The ecology of change in outdoor therapy (ECO-Therapy) model: A preliminary theoretical framework for nature-based pediatric occupational therapy practice


May 2023

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The vital childhood occupation of outdoor play in nature is on the decline in industrialized societies around the world. Ubiquitous technology use, sedentarism, over-protective parenting, and urbanization have caused a mass human migration to indoor lifestyles characterized by a lack of connection to the outdoors. This disconnection from nature has profound implications for children because contact with nature has myriad benefits for children’s physical health and emotional well-being throughout life. Re-connecting children to nature may support improved occupational participation and performance. Occupational therapy practitioners are beginning to take their work with children outdoors into nature, but a unifying model or theoretical framework incorporating nature does not yet exist in the field of occupational therapy. The purpose of this qualitative constructivist grounded theory study was to develop a theoretical model to illustrate the process of nature-based pediatric occupational therapy, based on analysis of the perspectives of occupational therapy practitioners currently engaging in nature-based pediatric practice with children ages 0–12 years. Twenty-seven photos and 23.5 hours of interview data were analyzed. The developed theory, the Ecology of Change in Outdoor Therapy (ECO-Therapy) Model, is a preliminary interpretive explanation of the causal conditions, contextual elements, and relationships between primary actors in the nature-based pediatric occupational therapy process. The ECO-Therapy Model proposes the core mechanism of change in nature-based occupational therapy intervention involves practitioners and children braving real-life challenges outdoors together as an impetus for growing adaptive capacity, leading to improved occupational participation and performance in daily life. As a constructivist grounded theory, the ECO-Therapy Model is an interpretive theoretical analysis representative only of this sample of participants in this socio-cultural context at this historical moment in time. Future research may test and refine the ECO-Therapy Model to assess applicability in other contexts, both within and outside of the field of occupational therapy.



Occupational therapy for children, Nature-based therapy, Outdoor recreation for children with disabilities