General

Guideline Title

Best evidence statement (BESt). Horticultural therapy for children and adolescents in residential treatment for mental health.

Bibliographic Source(s)

Cincinnati Children’s Hospital Medical Center. Best evidence statement (BESt). Horticultural therapy for children and adolescents in residential treatment for mental health. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2013 Feb 19. 5 p. [5 references]

Guideline Status

This is the current release of the guideline.

Recommendations

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a‒5b) are defined at the end of the “Major Recommendations” field.

It is recommended that horticultural therapy be provided for children and adolescents with mental health diagnosis to decrease depression (Gonzalez et al., 2011 [3b]; Gonzalez et al., 2010 [4a]; Cassidy, 1996 [4b]) and increase self-esteem (Local Consensus [5]).
There is insufficient evidence to make a recommendation regarding the effects of horticultural therapy on aggression in children with mental health diagnosis.

Note : Horticulture Therapy does not change or decrease active aggressive episodes. Children display fewer aggressive episodes while in horticulture therapy.

Definitions:

Table of Evidence Levels

Quality Level	Definition
1a† or 1b†	Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b	Best study design for domain
3a or 3b	Fair study design for domain
4a or 4b	Weak study design for domain
5a or 5b	General review, expert opinion, case report, consensus report, or guideline
5	Local Consensus

†a = good quality study; b = lesser quality study

Table of Recommendation Strength

Strength	Definition
It is strongly recommended that… It is strongly recommended that… not…	When the dimensions for judging the strength of the evidence are applied, there is high support that benefits clearly outweigh risks and burdens. (or visa-versa for negative recommendations)
It is recommended that… It is recommended that… not…	When the dimensions for judging the strength of the evidence are applied, there is moderate support that benefits are closely balanced with risks and burdens.
There is insufficient evidence and a lack of consensus to make a recommendation…

Note : See the original guideline document for the dimensions used for judging the strength of the recommendation.

Clinical Algorithm(s)

None provided

Scope

Disease/Condition(s)

Mental health disorders

Guideline Category

Management
Treatment

Clinical Specialty

Family Practice
Internal Medicine
Pediatrics
Psychiatry
Psychology

Intended Users

Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians

Guideline Objective(s)

To evaluate, among children and adolescents ages 8-18 years with mental health diagnosis, if participation in horticultural therapy compared to no participation in horticultural therapy decreases aggression and depression and increases self-esteem

Target Population

Children and adolescents, 8-18 years of age who are diagnosed with a mental health disorder; in residential treatment at a mental health facility

Note : Children and adolescent, 8-18 years of age in residential treatment at a mental health facility; who do not meet established criteria for on grounds activities are excluded from these recommendations.

Interventions and Practices Considered

Horticultural therapy

Note : The American Horticultural Therapy Association (AHTA) defines Horticultural Therapy as the engagement of a client in horticultural activities facilitated by a trained therapist to achieve specific and documented treatment goals.

Major Outcomes Considered

Aggression and aggressive episodes
Depression
Self-esteem
Patient and family satisfaction

Methodology

Methods Used to Collect/Select the Evidence

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Search Strategy

Databases : Medline, PubMed, CINAHL, PsycInfo, Cochrane Library
Search Terms : Depression, Horticultural Therapy, Mental Health, Psychiatry, horticulture, children, residential treatment, long-term, mental health treatment, activities, self-esteem, aggression, leisure activities and gardening.
Limits, Filters, Search Dates : 1987-2012 English
Date last search done : August 17, 2012

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level	Definition
1a† or 1b†	Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b	Best study design for domain
3a or 3b	Fair study design for domain
4a or 4b	Weak study design for domain
5a or 5b	General review, expert opinion, case report, consensus report, or guideline
5	Local Consensus

†a = good quality study; b = lesser quality study

Methods Used to Analyze the Evidence

Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Table of Recommendation Strength

Strength	Definition
It is strongly recommended that… It is strongly recommended that… not…	When the dimensions for judging the strength of the evidence are applied, there is high support that benefits clearly outweigh risks and burdens. (or visa-versa for negative recommendations)
It is recommended that… It is recommended that… not…	When the dimensions for judging the strength of the evidence are applied, there is moderate support that benefits are closely balanced with risks and burdens.
There is insufficient evidence and a lack of consensus to make a recommendation…

Note : See the original guideline document for the dimensions used for judging the strength of the recommendation.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

This Best Evidence Statement has been reviewed against quality criteria by two independent reviewers from the Cincinnati Children’s Hospital Medical Center (CCHMC) Evidence Collaboration.

Evidence Supporting the Recommendations

References Supporting the Recommendations

Cassidy T. All work and no play: a focus on leisure time as a means for promoting health. Council Psychol Q. 1996;9(1):77-90.
Gonzalez MT, Hartig T, Patil GG, Martinsen EW, Kirkevold M. A prospective study of group cohesiveness in therapeutic horticulture for clinical depression. Int J Ment Health Nurs. 2011 Apr;20(2):119-29. PubMed
Gonzalez MT, Hartig T, Patil GG, Martinsen EW, Kirkevold M. Therapeutic horticulture in clinical depression: a prospective study of active components. J Adv Nurs. 2010 Sep;66(9):2002-13. PubMed

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the “Major Recommendations” field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Decrease aggression and depression
Increase self-esteem

Potential Harms

Not stated

Qualifying Statements

This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Implementation of the Guideline

Description of Implementation Strategy

Applicability Issues

There are potential safety concerns when engaging in outside activities with children and adolescents in residential treatment. Client’s history of high risk behavior and risk of elopement should be assessed prior to participation.
An important element in this process is properly identifying clients for outside activities by utilizing residential psychiatry resources, such as an On Grounds Activity Planning Decision Tree.
A formalized procedure should be used to evaluate client’s interest, attitude, conflicting behaviors, aggression and mental status, such as an Elopement Risk Assessment.
Client and staff safety should be considered by providing adequate staffing in accordance to client needs and risk assessment.
Weather can also be a factor for outside activities.
Available resources and supplies can also be a barrier for effective horticultural therapy programs, such as inadequate gardening and activity materials and space. Adequate supplies aid in fascination and enhance clients’ interest, which may increase their attention to task and eliminate distractive behaviors.
Horticultural Therapy can be a labor and cost intense program, funding may be an issue. Development and continuation maybe funded by donations and or grant funding.

Implementation Tools

Audit Criteria/Indicators

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better
Living with Illness

IOM Domain

Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)

Cincinnati Children’s Hospital Medical Center. Best evidence statement (BESt). Horticultural therapy for children and adolescents in residential treatment for mental health. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2013 Feb 19. 5 p. [5 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2013 Feb 19

Guideline Developer(s)

Cincinnati Children’s Hospital Medical Center - Hospital/Medical Center

Source(s) of Funding

Cincinnati Children’s Hospital Medical Center

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Team Leader/Author : Tyra Warner, BS, CTRS, Division of OT/PT/TR in Psychiatry, TRII

Ad hoc Members : Margie Hay, Certificate in Horticultural Therapy, Certified Landscape Technician, Master Gardner, Gardner II Division of Psychiatry

Senior Clinical Director : Rebecca D. Reder OTD, OTR/L, Division of Occupational Therapy and Physical Therapy

Support/Consultant : Mary Ellen Meier MSN, RN, CPN; Center for Professional Excellence and Integration

Ad hoc Advisors : Matt Schwendeman MHSA, OTR/L, Division of OT/PT/TR in Psychiatry; Mary Gilene, MBA, Division of Occupational Therapy and Physical Therapy

Financial Disclosures/Conflicts of Interest

Conflict of interest declaration forms are filed with the Cincinnati Children’s Hospital Medical Center Evidence-based Decision Making (CCHMC EBDM) group. No financial or intellectual conflicts of interest were found.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Available from the Cincinnati Children’s Hospital Medical Web site.

Availability of Companion Documents

The following are available:

Judging the strength of a recommendation. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2008 Jan. 1 p. Available from the Cincinnati Children’s Hospital Medical Center.
Grading a body of evidence to answer a clinical question. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 1 p.
Table of evidence levels. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2008 Feb 29. 1 p. Available from the Cincinnati Children’s Hospital Medical Center.

In addition, suggested process or outcome measures are available in the original guideline document.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on May 22, 2013.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of this Cincinnati Children’s Hospital Medical Center (CCHMC) Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:

Copies may be provided to anyone involved in the organization’s process for developing and implementing evidence based care.
Hyperlinks to the CCHMC website may be placed on the organization’s website.
The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents.
Copies may be provided to patients and the clinicians who manage their care.

Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is appreciated.

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