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It’s no fantasy that children who play freely in the great outdoors are healthier in body and mind. New studies also suggest that active engagement with the natural environment reduces stress and relieves depression in all ages.
The American Academy of Pediatrics (AAP) recently issued a position statement emphasizing the importance of play in promoting healthy development, particularly in children aged 0 to 6 years.1 Whereas this play may be guided at first by parents, as children get older their free play becomes even more important. The benefits of such play are well documented, yet the benefits of exposure to the natural environment are less well studied in the medical literature. However, recent work in the fields of Psychology, Public Health, and Urban and Environmental Studies have shown a variety of physical and mental health benefits related to exposure to and interaction with outdoor green spaces.2
One way to combine the benefits of these areas is for pediatricians to recommend that parents promote nature play for their patients-that is, suggesting to parents that they should have their children go outside and encourage play in an engaging and active way. Such active engagement with the natural environment is likely to benefit children of all ages, not to mention their parents.
Overall health benefits of nature play
Play is critical to healthy child development. That children will spontaneously play and become engrossed in imaginary worlds is not news to any parent or pediatrician, but given the recent emphasis on preschool structured activities, it seems that policymakers have ignored the importance of play. Both the No Child Left Behind Act of 20013 and the Race to the Top Initiative from 20094 emphasized formal academic instruction and standardized testing of even elementary school-aged children.
Fortunately, the AAP strongly emphasizes the importance of play for children and provides a useful definition of something that seems intuitive but difficult to describe: “Play often creates an imaginative private reality, contains elements of make-believe, and is nonliteral.”1 Play is engaging and social, helping children learn new skills as well as how to get along with others and manage their own desires and emotions. Play can take place in any location, and outdoor play is a particularly important context. For example, promoting recess is one way to improve academic achievement,5 and simply having preschoolers go outside to freely play increases levels of moderately vigorous physical activity.6
One fascinating study from Los Angeles compared 2 elementary schools that were matched for proximity, playground square footage, and playground design. Both locations had outdoor space for basketball, kickball, dodgeball, volleyball, 4-square, tetherball, and handball, as well as an open field and other nondesignated space near the school buildings. The control school did not change its playground environment but the intervention school replaced about 21,000 square feet of asphalt with green space. This green space included the introduction of trees, mulch, and boulders; the replacement of an asphalt field with grass and trees; and the replacement of another asphalt field with an “outdoor classroom.” This outdoor classroom was made of decomposed granite flooring, mulch, and log seating with plant borders.
In addition to the hoped-for decreases in sedentary activities for the children with the “greened” playground, there also was a significant decrease in physical and verbal conflicts among these children.7 There are a variety of reasons why increased exposure to natural areas may have helped decrease conflicts. Most notably, children shifted away from prescriptive games with rules (such as kickball or basketball) and more toward imaginative and unstructured play, which may have decreased the opportunity for conflicts and helped develop improved socialization.
Other studies have identified additional benefits of nature exposure that also could play a role. For example, adults who intentionally sought “nature exposure” for at least 10 minutes 3 times weekly for 8 weeks saw a significant decrease in salivary cortisol and alpha-amylase, important biomarkers for general stress.8 Other studies have observed a decrease in internalized mental health symptoms in adolescent girls who spend more than one-half hour per week outdoors9; a decrease in depression symptoms in adults who spend more time outdoors10; and even improved long-term outcomes in adults with severe depression who participated in a rehabilitation gardening program.11
There are 3 key messages from these research studies to communicate to parents. Most importantly is the incredible value of simply encouraging their children to play outside. Although this might be easier in some climates than others, we are fond of recalling the old saying that there is no bad weather, only bad clothing choices. In addition to simply going outside, children should be exposed to the natural environment. This means not only outdoors on a playground but also outdoors in the woods or an open field with parental supervision, and the more exposure to green space, the better. This is healthy for all ages-infants carried by their parents, toddlers directly supervised, school-aged children more distantly supervised, and adolescents progressively granted more independence. Finally, when children are outside in the natural environment, they should be encouraged to participate in imaginative free play that they themselves (not a parent, not a teacher) direct.
University of Michigan’s Gaffield Children’s Garden
Like similar gardens throughout the country, Gaffield Children’s Garden at the University of Michigan’s Matthaei Botanical Gardens and Nichols Arboretum has applied these guiding principles in creating a natural, engaging environment that promotes creative and independent play for the children who visit the garden. A grounding principle of Gaffield Children’s Garden is the modeling of easily replicable nature play for all visitors.
Loose nature parts play is accessible and can be easily incorporated in home spaces, neighborhoods, backyards, apartment balconies, parks, and schoolyard settings. Loose parts play invites imagination and divergent thinking opportunities, and supports curiosity about the natural world. What makes loose parts play so compelling is that there is no single way to play, and, for the most part, loose parts are also found parts: twigs, branches, stones, seed heads, water, and so on. These parts can be combined, moved, manipulated, redistributed, and reassigned many times over, taking different roles in different settings and play times. Whereas Gaffield Children’s Garden is designed for nature play, the various areas also provide models for parents and children to continue their engagement with the natural world even when not visiting the Garden. Suggestions for using these models, both indoors and outdoors, are summarized in Table 1.
Loose parts play is a type of self-directed play that can feature both small parts and large parts, each offering different elements of play and discovery. Stocked with tree branches, fence planks, stumps, and boulders, the Builder’s Garden invites children to create child-sized structures, practice communication and negotiation, and experiment with physics, engineering, and, of course, imagination. Forts are built and rebuilt, simple lever-based machines are constructed, and play features such as balance beams and tree stump obstacle courses are constructed by children according to their play needs. This is boisterous, gross motor play.
Conversely, Fairy and Troll Knolls are stocked with the tiny, subtle bits of nature-stones, tree cookies, bits of bark, flower heads, and found ephemera-that invite children to create tiny worlds for imaginary creatures. This tends to be independent and quiet play. Children employ small motor skills, imagining single dwellings or entire ecosystems. Both these ideas can be replicated to varying degrees in backyards, schoolyards, parks, and on apartment grounds or balconies.
In the Grower’s Garden, children play by watering, mulching, raking, and composting, and, more importantly, they taste foods as they grow directly from the garden plots, again with parental supervision. At home, plants can be grown in cups or pots on window sills, community plots, or backyards.
Water and mud play is a magnet to young children, offering simple opportunities to experiment with early earth science and chemistry concepts, to create rivers, streams, lakes, and bridges, and to concoct elaborate “mud meals.” Animal models indicate that interactions with certain bacteria present in clean soils may strengthen immune responses and support mental wellbeing.12 Families can enjoy mud play simply by setting up a couple of pots or tubs, one with water, one with soil or sand, and a spoon and cup. Waterworks play can be added by offering hollow tubes, such as bamboo or plastic tubing, and a funnel.
The Cutting Garden invites children to observe plant-pollinator relationships, participate in social practices of creating bouquets, and to delight in the sheer beauty of angiosperms-flowering plants. At markets or in fields, children can help choose objects of seasonal beauty, arranging and rearranging them for aesthetic and celebratory displays. Families can take walks past neighborhood or public gardens to observe the insect and wildlife visitors foraging from the flowering displays. And, of course, families may wish to grow their own flowering plants in containers, backyards, or community plots. For children, seeing the enormous plant that grows quickly from a single sunflower is a delight and a wonder.
Nature observation play is a flexible type of play that may include quiet observation such as butterfly or bird watching, or lively, active play such as trying to catch insects, fish, frogs, and tadpoles. Across the spectrum, this type of play invites children to surreptitiously develop attention and classification skills. Walks in local parks, nature trails, or simply the walk to school or bus stops, can offer opportunities to observe nature in many kinds of settings. A look at the night sky-available to all of us no matter where we are-offers the opportunity to observe discreetly and over time.
How to promote nature play
Given the demands of a busy pediatric practice and the growing list of anticipatory guidance items in routine pediatric visits, adding another task to the checklist may seem daunting. However, questions about nature play can be easily integrated with the questions that we all ask regarding safety, play, and physical activity. For infants, guidance about safe clothing and sun protection can be provided along with messages about the importance of being outside. Developmental screening questions about types of play in toddlers and preschoolers can be asked along with the location of such play-time indoors versus outdoors, and free versus directed play. School-aged children and adolescents should be encouraged to get 60 minutes of physical activity daily,13 and pediatricians should emphasize the added benefits that being outdoors may confer. Specific examples of anticipatory guidance from Bright Futures14 are listed in Table 2.
In addition to discussing nature play with parents and patients, pediatricians should consider promoting nature within their offices. One simple practice to promote nature is to decorate offices with photos and other artwork depicting the natural environment. Providing such natural scenes also may have some direct benefit for patients. One study in adults found that participants who viewed photographs of nature scenes had quicker autonomic function recovery following an acute psychologic stressor when compared with those who viewed scenes of the manmade built environment.15 Thus, decorating with such scenes may help children manage the stress of a doctor’s appointment as well as demonstrating that the pediatrician’s office values the natural environment.
Finally, pediatricians should be advocates for local nature areas and parks. In addition to the developmental and other health information handouts that usually are available for parents to browse in the examination and waiting rooms, offices should include lists of local parks and other opportunities for families to get outside. Such information could include maps of local hiking areas; information about local outdoor play groups; local, state, and national park educational activities; and summer camps for children.
Examples of national and international advocacy groups are listed in Table 3. Many of these organizations offer free downloadable handouts for parents promoting nature play. The possibilities are numerous, and having such information readily available in the office may also spark conversations about the importance of families and children being outdoors together.
1. Yogman M, Garner A, Hutchinson J, Hirsh-Pasek, Golinkoff RM; Committee on Psychosocial Aspects of Child and Family Health; Council on Communications and Media. The power of play: a pediatric role in enhancing development in young children. Pediatrics. 2018;142(3):e20182058.
2. Bravender T, Smith Bravender L. Expanding the definition of pediatric environmental health. Pediatr Res. May 11, 2019. Epub ahead of print.
3. Ladd HF. No child left behind: a deeply flawed federal policy. J Pol Anal Manage. 2017;36:461-469.
4. Dragoset L, Thomas J, Herrmann M, et al. Race to the Top: Implementation and Relationship to Student Outcomes (NCEE 2017-4001). Washington, DC: National Center for Education, Evaluation, and Regional Assistance, Institute of Education Sciences, U.S. Department of Education; 2016. Available at: https://files.eric.ed.gov/fulltext/ED569959.pdf. Accessed February 3, 2020.
5. Murray R, Ramstetter C; Council on School Health; American Academy of Pediatrics. The crucial role of recess in school. Pediatrics. 2013;131(1):183-188.
6. Razak LA, Yoong SL, Wiggers J, et al. Impact of scheduling multiple outdoor free-play periods in childcare on child moderate-to-vigorous physical activity: a cluster randomised trial. Int J Behav Nutr Phys Act. 2018;15(1):34.
7. Raney MA, Hendry CF, Yee SA. Physical activity and social behaviors of urban children in green playgrounds. Am J Prev Med. 2019;56(4):522-529.
8. Hunter MR, Gillespie BW, Chen SY. Urban nature experiences reduce stress in the context of daily life based on salivary biomarkers. Front Psychol. 2019;10:722.
9. Piccininni C, Michaelson V, Janssen I, Pickett W. Outdoor play and nature connectedness as potential correlates of internalized mental health symptoms among Canadian adolescents. Prev Med. 2018;112:168-175.
10. Beyer KM, Szabo A, Nattinger AB. Time spent outdoors, depressive symptoms, and variation by race and ethnicity. Am J Prev Med. 2016;51(3):281-290.
11. WÃ¤hrborg P, Petersson IF, Grahn P. Nature-assisted rehabilitation for reactions to severe stress and/or depression in a rehabilitation garden: long-term follow-up including comparisons with a matched population-based reference cohort. J Rehabil Med. 2014;46(3):271-276.
12. Reber SO, Siebler PH, Donner NC, et al. Immunization with a heat-killed preparation of the environmental bacterium Mycobacterium vaccae promotes stress resilience in mice. Proc Natl Acad Sci USA. 2016;113(22):E3130-E3139.
13. US Department of Health and Human Services. Physical Activity Guidelines for Americans. 2nd ed. Washington, DC: US Department of Health and Human Services; 2018.
14. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grover Village, IL: American Academy of Pediatrics; 2017.
15. Brown DK, Barton JL, Gladwell VF. Viewing nature scenes positively affects recovery of autonomic function following acute-mental stress. Environ Sci Technol. 2013;47(11):5562-5569.