Nature Network. She held up an outsized pharmacy bottle. Within the bottle was a physician’s prescription — one that would be as appropriate for adults as it would be for children. The contents of the medicine bottle included a variety of information, including a Web address to National Wildlife Refuges, a guide to animal tracks, Leave No Trace tips, a link to information on planting native vegetation to help bring back butterfly and bird migration routes, a Power Bar, and other items—including a temporary tattoo of migratory birds.

The label read: Directions: Use daily, outdoors in nature. Go on a nature walk, watch birds, and observe trees. Practice respectful outdoor behavior in solitude or take with friends and family. Refill: Unlimited. Expires: Never.

In your practices, in every community, at every economic level, please consider suggesting to parents that they get their children and themselves into nature. The AAP has long dedicated itself to improving health by prescribing healthier habits and environments. The Academy is doing our part by calling on every pediatrician to calculate body mass index (BMI) for every child over the age of two at every well-child visit,” according to Dr. Judith Palfreey, AAP president. “We are encouraging our 60,000 pediatricians to give out official child-friendly prescriptions for healthy, active living—good nutrition and physical activity—at every well-child visit. Using these ‘prescriptions,’ pediatricians will work with families to set goals for good eating habits and physical activity. What else can pediatricians and pediatric health providers do, perhaps more specific to the nature connection?

• Learn more about the research on the restorative power of nature, and pass this information on to parents and other caregivers.

• Informally recommend green exercise in nearby nature to your patients and their families.

• Offer written information (the Children & Nature Network can help with this) about the health benefits of outdoor play.

• Educate families about the powers of nature for stress reduction for children and parents.

• Recommend nature time for parent-child family bonding, including infants.

• Provide information on where parents, grandparents and other caregivers can get outdoors.

• Provide safety information about nature: how to avoid ticks and noxious plants, for example.

• Get involved with or help start a regional campaign. (Over 80 already exist in North America; these groups are your nearby allies.)

• Use biophilic design principles in your office, clinic or hospital.

• When a family first comes to you, give them a Grow Outside! picnic or gardening basket filled with pamphlets, maps, a compass, a trowel.

• Attend one of the Nature Champion training sessions offered by the National Environmental Education Foundation (NEEF).

• Take a hike yourself; be restored in nature.

Pediatricians, pediatric nurse practitioners, and other health care professionals can also help by pushing for more research funding. But as Howard Frumkin, Dean of the University of Washington School of Public Health, often says, yes, we need more research, but we know enough to act.

Grow Outside! How to get started

To get started, log on to the Children & Nature Network, which offers a Grow Outside! Start Guide with links to our own extensive research pages, blogs, the regional or state campaigns in or near your community, family nature club tool kits (in English and Spanish), and Nature Rocks for fast and easy actions parents can take.

The guide, which also offers sample prescription forms for nature, will also lead you to the good works, related to pediatrics, of many organizations, including AAP, the National Wildlife Federation, Audubon, and NEEF, which has recently launched its ambitious Children and Nature Initiative.

NEEF’s program is designed to educate pediatricians and other pediatric health care providers about health benefits of spending time outdoors in nature, and connect them to local nature sites, so that they can refer families to safe and easily accessible outdoor areas. NEEF is holding a series of train-the-trainer workshops to prepare pediatric health care providers to serve as Nature Champions. NEEF offers adaptable nature prescription pads, patient brochures and pediatric environmental history forms, a training presentation, and a fact sheet highlighting key scientific studies. The Initiative is guided by an advisory committee of experts from major medical institutions, including AAP.

Directly related to Children & Nature Network’s work, in Holland, Michigan, Dr. Paul Dykema changed his pediatrics clinic waiting area to include posters about reconnecting children and nature, for their health and well-being. He provides a waiting room video about the benefits to children and families from nature-based experiences; incorporates recommendations for nature-based time outdoors in all the regular family wellness meetings for parents and children from birth and older; and has a special instruction pad for children prescribing an hour a day of outdoor play in nature, and 20 minutes of reading a day. And in Ohio, Dr. Wendy Anderson is taking the lead with the medical community, as part of the Leave No Child Inside Central Ohio Collaborative — one example of how regional campaigns can build public support.

The nature prescription isn’t for everyone, and it’s no panacea. The experience must take place in a larger context of healthy relationships, diet and environment. But based on the emerging evidence, the restorative power of nature can help many children.

Within the health professions, interest in the nature prescription is already growing. Healing gardens on hospital grounds are now popular. Dr. Daphne Miller, a general practitioner in Noe Valley, California, envisions nature prescriptions as part of the burgeoning field of integrated medicine. Nature is another tool in our toolbox, says Miller, who, in addition to her medical practice, is associate clinical professor in the Department of Family and Community Medicine, University of California, San Francisco. She also believes that park rangers can, in effect, become health providers. So can whole park districts.

Santa Fe, New Mexico, in an effort to fight the high rate of diabetes there, launched its Prescription Trails program, which is partially funded by the Centers for Disease Control and Prevention. Besides trail time, physicians can refer their patients to a trail guide. In 2010, a pilot program in Portland, Oregon, began pairing physicians with park professionals, who will record whether the outdoor prescriptions are fulfilled; the park prescription program will be part of a longitudinal study to measure the effect on health.

Any parent whose child has ever been sick — which means all of us — has deep respect, even love, for the pediatricians and other pediatric health providers in their lives. It’s one thing to put our trust for our own lives in a doctor’s hands; it’s quite another thing when the lives at stake are our children’s. The gift you give us is much more than your technical knowledge. You give us your kindness and wisdom. You calm our fears. So I’m here today to ask your help in the movement to reconnect our children and future generations to the natural world. I ask this for their physical and psychological health, their ability to learn, their capacity for wonder — for their ability to feel fully alive in a very real world.

Check Out More News and Resources