Green Space and Internalizing or Externalizing Symptoms among Children

Nissa Towe-Goodman, Kristen L. McArthur, Michael Willoughby, Margaret M. Swingler, Cara Wychgram, Allan C. Just, Itai Kloog, Deborah H. Bennett, Daniel Berry, Marnie F. Hazlehurst, Peter James, Marcia Pescador Jimenez, Jin Shei Lai, Leslie D. Leve, Lisa Gatzke-Kopp, Julie B. Schweitzer, Traci A. Bekelman, Catrina Calub, Susan Carnell, Sean DeoniViren D'Sa, Carrie Kelly, Daphne Koinis-Mitchell, Michael Petriello, Gita Thapaliya, Rosalind J. Wright, Xueying Zhang, Amii M. Kress

Research output: Contribution to journalArticlepeer-review


Importance: Evidence suggests that living near green space supports mental health, but studies examining the association of green space with early mental health symptoms among children are rare. Objective: To evaluate the association between residential green space and early internalizing (eg, anxiety and depression) and externalizing (eg, aggression and rule-breaking) symptoms. Design, Setting, and Participants: Data for this cohort study were drawn from the Environmental Influences on Child Health Outcomes cohort; analysis was conducted from July to October 2023. Children born between 2007 and 2013 with outcome data in early (aged 2-5 years) and/or middle (aged 6-11 years) childhood who resided in 41 states across the US, drawing from clinic, hospital, and community-based cohorts, were included. Cohort sites were eligible if they recruited general population participants and if at least 30 children had outcome and residential address data to measure green space exposure. Nine cohorts with 13 sites met these criteria. Children diagnosed with autism or developmental delay were excluded, and 1 child per family was included. Exposures: Green space exposure was measured using a biannual (ie, summer and winter) Normalized Difference Vegetation Index, a satellite image-based indicator of vegetation density assigned to monthly residential history from birth to outcome assessment. Main Outcome and Measures: Child internalizing and externalizing symptoms were assessed using the Child Behavior Checklist for Ages 1½ to 5 or 6 to 18. The association between green space and internalizing and externalizing symptoms was modeled with multivariable linear regression using generalized estimating equations, adjusting for birthing parent educational level, age at delivery, child sex, prematurity, and neighborhood socioeconomic vulnerability. Models were estimated separately for early and middle childhood samples. Results: Among 2103 children included, 1061 (50.5%) were male; 606 (29.1%) identified as Black, 1094 (52.5%) as White, 248 (11.9%) as multiple races, and 137 (6.6%) as other races. Outcomes were assessed at mean (SD) ages of 4.2 (0.6) years in 1469 children aged 2 to 5 years and 7.8 (1.6) years in 1173 children aged 6 to 11 years. Greater green space exposure was associated with fewer early childhood internalizing symptoms in fully adjusted models (b = -1.29; 95% CI, -1.62 to -0.97). No associations were observed between residential green space and internalizing or externalizing symptoms in middle childhood. Conclusions and Relevance: In this study of residential green space and children's mental health, the association of green space with fewer internalizing symptoms was observed only in early childhood, suggesting a sensitive period for nature exposure. Policies protecting and promoting access to green space may help alleviate early mental health risk.

Original languageEnglish
Pages (from-to)E245742
JournalJAMA network open
Issue number4
StatePublished - 10 Apr 2024
Externally publishedYes

ASJC Scopus subject areas

  • General Medicine


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