ADHD and Restoration Theory

ADHD and Attention Restoration Theory

ADHD affects approximately 5% of the global population (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007). Although ADHD can have a broad range of effects on the individual, the DSM-IV (American Psychiatric Association, 2000) names only inattention (in ADD) and impulsivity/hyperactivity (in ADHD) as criteria for diagnosis (see appendix for complete DSM-IV clinical diagnostic criteria). Also, it is expected that many students with ADHD symptoms will have overlapping co-morbidities, such as dyslexia, Sensory Integration Disorder, and other SpLDs (approximately 70%, according to Mayes, Calhoun, & Crowell, 2000).

Although current recommendations for classroom environment (Barkley, 2006; Carbone, 2001) are based on early research indicating that children with ADHD learn better in a quiet, highly structured environment with as few distractions as possible (Greenewald & Walsh, 1996; Harrell, 1996; Weinstein, 1976; Whalen, Henker, Collins, Finck, & Dotemoto, 1979), new evidence suggests that exposure to green outdoor environments reduces symptoms of ADHD (Kuo & Taylor, 2004; Taylor & Kuo, 2011 and 2006; Taylor, Kuo, & Sullivan, 2001).

The detrimental effects of stress on memory is well-documented (Abercrombie, Kalin, Thurow, Rosenkranz, & Davidson, 2003; Elzinga, Bakker, & Bremner, 2005; Newcomer et al., 1999). Studies on the environmental effects on children with ADHD are founded upon research begun on adults in 1979 and continuing into the present collectively finding that exposure to natural settings reduces stress and negative emotion in adults (Hartig, Mang, & Evans, 2003; Herzog & Strevey, 2008; Ulrich, 1979; van den Berg, Hartig, & Staats, 2007). Building upon these findings, psychologists Kaplan and Kaplan developed Attention Restoration Theory (ART), which is based on the idea that natural environments enhance mental functioning. Wells and Evans (2003) explain this phenomenon as such:

…exposure to nature bolsters one’s cognitive resources by allowing neural inhibitory mechanisms to rest and recover from use…A person whose attention resources have been restored will be able to inhibit the urge to respond to potentially distracting stimuli, able to focus attention, and able to more effectively manage the challenges of daily life (p. 325).

While the cognitive underpinnings of ART are unclear, its effects have been validated numerous times. In 1991, Hartig, Mang, and Evans found in a controlled study that university students engaged in a nature walk (versus an urban walk or relaxation) before performing cognitive tasks had better attentional performance. The authors attributed the results to the ability of natural environment to facilitate recovery from mental fatigue. Similarly, in studying inner-city residents, Kuo (2001) found that attentional performance is systematically higher in individuals living in greener surroundings.

A 1995 study by Tennessen and Cimprich showed that university dormitory residents with more natural views from their windows scored significantly better than those with less natural views on tests of directed attention.  Likewise, in research by Berto (2005), participants exposed to photographs of natural environments (as opposed to built environments or geometrical patterns) improved their performance on attention tests. Berman and Kaplan (2008) conducted two experiments showing, respectively, that walking in nature and viewing pictures of nature can improve directed attention. These studies indicate that even viewing natural environments has a restorative effect on attentional performance. However, Fuller and colleagues (Fuller, Irvine, Devine-Wright, Warren, & Gaston, 2007) determined that the psychological benefits of immersion in a natural environment increased with levels of species richness so that increased biodiversity or biological complexity resulted in increased levels of cognitive restoration.

Additional evidence includes a 2006 study by Gulwadi on how teachers prefer to lower vocational stress found that proximity to or immersion in natural environments was an effective strategy for dealing with the stresses of the teaching profession. Mayer and colleagues (Mayer, Frantz, Bruehlman-Senecal, & Dolliver, 2009) found that exposure to nature resulted in increased connectedness to nature, attentional capacity, positive emotions, and ability to reflect on a life problem. Conversely, a 2011 study in Germany (Lederbogen, et al.) used fMRI to show that urban residents handled stress differently than rural residents, and that an urban upbringing negatively impacted neuronal connectivity in areas of the brain related to memory and stress processing.

Kaplan and Berman (2010) offer a cognitive explanation of ART via its relationships to executive functioning and self regulation, the mechanisms involved in decision-making and impulse control, respectively:

Research on executive functioning and on self-regulation have each identified a critical resource that is central to that domain and is susceptible to depletion. In addition, studies have shown that self-regulation tasks and executive-functioning tasks interact with each other, suggesting that they may share resources. Other research has focused specifically on restoring what we propose is the shared resource between self-regulation and executive functioning. Utilizing a theory-based natural environment intervention, these studies have found improvements in executive-functioning performance and self-regulation effectiveness, suggesting that the natural environment intervention restores this shared resource (p. 1207).

While the majority of ART research has been directed toward adults, a number of studies in the past decade indicate an improvement in children’s cognitive performance as a function of exposure to nature. In 2000, Wells found that following relocation, children whose homes improved the most in terms of greenness also tended to have the highest levels of cognitive functioning following the move.  A 2002 study by Taylor, Kuo, and Sullivan found that for girls, green space immediately outside the home “helped them lead more effective, self-disciplined lives.” Wells and Evans (2003) also found that for children living in a rural setting, levels of nearby nature moderate the psychological impacts of stressful life events. A 2008 study by Matsuoka found that high schools with greater quantities of natural features near classroom and cafeteria windows were related to higher standardized test scores, graduation rates, and percentages of students planning to attend college. Also, schools that allowed students to eat lunch outdoors were associated with enhanced test scores and college plans. A 2000 study looked at California schools utilizing Environment as an Integrated Concept for Learning (EIC), designated as “using a school’s surroundings and community as a framework within which students can construct their own learning, guided by teachers and administrators using proven educational practices.” Results indicated “better performance on standardized measures of academic achievement in reading, writing, math, science, and social studies; reduced discipline and classroom management problems; increased engagement and enthusiasm for learning; and greater pride and ownership in accomplishments” (Lieberman, 2000).

In 2001, Taylor, Kuo, and Sullivan presented the first evidence that ART applies to both adults with normal attentional functioning and children with ADHD.  Results of their study indicate that “children function better than usual after activities in green settings and that the ‘greener’ a child’s play area, the less severe his or her attention deficit symptoms.” Additional research by Kuo and Taylor in 2004 found that green outdoor activities reduced ADHD symptoms significantly more than did activities conducted in other settings, based on parent reports. A 2011 study in the Netherlands found that children with ADHD performed better on a concentration test in a rural rather than an urban environment (van dan Berg & van dan Berg, 2011).

Furthermore, a 2009 study by Taylor and Kuo showed that children with ADHD performed better on Digit Span Backwards (a common measurement of working memory) after a 20-minute walk in a park than in either of two urban environments. The difference between the two groups was substantial – equivalent both to the difference between ADHD and non-ADHD children, as well as to the difference between ADHD children experiencing the peak effects of extended-release methylphenidate and non-medicated ADHD children. Another study in 2011 by Taylor and Kuo found that “children with ADHD who play regularly in green play settings have milder symptoms than children who play in built outdoor and indoor settings.”

Kuo and Taylor (2004) propose an explanation for how ART might be related to potential improvement in ADHD for children:

              In non-ADHD populations, the right prefrontal cortex has been implicated in both the capacity to deliberately direct attention and the presence of attention fatigue. A number of studies have produced evidence of a right frontal–cortical locus of attention control (Coull et al., 1998; Marshall et al., 1995) and another has shown that the right prefrontal cortex is subject to fatigue after sustained demands on directed attention (Glosser & Goodlass, 1990). Correspondingly, the right prefrontal cortex 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 (Casey et al., 1997; Filipek et al., 1997; Heilman et al., 1991; Hynd et al., 1990) and severity of ADHD symptoms has been shown to be proportional to degree of asymmetry between left and right prefrontal cortex regional cerebral blood flow (Langleben, 2001). Thus, it may be that attention fatigue and ADHD represent different problems in the same underlying mechanism (p. 1581).

(the above text is from a section of the literature review of a graduate thesis titled “The Green School Effect” on Students with Specific Learning Differences by Jennipher Spector)

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