Journal of Pediatric Nursing 37 (2017) 3–7

Contents lists available at ScienceDirect

Journal of Pediatric Nursing

Does Access to Green Space Impact the Mental Well-being of Children:

A Systematic Review
Rachel McCormick, MSN

a r t i c l e i n f o a b s t r a c t

Article history: Problem: An increasing body of research is showing associations between green space and overall health. Chil-
Received 14 April 2017 dren are spending more time indoors while pediatric mental and behavioral health problems are increasing. A
Revised 8 August 2017 systematic review of the literature was done to examine the association between access to green space and
Accepted 21 August 2017 the mental well-being of children.
Eligibility Criteria: Articles were limited to English language, ages 0–18 years, and publish date 2012–2017.
Keywords:
Sample: The search yielded 341 articles in Ovid, 81 in Pub Med and 123 in Scopus. Articles that were not original
Green space
Access
research and that were not a pediatric population were excluded. Twelve articles fit the selection criteria.
Mental health Results: Twelve articles relating to green space and the mental well-being of children were reviewed. Three arti-
Stress cles outside the date criteria were included as they are cited often in the literature as important early research on
Children this topic.
Conclusions: Access to green space was associated with improved mental well-being, overall health and cognitive
development of children. It promotes attention restoration, memory, competence, supportive social groups, self-
discipline, moderates stress, improves behaviors and symptoms of ADHD and was even associated with higher
standardized test scores.
Implications: Scientific evidence demonstrating the mental health benefits of access to nature for children can
guide policy and urban planning, while nursing interventions and initiatives can enhance health by promoting
outdoor play, educating patients and families, advocating for recess times and green environments at school as
well as healing gardens in hospital settings.
© 2017 Elsevier Inc. All rights reserved.

Background
There is a rapidly growing body of research examining the relation-
ship between green space and mental and physical well-being. Green
space is defined as “an area of grass, trees, or other vegetation set apart
for recreational or aesthetic purposes in an otherwise urban environ-
ment” (Oxford University Press, 2017). Green space has been associated
with health promoting benefits for adults and children including en-
hanced mood and self-esteem (Barton & Pretty, 2010), a buffer for daily
stress (Wells & Evans, 2003), greater self-discipline (Taylor, Kuo, &
Sullivan, 2002), lower levels of depression, anxiety and stress (Beyer et
al., 2014), improved mental and social health, increased physical activity
(Cox et al., 2017), reductions in violence and crime (Bogar & Beyer,
2016), and lowering health related inequalities (Mitchell & Popham,
2008). Literature suggests that developing access to nature could be an
important investment in the health and well-being of communities.
Recently, research has focused on the relationship between
green space and child development, mental well-being, behaviors and
cognition. In 2016, researchers from the Center for Disease Control re-
ported that one out of seven children in the United States ages two to
E-mail address: Rachmcc127@gmail.com.
eight years old suffers from a mental, behavioral, or developmental dis-
order (Bitsko et al., 2016). Disorders include attention-deficit/hyperac-
tivity disorder (ADHD), depression, anxiety problems, behavioral or
conduct problems, and learning or developmental delays. Evidence
that children are spending less time in nature than previous generations
(Clements, 2004) has prompted researchers to explore the connection
between exposure to green spaces and rising mental and behavioral
problems.
Children living in disadvantaged urban areas have a greater chance
of having an emotional disorder (Rudolph, Stuart, Glass, & Merikangas,
2014) and being diagnosed with depression/anxiety or ADHD/disrup-
tive behavior (Butler, Kowalkowski, Jones, & Raphael, 2012). At risk chil-
dren are more likely to live in neighborhoods that are in poor condition
without amenities such as sidewalks and libraries (Bitsko et al., 2016).
Children in deprived neighborhoods may lack access to green space
for a variety of reasons including long walking distances (Aggio,
Smith, Fisher, & Hamer, 2015) and parental safety concerns that keep
children inside (Clements, 2004).
In general, children are spending more of their free time indoors
with television, video games and computers (Arundell, Fletcher,
Salmon, Veitch, & Hinkley, 2016), but children who have to walk
N20 min to reach green space are watching greater than 2 hours more

http://dx.doi.org/10.1016/j.pedn.2017.08.027
0882-5963/© 2017 Elsevier Inc. All rights reserved.
4 R. McCormick / Journal of Pediatric Nursing 37 (2017) 3–7
television weekly than children living within a five minute walk from
green space (Aggio et al., 2015). A national study in 2010 reported
that children aged 8–18 spend an average of 7.5 hours daily in front of
media and in a typical week only 6% of children age 9–13 play outside
on their own (Rideout, Foehr, & Roberts, 2010). A sedentary lifestyle
places children at risk for obesity, asthma, ADHD and vitamin D defi-
ciency (McCurdy, Winterbottom, Mehta, & Roberts, 2010).
Environmental Inequality research has examined the relationship
between race and class-based inequalities including the disproportion-
ate concentration of pollution, waste, and toxic industries in minority
and impoverished communities (Brulle & Pellow, 2006; Downey &
Hawkins, 2008; Pastor, Sadd, & Hipp, 2001). Although some studies
do not find a difference in the total number or area of parks based
upon socioeconomic neighborhoods (Timperio, Ball, Salmon, Roberts,
& Crawford, 2007), public open spaces in higher socioeconomic com-
munities tend to have better amenities such as picnic tables, drinking
fountains, trees for shade, walking paths and lighting that may invite
more activity and usage (Crawford et al., 2008). Perception of neighbor-
hood safety can be an important factor in the willingness of a communi-
ty to access nature. Communities where members did not feel safe had
difficulty reaping the positive health benefits of green spaces (Weimann
et al., 2017). Knowledge of a rape or assault near a park has been shown
to decrease outdoor and green space physical activity (Ou et al., 2016).
Green space is an important social determinant of health as it is part
of “the conditions in which people are born, grow, live, work, and age”
(World Health Organization, 2017). A systematic review of the litera-
ture was undertaken to address the question: does access to green
space impact the mental well-being of children?
Methods
Ovid was searched using the term “green space” with the following
categories related to green space: city planning, environmental design,
residence characteristics, and urban health. This search yielded 75,904
results. This search was combined with “mental health” yielding 1107
results. The search was further limited to English language, humans
and children age 0–18 which yielded 341 results. Pubmed was searched
with the terms “green space” and “mental health” resulting in 81 arti-
cles. Scopus was searched with the terms “green space” and “mental
health” with a result of 123 articles.
Selection criteria for this review was original research published be-
tween 2012 and 2017 in English focusing on the mental well-being of
children in relation to access to green space. Three seminal studies dat-
ing back farther than five years were included (Kuo & Faber Taylor,
2004; Taylor et al., 2002; Wells & Evans, 2003). A total of 12 articles fit
the selection criteria (Table 1).
Results
The articles reviewed indicate that access to green space impacts the
mental well-being of children in a variety of ways. One qualitative study
found that students learning and playing in school areas such as wooded
playgrounds, natural habitats, and gardens were able to find relief from
stress, improve focus, build confidence and form supportive social
groups (Chawla, Keena, Pevec, & Stanley, 2014). The remaining 11 arti-
cles are quantitative research using a variety of surveys, tests and demo-
graphic information to measure mental well-being and cognitive
development in children in relation to access to green space. Overall
well-being and psychological distress were measured using the
Strengths and Difficulties Questionnaire (SDQ) in three studies finding
that high quality and quantity green space was associated with better
child well-being (Feng & Astell-Burt, 2017), less total difficulties, emo-
tional symptoms, and peer relationship problems (Amoly et al., 2014),
and a N20 min walk to green space was associated with worse mental
and overall health (Aggio et al., 2015).
Four studies examined the impact of exposure to green space on at-
tention restoration, attention deficit/hyperactivity disorder (ADHD),
and behavior problems. High school greenness was found to contribute
to student perception of restoration (Akpinar, 2016), green outdoor set-
tings were found to reduce the symptoms of inattention and hyperac-
tivity in children diagnosed with ADHD (Kuo & Faber Taylor, 2004),
and an inverse relationship was found between residential greenness
and ADHD/DSM-IV total and inattention scores (Amoly et al., 2014).
Poor access to urban green space was associated with behavior prob-
lems most consistent with hyperactivity and inattention in ten-year-
old children (Markevych et al., 2014), and children performed better
on attention tasks and spatial working memory after a walk in nature
compared to a walk in an urban landscape (Schutte, Turquati, &
Beattie, 2017).
A 12-month study measuring working memory, superior working
memory and inattentiveness in seven to ten-year-old children revealed
a beneficial association between exposure to green space and cognitive
development (Dadvanda et al., 2015). This study employed the use of a
high-resolution satellite to determine amount of local green space rath-
er than parental reporting. Additionally, the researchers have made a
link between improved cognitive development, greater amounts of
green space and reduced exposure to air pollution (Dadvanda et al.,
2015). There may be other benefits from green neighborhoods on the
environment and overall health of communities that deserve further ex-
ploration. Data from 905 Massachusetts public schools were collected
between 2006 and 2012 revealing a consistent positive association be-
tween “greenness” of schools and performance in English and Math
on standardized tests (Wu et al., 2014). Again, data on greenness near
schools was collected via satellite from NASA's Earth Observing System.
Three studies prior to 2012 have been included in this review as they
are often cited in the literature as important early research on the topic
of green space and the mental well-being of children. The 2004 article
by Kuo and Faber Taylor was the first nation-wide study exploring
green outdoor settings as a potential treatment for ADHD. Research on
the attention restoration benefits of nature for individuals with and
without the diagnosis of ADHD has increased following the publication
of this study. Much attention is paid to the importance of urban green
space, but in 2003, Wells & Evans found that nature was vital in moder-
ating the impact of stressful life events on rural children as well. Addi-
tionally, Taylor, Kuo, & Sullivan published in 2002 that a view of green
space outside the homes of inner city girls living in deprived neighbor-
hoods can increase self-discipline as measured by tests of concentration,
impulse control and delayed gratification. Self-disciple is an important
quality for inner-city youth who are at a high risk for academic prob-
lems, teenage pregnancy and drug abuse.
Discussion
The results indicate that access to green space is important to the
mental well-being, overall health and cognitive development of chil-
dren. It promotes attention restoration, moderates the impacts of stress,
improves behaviors and symptoms of ADHD and was even associated
with higher standardized test scores. Children living in high risk neigh-
borhoods and under stressful conditions need to be given more oppor-
tunities to interact with nature. Research examined the amount of green
space near the home and in the school setting and both were found to
be beneficial for children.
Schools are important environments to assess for quantity and
quality of green space as children spend a large amount of time in
these settings. Increased emphasis on academic subjects and stan-
dardized testing has caused many public schools to decrease recess
times (American Academy of Pediatrics, 2013). Physical Activity
Guidelines for Americans established by the Department of Health
and Human Services, recommend 20 min daily for recess and
150 min/week of Physical Education (PE) (US Department of Health
and Human Services, 2009). The odds of schools having 150 hours/
 R. McCormick / Journal of Pediatric Nursing 37 (2017) 3–7
Table 1
Citation Population
(Aggio et al., 2015) 3586 children
(average age 5.9 years)
(Akpinar, 2016) 223 high school students
age 12–20 years
(Amoly et al., 2014) 2111 schoolchildren
(age 7–10 years) from
36 Barcelona schools
(Chawla et al., 2014) Children in 6 locations: young
elementary school children's play
in wooded areas during recess;
older elementary school children's
use of a naturalized habitat for
science and writing lessons; and
high school students' involvement
in gardening
(Dadvanda et al., 2015) 2593 children (7–10 years)
from 36 Barcelona schools
(Feng & Astell-Burt, 2017) 3083 children (12–13 years)
and their parents and teachers
(Kuo & Faber Taylor, 2004) 452 guardians of children
age 5–18 years diagnosed
with ADHD
(Markevych et al., 2014) 1932 ten-year-old children
(Schutte et al., 2017) 34 seven to eight year-olds
and 33 four to five year-olds
(Taylor et al., 2002) 169 inner-city boys and girls
(Wells & Evans, 2003) 337 children (mean age 9.2 years)
(Wu et al., 2014) Data from 905 Massachusetts
public schools collected between
2006 and 2012 (n = 6333)
week of PE or 20 min daily of recess increased if they were located in
states or school districts that had laws or policies requiring this time
commitment. However, time spent in recess was found to be inversely
related to time spent in PE and vice versa indicating that schools are
most likely substituting one form of physical activity for another
(Slater, Nicholson, Chriqui, Turner, & Chaloupka, 2012). These results
are troubling given the findings that time in nature can restore
Methods
Caregivers questioned on walking distance to park
(in minutes), hours of TV time per week and
psychological distress of children was measured by
the Strengths and
Difficulties questionnaire (SDQ)
Measures-Attention Restoration Theory
components (i.e. being away, fascination,
coherence, and compatibility), naturalness of
school greenness, and health indicators
(i.e. stress, mental health, physical health,
and quality of life).
Survey and Strengths and Difficulties Questionnaire
(SDQ) by parents and ADHD/DSM-IV
questionnaire for teachers
Qualitative: Observation and Student Interviews
12-month cognitive development in working
memory, superior working memory and
inattentiveness measured every three months
via computerized cognitive tests. Green space
exposure measured via high resolution satellite
Goodman's strengths and difficulties questionnaire,
General Health Questionnaire, Warwick-Edinburgh
Mental Well Being Scale, Answered by children,
parents and teachers
Survey, demographic questionnaire
GINIplus and LISAplus strengths and difficulties
questionnaire
Activity to fatigue attention followed by a nature
walk and an urban walk. After each walk, children
completed assessments on working memory,
inhibitory control and attention
Parent ratings of the naturalness of the view
from home
Tests of concentration, impulse inhibition,
and delay of gratification
Survey and Interview
Standardized test scores of 3rd grade students
The amount of trees and vegetation (“greenness”)
in the vicinity of schools was obtained via
satellite from NASA's Earth Observing System data
attention, buffer stress, improve behaviors and decrease symptoms of
ADHD. Evaluating the quality of recess environments is also important.
Indoor and blacktop playgrounds are not green space and do not afford
children the same benefits as natural settings. Despite longer times
spent on academic subjects, teachers may find themselves expending
large amounts of energy dealing with distracting behaviors and children
with attention fatigue.
5
Findings
-Children N20 min walk to green space had worse
mental health per SDQ scores, had worse general
health, were of lower socioeconomic group and
watched over 2 hours more television than children
living b5 min walk to green space
-High school greenness contributes to students'
perceived restoration. Younger students reported
better health and quality of life with more green
space at school.
-Inverse association between green space
playing time and SDQ total difficulties, emotional
symptoms, and peer relationship problems
-Inverse relationship between residential greenness
and SDQ total difficulties and ADHD/DSM-IV
total and inattention scores
-Natural areas enabled students to escape stress,
focus, build competence, and form
supportive social groups
-Beneficial association between exposure to green
space and cognitive development among
schoolchildren partly mediated by reduction in
exposure to air pollution.
-High green space quantity and quality
associated with better child well-being on
all three measures regardless of informant
-Associations with green space quantity only
significant for parent reported total difficulties
and internalized subscale
-Associations with green space quality noted
with parent and child reported outcomes
-Green outdoor settings appear to reduce
ADHD symptoms
-Poor access to urban green space was associated
with behavioral problems, most consistent with
hyperactivity/inattention
-Children performed faster on attention task
after nature walk
-School age children performed significantly
better on attention task than preschoolers
after nature walk
-Preschoolers had more stable spatial working
memory after nature walk
-A view of green space directly outside the home
can increase self-discipline in girls
-Nature moderates the impact of stressful life
events in rural children
-Consistently positive significant association
between the greenness of the school in the
spring and school-wide performance on both
English and Math tests.
6 R. McCormick / Journal of Pediatric Nursing 37 (2017) 3–7
Adult studies are improving understanding of how the body and
mind reacts to green space and can inform future pediatric research. A
2011 study in an impoverished urban setting found that salivary cortisol
levels varied in relation to exposure to green space in the living environ-
ment (Ward Thompson et al., 2012). The secretion of cortisol is impor-
tant in regulating circadian rhythm. The largest concentration of cortisol
is found shortly after awakening and this amount declines steeply
throughout the day. A disrupted secretion pattern is indicative of chron-
ic stress and is associated with poor mental health. A positive correla-
tion was found between the decline in cortisol throughout the day
and the percentage of green space (Ward Thompson et al., 2012). This
study is significant because it has identified a biomarker that can be eas-
ily sampled to explore the effects of environment on chronic stress and
mental health through quantitative measurements.
Advances in neuroscience technology have allowed researchers to
explore the physiologic impact of nature on brain activity though func-
tional magnetic resonance imaging (fMRI) (Tang et al., 2017). Partici-
pants viewed different environments: urban, mountain, forest and
water while in an fMRI scan. Water and mountain landscapes had the
most restorative benefits as shown by a rest in brain activity. Viewing
urban scenes activated the attention and visual areas of the brain and
participants showed a diminished ability to recover from fatigue. Simply
using photographs of natural and urban settings, the fMRI detected dif-
ferences in brain activity (Tang et al., 2017). The population for this
study was young men and women 20–30 years old. Further studies
that involve children can expand these findings to pediatrics and may
have implications for decorating classrooms and improving windows
views.
Limitations and Future Research
Data from quantitative studies was collected from a variety of
sources such as parents, teachers and children. Additionally, many
tools and instruments were used to collect data. Comparing heteroge-
neous measurements in research can be difficult to synthesize. One
study attempted to address this problem by administering three differ-
ent types of questionnaires (SDQ, the General Health Questionnaire, and
Warwick-Edinburgh Mental Well-Being Scale) with parents, teachers
and children (Feng & Astell-Burt, 2017). High quality and quantity of
green space was associated with better child well-being on all three
measures and with all three informants. Some differences were noted
between informants. For example, green space quantity was only signif-
icant for parent reported total difficulties (Feng & Astell-Burt, 2017). Fu-
ture research could be enhanced by exploring the differences between
informant responses and the scales/questionnaires that are used for
measurement. While these differences can be seen as a limitation in
comparing literature, they may also be viewed as a strength. Using a va-
riety of measurements and methods, all studies showed either a positive
association with green space and the mental well-being of children or
an association between reduced access to nature and negative mental
and general health.
An area for future growth is examining specific biomarkers in chil-
dren in relation to time spent in green space. Adult research has studied
the impact of green space on salivary cortisol levels and brain activity.
Other measures could be blood pressure, heart rate, and temperature.
No studies were found in this literature search that examined bio-
markers in children.
The question of time in green space for children is also worth further
exploration in research. Is there an optimal amount of time that helps to
promote restoration of attention, reduction of problem behaviors, and
hyperactivity? Adult literature indicates that small doses of nature are
beneficial in promoting self-esteem and mood even in five-minute du-
rations (Barton & Pretty, 2010). Research on this topic for children can
help to guide school policies on recess times. Perhaps multiple outdoor
breaks throughout the day will help to improve attention and
distracting behaviors, making class-time more productive.
Implications for Nursing Practice
Research on the importance of green space for the mental well-being
of children is applicable to all nurses who encounter pediatric patients
in their practice. Nurses in public health, policy making, and urban plan-
ning can use the evidence to advocate for initiatives that improve access
to green space in at risk neighborhoods and schools. Both inpatient and
outpatient nurses can include access to green space in their assessment
of social determinants of health. Asking children if they have a safe place
to play is an important part of their psychosocial assessment. If the an-
swer is “no”, then nurses can help the patient and family to brainstorm
alternatives such as a weekend trip to the park, a small family garden, or
some potted plants on the windowsill. Urban community gardens are
growing in popularity and are a way for children to connect with their
food sources, learn stewardship and experience the positive effects of
green space in their daily lives (Cairns, 2017).
Primary care pediatricians have piloted studies giving prescriptions
to children to spend time in nature and engage in outdoor play
(Christiana, Battista, James, & Bergman, 2017; Coffey & Gauderer,
2016). The outdoor prescription studies have given healthcare pro-
viders the opportunity to open a conversation about the importance of
contact with nature and outdoor play. In the Park Rx study in Vermont,
a partnership was formed between the state parks department, the
State University Department of Nursing and the state chapter of the
American Academy of Pediatrics (Coffey & Gauderer, 2016). The park
prescriptions doubled as a free day pass to a Vermont State Park.
Understanding the benefits of green space on overall well-being and
stress reduction, inpatient nurses and hospital administrators can advo-
cate for healing gardens within hospitals. Patients who do not have any
contraindications should be encouraged to visit inpatient gardens when
available. Nurses working in neurodevelopment and psychology who
often encounter children with ADHD and behavioral problems can uti-
lize their knowledge of the benefits of green space by educating patients
and families, encouraging outdoor study breaks and perhaps moving
some therapies outdoors.
School nursing can take an active role in advocating for natural
grounds for outdoor play, insisting on at least 20 min daily of re-
cess per the American Academy of Pediatrics Policy Statement
(American Academy of Pediatrics, 2013), and influencing educa-
tors to attempt outdoor learning and gardening. Natural outdoor
experiences were proven beneficial in the subjects of science
and creative writing in this review (Chawla et al., 2014), and can
easily be expanded to classes such as art, health and history.
Classrooms can be decorated with indoor plants and images of na-
ture that promote restoration. Windows can provide views of
trees and vegetation.
Collaborating with multiple disciplines and stakeholders will be es-
sential in implementing initiatives and conducting future research on
the benefits of green space for children. A variety of professionals have
been engaged in research on this topic from education, public health, so-
ciology, environmental science, urban planning, and medicine. Barriers
to accessing green space, and unequal distribution of quantity and qual-
ity of this resource deserves further exploration. Longitudinal studies
can be designed to examine green space in relation to the development
of resilience in children. Nursing is well positioned to bridge the gap and
promote a multidisciplinary approach to addressing this important so-
cial determinant of health.
Conclusion
This systematic review indicated that there is a positive association
between access to green space and the mental well-being of children.
Nurses can advocate for polices that promote greater quantity and qual-
ity of green space and encourage open dialog between patients and pro-
viders. Research can inform practice for patients diagnosed with ADHD
and behavioral problems and school nurses can influence school
 R. McCormick / Journal of Pediatric Nursing 37 (2017) 3–7
environments and recess times. Longitudinal studies may be beneficial
in understanding resilience in youth and changes in relationships to
green space over time. The concept of a “dose” of nature for children
needs to be further explored and research that measures objective bio-
markers such as salivary cortisol levels and brain activity can add to the
current literature.
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