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Name: Kamrie Fryer & Sotheavy Moeung

Date: October 1, 2014

Focus Question: Do wilderness or adventure experiences improve behavioral or self-efficacy skills of adolescents and young adults with mental health
problems?

Rationale for inclusion/exclusion criteria applied to determine which articles should be included in the evidence table:
Inclusion: The inclusion criteria included any wilderness/ adventure experiences with adolescents and young adults with a mental health and behavioral disorder.
Key terms include wilderness, adventure, outdoor, adolescents, behavior, and mental health.

Exclusion: The exclusion criteria included adults or children younger than 12 years old. Additionally any wilderness or adventure experiences that were
residential or community (indoor rehab settings) were excluded. Articles published prior to 2004 were also excluded.

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
Bettmann,
Russell, &
Parry
(2013)
This study was
designed to explore
the impact of
motivation to
change and
substance abuse
recovery skills on
symptom reduction
among adolescent
WT participants.
Level of Evidence:
Level III

Design:
A time series research
design with a single
baseline assessment
was used. Participants
completed pre- and
post- assessments.

Subjects:
A convenience sample
of 189 adolescents was
Intervention:
An 8 week treatment
intervention was utilized.
Adolescents lived in a
wilderness environment
with primary care staff
and received group and
milieu treatment daily
that was supervised and
delivered by licensed
clinicians.

A strong family
component guided the
The study sample
showed clients
scored significantly
higher at admission
(t(42) = 2.14, p =
.038) on the
behavioral
dysfunction scale of
the Y-OQ.

The Stages of
Change scores at
admission showed
that the study
Limitations
include not
using random
assignment
and control
groups.
Another
limitation was
the small
sample size
which limits
generalizabilit
y of the
findings.
Clinical/ Community Based OT:
The results showed that Y-OQ
scores improved significantly at
post and follow up assessments.
These scores display an increase
in the following areas: (a)
interpersonal stress (b) Somatic
(distress) (c) Interpersonal
Relations (d) Critical Items (e)
Social Problems (f) Behavioral
Dysfunction. This improvement
can help their overall quality of
life.

School of Occupational Therapy Touro University Nevada
OCCT 643 Systematic Reviews in Occupational Therapy Critically Appraised Topic Project
EVIDENCE TABLE WORKSHEET

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
admitted to an 8-week
WT program.
Participants were
selected based off the
following criteria: (a)
they had consented to
participate in standard
outcome monitoring
processes by the
program, and (b) they
had completed a
pretreatment Y-OQ
assessment that could
be used as a baseline
measure of client well-
being at intake.

To be included in the
study participants were
required to a set of
assessments were
required at admission,
discharge, & at a six
month follow up. This
reduced the sample size
to 41 clients or 21.2%
of the original sample.

treatment process and
included the development
of a detailed care plan to
help transfer learning to
their daily lives post
treatment and make the
transition back to their
family, peers, and school.

The program was located
in Southwestern
Colorado.

Outcome Measures:
The University of Rhode
Island Change
Assessment (URICA)
was used to assess the
participants readiness to
implement major lifestyle
changes. It assesses level
of motivation to modify
behaviors such as drug
and alcohol consumption.

Adolescent Relapse
Coping Questionnaire
(ARCQ) measured
temptation coping
response among
adolescents with a history
of alcohol and drug
abuse. This measure
included three coping
strategies participants
could use in order to
resist substance abuse
when placed in certain
sample scored
higher on the Pre-
contemplation scale
(t(43) = 2.184, p =
.02). The total
Readiness to
Change score was
also higher (t(50) =
2.397, p = .02). This
suggests that the
study sample was
less motivated at
admission and could
have had higher
symptoms of
behavioral
dysfunction.

Results showed that
participants entered
treatment in the
severe range of
presenting issues
with an average
total score of 74.95.
Discharge scores
were below the cut
score of 46 or less,
indicating both
clinically and
statistically
significant
improvements from
treatment on the
total Y-OQ score
(t(39) = 4.85, p <
.001; d = .95, [.40,
1/32]. Also there
Additionally
this 8 week
WT
intervention
used a specific
model thus
findings
should be
interpreted
cautiously and
generalizabilit
y to other WT
programs is
not applicable.
Program Development: Based
upon the findings of the present
study, more WT programs
should focus on strengthening
interventions that encourage the
development of abstinence-
focused coping strategies.

Societal Needs:
The abstinence-focused coping
strategies accounted for
significant improvements in
treatment outcomes. By
continuing to practice these
strategies, the participants can
continue to make better choices
when it comes to substance
abuse, thus helping them to
better integrate into adulthood
and society.

Healthcare Deliver/ Policy:
It is evident that WT is effective
form of treatment. With the
assistance of health care
reimbursement, further studies
focused on abstinence-focused
coping strategies related to
substance abuse should prompt
more research and funds.

Education/Training OT students:
WT has been proved to be an
effective intervention for
substance recovering
adolescents. OT students can
successfully assist this
population by providing

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
situations. The first
includes cognitive and
behavioral problem
solving, second self-
critical thing (self-
efficacy and self-esteem)
and third abstinence-
focused cognitive and
behavioral coping.

Youth Outcome
Questionnaire (Y-OQ)
used dependent variable
to determine treatment
outcome indicated by
statistically and clinically
significant changes
between admission and
discharge scores and the
maintenance of change at
six-month post treatment.
The Y-OQ contains six
subscales that were used
to explore the
relationship of various
independent variables to
change in total Y-OQ
scores including (a)
interpersonal stress (b)
Somatic (distress) (c)
Interpersonal Relations
(d) Critical Items (e)
Social Problems (f)
Behavioral Dysfunction.

were clinical and
statistical
differences for each
subscale suggest
that this sample
treatment was
effective across
multiple
dimensions.

Social Problem
subscale scores were
significantly
different than
discharge scores
suggesting
significant
improvement in this
domain from
discharge t(39) =
3.167, p = .003; d =
.60, [.04, .76].

The results also
showed that clients
maintained their
positive treatment
outcomes across all
of the Y-OQ
domains; presenting
improvement
clinically and
statistically
significant changes
in Social Problem
subscale at six
months post
treatment.
abstinence based coping
strategies.

Refinement,
Revision/Advancement of
Factual Knowledge or Theory:
Further studies of WT designed
to improve behavior of
adolescents with various mental
health disorders need to be
conducted to identify specific
intervention procedures.
Additionally, determining more
precise results for refined future
research guidelines should also
be a focus.



Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT

Abstinence-focused
coping strategies (p
= .01) was the only
variable that was a
significant predictor
of Y-OQ change.

However URICA
scores were not
significantly related
to such changes,
while ARCQ
subscale of
abstinence focused
coping strategies
accounted for a
significant
proportion of the
variance in Y-OQ
change. Thus
results indicate that
clients in WT do not
need to necessarily
want to change in
order to do so.
Bettmann
& Tucker
(2011)
This study examined
shifts in
adolescents
attachment
relationships with
parents and peers
during a 7 week
wilderness therapy
program.
Level:
Level III

Design:
This study utilized one-
group pre-post design.
Data was collected
from adolescents on
their first day during the
intake process and on
the last day in the
program after spending
Intervention:
The WT program was 7
weeks long and was held
in Southern Utah during
which adolescents lived
in the wilderness with
primary care staff and
received group and
milieu treatment daily.
Adolescents received
individual and group
psychotherapy from a
There were mixed
findings. For the
AAQ, adolescents
reported less
confidence in the
availability and
responsiveness of
their parents (t = -
5.16, df = 53, p <
.001) and less
empathy (t = - 6.30,
df = 53, p < .001).
The main
limitation of
the study was
the racial
homogeneity
of the sample
with 89.6%
being a white
sample. This
limitation then
limits the
generalizabilit
Clinical/ Community Based OT:
Adolescents reported improved
attachment relationships in terms
of anger and increased emotional
connection towards parents.
These findings indicate that WT
had a positive effect on parent
and adolescent attachment
relationships.

Program Development:
According to the findings, WT

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
several days in a family
workshop with their
families in the
wilderness.

Subjects:
The study utilized a
convenience sampling
of 96 adolescents
placed by their parents
in a WT program in
Southern Utah. There
were 59 males and 37
females. The racial
make-up included 86
White, 3
Hispanic/Latino, 2
Native American, 1
Asian. The participants
ranged from 14-17
years old with a mean
of 15.98. At admission,
participants were
diagnosed with
Oppositional Defiant
Disorder. The second
issue was depression
disorder, substance
dependence, ADHD,
and substance abuse. A
high percentage of the
sample was dually
diagnosed, most often
with substance
abuse/dependence and
oppositional defiant
disorder.
mater and doctoral level
clinicians 2 days a week.
These clinicians created
individualized plans for
each client and worked
with each family to
provide appropriate
aftercare planning.

Adolescents lived in the
wilderness in groups of
nine peers with three or
four staff and hiked most
days to primitive
campsites. Adolescents
worked together to
accomplished daily living
tasks, such as pack-
building, primitive fire
making, and meal
preparation. Adolescents
participated in daily
academic curriculum and
they received academic
credit upon completion.

The program also
incorporated family
elements throughout the
program, which required
families to participate in
weekly family therapy at
their home, phone calls,
weekly written
assignments from parent
and adolescents. Also at
the end of the program
families traveled to the
These scores led to
decreased
perception of
attachment by the
participants with pre
and post with
changes in AAQ
score (t = - .548, df
= 53, p < .001).

Participants reported
AUAQ scores
indicated they had a
much higher
perception of Failed
Protection of their
parents.

Adolescents
similarly reported
improved
attachment
relationships in
terms of decreased
anger/alienation
towards their
mother (t = 3.791, df
= 50, p < .001)
father (t = 3.667, df
= 47, p < .001).
Findings also
indicated
adolescents
perceived their
mothers and fathers
as being less
sensitive and
responsive to their
y of the
findings.
has improved certain aspects of
parent and adolescent attachment
relationships. However, due to
the complexity of these
attachment relationships, future
studies need to determine the
long term effects of WT
interventions.

Societal Needs:
Positive interactions with parents
can help foster better interaction
skills with others in society.
This can help the adolescents
effectively communicate and
interact as active members of
society.

Healthcare Deliver/ Policy:
Insecure attachment in
adolescence has been linked
with internalizing problems such
as; anxiety and depression and
externalizing problems including
conduct difficulties and
opposition. Thus, WT
interventions have improved
attachment relationships which
have decreased overall health
care costs; therefore healthcare
policies should consider WT as
reimbursable intervention.

Education/Training OT students:
OT students can assist with WT
interventions. By educating
adolescents on how to improve
attachment relationships; by

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
wilderness site for a 3
day family therapy
process (therapy
exercises, games, solo
time, behavioral
contracts) .

Outcome Measures:
The study used three
attachment measures
including Adolescent
Attachment
Questionnaire (AAQ),
Adolescent Unresolved
Attachment
Questionnaire (AUAQ),
and the Inventory of
Parent and Peer
Attachment.
emotional states (t =
-4.046, df = 50, p <
.001); father (t = -
4.612, df = 47, p <
.001). Participants
were less trusting by
the end of treatment
that parents would
understand their
needs and desires
(mother: t = - 3.322,
df = 50, p < .002;
Father: t = -3.418, df
= 47, p = .02).

Adolescents showed
more troubled
attachment
relationships in
terms of trust and
communication with
parents.

Also adolescents
reported similarly
mixed results in
both a positive and
negative direction
regarding peers.
utilizing positive coping
strategies and effective
communication skills in order to
have decreased anger and
increased connection towards
their parents.

Refinement,
Revision/Advancement of
Factual Knowledge or Theory:
The mixed results regarding
parent attachment relationships
indicate how complex a parent-
adolescent relationship truly is;
particularly considering the
context of out of home care and
the importance of continued
research in this area.

Clark,
Marmol,
Cooley, &
Gathercoal
(2004)
To evaluate the
effects of 21 day
WT program on the
defense styles,
perceived
psychosocial
stressors (expressed
concerns),
dysfunctional
Level:
Level III

Design:
Multiple interrupted
time series design.
Treatment groups were
sent to different
wilderness areas at
Intervention:
The WT program used
was the Catherine Freer
Wilderness Therapy
Expedition. The program
was 21 days long. A dual
diagnosis treatment
program that combines
naturally healing
The findings
showed statistically
significant
improvements on
immature defense
scores (t (108) =
3.71, p < .01); and
maladaptive
behavioral scores
The
limitations in
the study
included non-
utilization of
comparison
group and the
analysis of the
outcome
Clinical/ Community Based OT:
Results indicated that WT
interventions improved
immature defense and
maladaptive behavior scores
including; Expressed Concerns,
Dysfunctional Personality
Patterns, and Clinical
Syndromes. Thus WT facilitated

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
personality patterns,
clinical syndromes,
and maladaptive
behaviors of 109
troubled
adolescents.
Additionally, the
article looked at the
use of assessment to
begin identifying the
types of clinical
concerns on Axes I,
II, and IV which
WT was most
effective.
different times of the
year. No comparison
group was utilized, due
to financial constraints.

Subjects:
Catherine Freer
Wilderness Therapy
Expeditions (CFWTE)
participants were
referred to WT because
they have not
responded well to more
traditional treatment
modalities. The
adolescents typically
engaged in self-
destructive behaviors
and their parents were
desperately seeking
help. The sample
included 109 subjects
selected by a
convenience sample.
All subjects were
between the ages of 13-
18. The enrollment
varied from four to
eight adolescents per
treatment group and not
all enrollees
participated so the pool
data was drawn from 23
different wilderness
therapy treks.


wilderness setting with
behavioral management,
twelve step approach to
drug and behavior
problems, individual and
group psychotherapy
(behavioral, cognition,
psychodynamic and
family systems theories
and techniques were
used.

Outcome Measures:
The Defense Style
Questionnaire (DSQ)
consisted of 40 self-
reported items which
participants rated their
degree of agreement with
each item on a 9-point
scale indicating strong
agreement or
disagreement.

Personality patterns,
expressed concerns and
clinical syndromes were
assessed using the
MACI. It is intended for
disturbed adolescents and
the MACI has 4 response
scales and 27 content
scales separated into
three clinically-relevant
categories (a) personality
(b) expressed concerns
(c) Clinical Syndromes.
Personality patterns
(Cohens d = 1.87);
and on expressed
concerns (t (108) =
2.65, p <.01),
dysfunctional
personality patterns
(t (108) = 2.65, p <
.05); and clinical
syndromes scores (t
(108) = 3.66, p <
.01) of subjects.

Moderate to large
effects were found
for a wide range of
clinical concerns on
Axes I, II, and IV.

The most striking
finding in this study
was that WT
appears to facilitate
positive character
change in
adolescents with
clinically elevated
MACI Personality
Pattern scores.
measures
focused on
subjects who
had clinically
elevated pre-
test scores on
any of the
MACI
subscales.

positive character changes in
adolescents with clinically
elevated MACI Personality
Patterns.

Program Development: While
the findings support the
effectiveness of WT for a wide
range of adolescent clinical
concerns on Axes I, II, and IV, it
is not recommended to
generalize the studys findings to
all WT programs, particularly
those that arent licensed by state
agencies.

Societal Needs:
The improved immature defense
and maladaptive behavior scores
can help these troubled
adolescents to reintegrate into
the community and be more
valued citizens in society.

Healthcare Deliver/ Policy:
Adolescents with behavioral
problems who have undergone
WT interventions have improved
their overall behavioral health.
Thus, healthcare insurances need
to consider WT as a
reimbursable intervention to aid
future WT programs.

Education/Training OT students:
OT students can assist other
healthcare professionals with
WT interventions; which support

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
scales parallel to the
DSM-IIIR/IV personality
disorders in the order of
their presentation on the
Millon Clinical
Multiaxial Inventory- III.

For an objective measure
of behavior, the Youth
Outcome Questionnaire
YOQ 2.0 was also
utilized. The YOQ
measured the major areas
of behavior and
quantifies the severity of
disturbance in
adolescents. Maladaptive
behaviors were also
identified using the
YOQ.
adolescents to change and cope
with psychiatric and behavioral
health problems.

Refinement,
Revision/Advancement of
Factual Knowledge or Theory:
Future Catherine Freer
Wilderness Therapy Expedition
should use measures that are
multidimensional and
psychometrically-sound such as
MACI; including follow up data
using one and three intervals to
find the long term effects of WT.
Harper,
Russell,
Cooley, &
Cupples
(2007)
This study aimed to
identify practical
adolescent and
family outcomes
following
participation in a 21-
day wilderness
therapy program for
adolescents with
emotional,
behavioral, and
substance use
problems.
Level of Evidence:
Level IV

Design:
Exploratory
longitudinal case study

Subjects:
The sample consisted of
252 adolescent
participants enrolled in
a 21-day WT program
for treatment of
emotional, behavioral,
or substance use
diagnoses.

Participants ranged
Intervention:
Catherine Freer
Wilderness Therapy
Expeditions (CFWT) was
selected as a case for this
study because the
program is short-term (3-
weeks) and attempts to
include families in their
treatment process and
follow-up practices.
Also, the majority of
clients return to the home
environment following
treatment, and not to
residential extended care
destinations like
therapeutic boarding
For adolescent
behavior, following
house rules,
impulsivity, anger
management and
communicating with
parents were the
biggest issues for
adolescents.
Significant
differences were
found between
males and females,
with females having
more serious issues
with following
house rules and
communicating with
The
limitations
included non-
utilization of
control groups
for
randomization
of treatment.
Also, this
study utilized
an instrument
that was
developed
with
practitioners
for practical
purposes and
has not been
Clinical/ Community Based OT:
Findings suggest that CFWT
intervention may contribute
significantly to the stabilization
of adolescent problem behaviors
and that treatment effects can
contribute to lasting changes for
clients and families.

Program Development:
Improvements in long-term
sustainability of systemic family
health following WT
interventions should also include
supportive community resources,
since there were regressions on
items in family functioning 12
months post treatment.

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
from 1318 years of
age and averaged 15.5
years. Males comprised
62% of the adolescent
sample which was
primarily Caucasian
American (92%) with
8% Native American,
Hispanic, African
American and others.

Primary diagnoses were
substance abuse and
misuse issues (61%)
including cannabis,
alcohol, cocaine and
amphetamines, and
mood and anxiety
disorders (24%)
including depression,
post-traumatic stress,
and attachment and
adjustment disorders.

Additionally,
behavioral diagnoses of
opposition defiance and
conduct disorders were
present, but not often
identified as the
primary diagnoses in
treatment planning.



schools or treatment
centers.

CFWT offers three- and
seven-week (developed
after data collected for
this study) expeditions
depending on client
needs and treatment
success. Expeditions
generally contain cohorts
of seven youth and are
facilitated by a treatment
team consisting of a
clinical supervisor,
medical supervisor, field
therapists and wilderness
leaders who work in
collaboration to provide a
safe, ethical, and
meaningful intervention
for each client.

Outcome Measures:
The outcome measures
used included the Family
Assessment Measure
(FAM), Youth Outcome
Questionnaire, Defense
Style Questionnaire, and
the Millon Adolescent
Clinical Inventory
(MACI). The following
constructs were assessed:
1. Family function
2. Adolescent
behavior
3. Adolescent
parents. In the area
of mental health,
two issues stood out
as being most
serious, emotional
problems and drug
and alcohol use,
with males showing
more extreme
problems with drug
and alcohol use (M
= 1.67 for males
compared with M =
1.98 for females),
and girls indicating
emotional problems
were significantly
more extreme than
males (M = 1.46 for
females compared
with M = 1.87 for
males). For the
family functioning
items, family time
outside of the home,
evenings home
together, parent
child conversations,
and the childs
participation in
chores were rated as
most extreme, with
males indicating
significantly more
extreme problems
with evenings home
together and parent
child conversations.
psychometrica
lly assessed.
Caution is
expressed for
interpretations
of these
exploratory
results.

Societal Needs:
Alcohol and drug use scores
regressed to near statistical
significance between two and
twelve months post treatment.
This is important since the youth
will stop breaking the laws of
society as well as preventing
possibility of future
imprisonment which is quite
costly to societys tax payers.

Healthcare Deliver/ Policy:
Transition planning and after
care have been defined as critical
to the success of short-term
intensive interventions such as
wilderness therapy. Healthcare
systems should better support
mental professionals beyond WT
intervention in order to sustain
successful maintenance of
change for the youth and their
family.

Education/Training OT students:
More intentional and direct
involvement of families in the
change process may be
appropriate to help families
address issues preventing
effective family functioning. OT
students can help foster better
family relationships and
communication.

Refinement,

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
mental health
4. School success
5. Social
engagement

Females showed
significantly more
extreme problems
for five of the six
mental health items.

There were
improvements in
suicide thoughts and
school performance
overall.

Additionally,
alcohol and drug use
decreased to a near
statistical
significance.

Revision/Advancement of
Factual Knowledge or Theory:
More direct systemic family
dynamics should be integrated
into current wilderness therapy
and community based practices
during adolescent treatment.
Larson
(2007)
The aim of the
current study is to
examine the effects
of an adventure
camp program on
the self-concept of
adolescents with
behavioral
problems.
Level of Evidence:
Level I

Design:
Randomized Control
Trial

Subjects:
61 randomly selected
male and female
adolescents ranging
from 9-17 years old
with behavioral
problems.

The treatment group of
31 adolescents was
randomly selected from
a population of
adolescents with
Intervention:
The camp is based on
decentralized camping
structure with small, self-
sufficient groups
comprised of 8-10
campers and three
counselors. The campers
are exposed to an
adventure camp program
that lasts 5 days and 4
nights. During this, the
campers are asked to
share in the responsibility
of living and working
together in meeting the
challenges of living in
the outdoors. Life
Adventure Camp lists
three goals for the
Hypothesis 1: No
significant
difference between
experimental and
control group
pretest and posttest
self-concept gain
scores as a result of
participation in the
program as
measured by
PHCSCS. However,
t-test indicated
significant
difference in
experimental group.

Hypothesis 2: No
significant
difference between
The
limitations in
the study
included that
the control
group was
involved in
behavioral
modification
treatment
during a study
period.
Also, having
to randomly
choose
subjects from
a population
who
volunteered to
participate in
Clinical/ Community Based OT:
The individuals self-concept is
highly influential in their
behavioral and mental health.
Those who see themselves as
undesirable and worthless tend
to act accordingly. Adolescents
with behavioral problems tend to
exhibit this, thus it is clinically
important to address this.

Program Development:
While this study investigated on
adventure therapy model, studies
of other programs should be
considered to help predict a
model or program that is specific
to bringing about change in
adolescents self-concept. This
would allow agencies to be more

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
behavioral problems
who voluntarily
attended an adventure
camp.

The control group of 30
adolescents was
randomly selected from
a population that
underwent treatment for
behavioral problems.

campers: self-concept,
social skill development,
and appreciation of
natural environment.
Objectives were set for
each area of camper
development. They used
a sequential adventure
program model adapted
from Roland (1993). It
begins with the readiness
level of each participant
or group. Once they meet
the objectives of one
level, then they can
progress to the next level.

Outcome Measures:
The Piers-Harris
Childrens Self-Concept
Scale (PHCSCS) was
used as a measuring
instrument to assess how
the children and
adolescents feel about
themselves. It assessed
the following areas:
1. Behavior
2. Intellectual and
school status
3. Physical
appearance and
attributes
4. Anxiety
5. Popularity
6. Happiness and
satisfaction

experimental and
control group
pretest and posttest
self-concept gain
scores as a result of
participation in the
program as
measured by
PHCSCS. t-test
indicated significant
difference in
experimental group
in 3 out of 6
subscales
(intellectual and
school status;
popularity; and
happiness and
satisfaction). The
control showed
significant
difference in 2 out
of 6 subscales
(intellectual and
school status;
physical appearance
and attribute.)

Hypothesis 3: One
way analysis of
variance showed
significant
difference between
the experimental
and control groups
9-11 year olds self-
concept. The F-ratio
was a 4.30 with 26
the study also
limits the
studys
results.
efficient in providing services to
this group.

Societal Needs:
Adolescents with behavioral
problems are labeled at-risk are
pre-delinquent and hostile youth
with few goals. This, along with
low self-concept causes them to
be alienated from society and its
rules and regulations.

Healthcare Deliver/ Policy:
The authors noted that the
treatment periods were not of
sufficient duration to get
statistically significant
differences in self-concept. If
health care would reimburse for
this type of treatment, then
greater duration would be given
to get more favorable results.

Education/Training OT students:
If a short duration of adventure
therapy showed positive impact
on adolescents with behavioral
problems then a longer duration
would show even more positive
outcomes. OT students can be a
part of the interdisciplinary team
to help set goals and decide on
what duration is best for this
particular group to elicit the best
results.

Refinement,
Revision/Advancement of

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
degrees of freedom
and significant at
the .05 level. No
other age group
showed significant
difference.


Factual Knowledge or Theory:
9-11 year olds were the only
group to show significant
improves with self-concept.
Thus, future research should be
conducted to see if intervening at
a younger age would get better
retaining of positive self-
concept. If so, adventure therapy
should be utilized especially
with the younger ages.
Lewis
(2013)
This study evaluated
Outdoor Behavioral
Health (OBH)
therapeutic
outcomes
(examining changes)
in substance use and
conduct problems
among treatment-
seeking adolescents.
The hypothesis was
the OBH treatment
would be associated
with a reduction in
psychiatric
symptomatology
from baseline to
post treatment.
Level
Level III

Design
A repeated measures
design, with a
naturalistic follow up
was employed. The
assessment protocol for
Part 1 included
Baseline, Day 7 and
Graduation
assessments; Part II
included a months and
12 months post-
treatment evaluation.

Subjects
Participants included
190 treatment seeking
13-17 years old
adolescents.
Adolescents parents
sought admission for
mental health and
substance related
treatment at one of
Intervention
The focus of the
intervention was based
on problems being and
helping the adolescents
change behaviors. The
next context allowed
participants to develop
skills that can be
employed upon returning
home. They are able to
engage in the natural
consequences of behavior
and participate in a
therapeutic milieu with
peers who are
developmentally similar.
Participants were placed
in groups of 8-10 same
gender peers with similar
presenting problems and
clinical needs. Program
curricula designed to
prepare clients for
outdoor activities assess
and conceptualize their
clinical needs, develop
Results suggest that
pre-treatment levels
of conduct problems
m=4.57, SD=5.62)
were significantly
lower than t
(165)=6.15 p>.001
lower rate the post-
treatment
assessment
(m=1.87, SD=4.40).

Similarly levels of
substance use
problems were
significantly lower
(t(165)=7.51,
p>.001) lower at
post treatment
assessment
(m=2.32, SD=3.87)
compared to the pre-
treatment
assessment(m=4.96,
SD=2.32). Of the
166 participants
completed the post
A primary
limitation of
the study was
the lack of
random
assignment to
treatment
conditions and
the absence of
a comparison
group.
Without these
components,
firm
conclusions
about
causality
cannot be
made.

Clinical/ Community Based OT:
Youth that participated in OBH
programs reported
improvements in symptoms of
disruptive behavior disorders.
These therapeutic gains were
maintained regardless of whether
the youth selected a continuing
care residential intervention or
returned home. A similar pattern
emerged for symptoms of
substance abuse.

Program Development: The
findings of the OBH
demonstrated that post treatment
does not fade across time, but
persisted for the follow up
assessment period of 12 months.
Additionally, it was not
associated with the use of
additional residential treatment
following the OBH program
completion.

Societal Needs:
Youth that participated in OBH

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
three Outdoor
Behavioral Health
programs, located in
North Carolina, New
York, and Idaho. The
sample was obtained
using continuous
enrollment protocol
from a group of 230
adolescents between
2006 and 2008. 25% of
the final sample
endorsed one or more
psychotropic
medication
prescriptions at the time
of their admission.
25% reported
experiencing one or
more psychiatric
hospitalization and 75%
reported working with
one therapist prior to
admission of the
program.

individualized treatment
plans and provide weekly
group and individual
therapy was provided by
a clinical team. The team
was led by a masters-
level therapist and
includes bachelors-level
residential staff.
Multiple behavioral
management strategies
are employed to teach,
reward, and elicit
adaptive behavior.

Outcome Measures:
The Youth Version of the
Treatment Outcome
Package (TOP) was used
as the primary index of
treatment outcomes. The
TOP measures subjective
distress, symptomatic
states, and overall
functioning; these
psychological domains.
For the 58 phrases in the
youth version had
trouble concentrating or
making decisions
Participants were asked
to rate the frequency of
the described experience
on a 1 (all the time) to 6
(none of the time) scale
which yields scores on 11
subscales. The following
9 factors were examined:
treatment
assessment, 111
(66%) reported
lower levels of
substance use
problems as the
post-, compared to
pre-treatment
assessment; 90
(54%) reported
lower levels of
conduct problems.

Conduct was
statistically
significant
variability in both
post treatment
symptom levels
(z=2.70, p<.0001.
With a TOP of 2.46
and it significantly
decreased across the
follow up period by
approximately 0.92
per assessment point
t= -2.95, p<.01).

Substance use was
statistically
significant
variability in both
pre and post
treatment. The TOP
substance use factor
and it significantly
decreased across the
follow up period by
programs reported
improvements in symptoms of
disruptive behavior disorders;
these therapeutic gains can assist
the adolescents becoming
functional members of society.

Healthcare Deliver/ Policy: As
the results have indicated OBH
intervention improved symptoms
of disruptive behavior disorders
in adolescents. Therefore,
healthcare policies should
consider OBH programs as
reimbursable interventions
which will can decrease
healthcare costs long-term.

Education/Training OT students:
OT students with a background
in mental health can assist with
OBH interventions to improve
adolescents overall behavior and
mental health deficits.

Refinement,
Revision/Advancement of
Factual Knowledge or Theory:
Random assignment to treatment
and inclusion of a comparison
group should be considered in
future studies.

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
(a) ADHD, (b) Conduct,
(c) Depression/anxiety,
(d) Substance Abuse, (e)
Academic Functioning,
(f) Violence, (g)
Suicidality (h) Sleep
Disruption and (i) Social
Conflict.
.68 per (p<.05).
Margalit &
Ben-Ari
(2014)
The purpose of the
study was to
examine the effect
of wilderness
therapy participation
on cognitive
autonomy and self-
efficacy.

Level of Evidence:
Level II

Design:
A non-randomized pre-
post design with a
control group.

Subjects:
The sample included 93
male adolescents at risk
aged 14-16, from a
boarding school in
Israel.

Participants took part in
a full wilderness
therapy intervention,
partial and control
condition. Allocation
was not randomized.

Assessments included
the cognitive autonomy
and self-evaluation
inventory and the
potency scale were
administered in 3 waves
the beginning, end and
at the five month follow
Intervention:
The program includes 10
preparation meetings, a 4
day backing trip, and two
closure meetings.

The program
incorporated behavioral
elements such as
modeling, positive and
negative reinforcement,
and problem solving
alongside of therapeutic
elements administered by
a mental health
professional.

The first 10 weekly
preparation meetings
included outdoor
camping, outdoor
training, navigation, and
constructing devices.

All participants of the
full program participated
in 4 day backpacking
trip. The daily schedule
included building a hide
out, and looking for a
The intervention
group showed a
significant increase
in cognitive
autonomy across the
3 waves of study
was found in wave
1( r = 0.93, p <
0.001), wave 2 (r =
0.84, p < 0.001),
wave 3 (r = 0.86, p
<0.001) following
wilderness therapy
participation.

Additionally
cognitive autonomy
scores in wave 2
correlated
significantly with
self-efficacy scores
in wave 3 (r = 0.71,
p < 0.001).

Similar results were
found with self-
efficacy found a
significant increase
found across the 3
waves of study, F(2,
The sample
included only
male
adolescents
thus limiting
viewpoints
associated
with gender
differences in
adolescents
cognitive
autonomy.

Significant
correlations
found between
cognitive
autonomy and
self-efficacy
ratings in the
3 waves of
study attesting
to how
discriminative
validity of
these
constructs.
These
correlations
may be due to
Clinical/ Community Based OT:
This study found that WT
participation increased self-
efficacy among male
adolescents. WT programs
targeted at improving behavioral
actions and discussing emotional
reactions is a clinically effective
intervention for at risk
adolescents, and particularly
with males.

Program Development:
Evidence reported significant
cognitive autonomy benefits
among male adolescents
following WT participation.
These findings suggest that WT
may provide adolescents with
the capacity to tackle decision
making dilemmas in a
successful, constructive manner.

Societal Needs:
The adolescents may have the
ability to alter previous decision
making involving risky
behaviors after the intervention.
Thus WT provided adolescents
with the capacity to tackle these

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
up.

source of water, group
tasks (2-3 persons) such
navigation and rock
climbing and setting a
fire naturally.

Outcome Measures:
Cognitive autonomy was
measured by the CASE
(cognitive autonomy and
self-efficacy) inventory.
Self-efficacy was
measured via the potency
scale. Data analysis was
conducted using SPSS.
In order to examine
cognitive autonomy and
self-efficacy differences
between groups in wave
1, one way ANOVA was
conducted for each of
these variables.
180) = 78.83, p <
0.001, n = 0.47, as
well as a significant
difference between
the study groups,
F(3, 90) = 57.14, p
< 0.001, n = 0.66.

Partial wilderness
therapy participation
engendered a
significant increase
in cognitive
autonomy when
compared to no
participation.


similarities in
the self-
concepts
tapped by the
CASE
(thought
evaluation,
voicing
opinions) and
the potency
scale (self-
confidence,
mastery).

dilemmas in a successful,
constructive manner.

Healthcare delivery and policy:
The results showed that WT
interventions are effective in
improving self-efficacy with
adolescents who previously
engaged in risky behaviors.
Therefore, healthcare providers
should consider WT as possible
reimbursable intervention.

Education/Training of OT
Students: The current data
showed the positive effects of
WT interventions with
adolescents who engaged in
risky behaviors. Evidence found
an increase in adolescents self-
efficacy after receiving a WT
intervention. Likewise it would
be beneficial to receive WT
interventions from skilled
interdisciplinary team members
such as an OT.

Refinement, Revision/
Advancement of factual
Knowledge or Theory:
Further research should be
carried out with random
assignment to treatment
conditions and consideration of
risk profiles further analyzed to
establish the efficacy of the
intervention.
Norton The purpose of this Level of Evidence: Intervention: Prevalence of One limitation Clinical/ Community Based OT:

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
(2008) study was to explore
the impact of
wilderness therapy
on adolescent
depression and
psychosocial
development, in
particular. This
study explored the
relationship that
exists between
adolescent
depression and
psychosocial
development and
sought to understand
the connection
between the two in
greater depth.
Level III

Design:
Mix method
quantitative/ qualitative.
Quantitative using a pre
and post design.

Subjects:
The research population
for this study consisted
of adolescent
participants in a
therapeutic wilderness
program called
Intercept, affiliated with
Outward Bound
Wilderness. This group
was made up of males
and females ages 13
17, of mixed racial and
ethnic backgrounds;
however, the subject
pool was somewhat
limited in this area,
with almost 81% of the
sample population
being Caucasian.
Although students in
Outward Bound courses
also reflect a varying
level of socioeconomic
diversity, this author
did not have access to
the financial
backgrounds of each
participant in the study.

The research population
for this study consisted of
adolescent participants in
a therapeutic wilderness
program called Intercept,
affiliated with Outward
Bound Wilderness. This
group was made up of
males and females ages
1317, of mixed racial
and ethnic backgrounds;
however, the subject pool
was somewhat limited in
this area, with almost
81% of the sample
population being
Caucasian. Although
students in Outward
Bound courses also
reflect a varying level of
socioeconomic diversity,
this author did not have
access to the financial
backgrounds of each
participant in the study.

Outcome Measures:
Prevalence of depression
Rate of depression
Psychosocial health
Depression: 33%
decrease in the
prevalence of
depression with
statistically
significant change
(p=.001).

Rate of Depression:
Overwhelming
majority of youth
had decreased
depression,
statistically
significant change
of p=.02.

Other Findings:
Decrease in learned
helplessness,
increase in self-
worth, increase in
sense of future, no
symptoms of
depression during
course, elevation in
mood upon
completion of
course, and stability
in mood three
months post course.

Psychosocial
Health: 52%
increase in
prevalence of
psychosocial health
(p=.0001), and
was that the
subject pool
was almost
81%
Caucasian.
This study impels that social
work and OT practitioners
should utilize psychosocial
interventions to treat adolescent
depression. It also provides these
practitioners with clinical
evidence to feel comfortable
referring youth with depression
to wilderness therapy programs.

Program Development:
This program looked at which
specific aspects of depression
and psychosocial development
should be targeted. This allowed
practitioners to more accurately
assess the fit between the
adolescents and a specific
wilderness therapy program.

Societal Needs:
Other findings in addition to
depression included decrease in
learned helplessness, an increase
in self-worth, and an increase in
sense of future; all of which are
very important for these
adolescents to have a better
chance in integrating back to
society and having a brighter
future.

Healthcare Deliver/ Policy:
During the course, the youth
reported no symptoms of
depression and upon completion;
participants reported an actual
elevation in mood. Additionally

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
increased levels of
psychosocial health
p=.0009

Other Findings:
Increased coping
skills, confidence
(self-esteem and
self-efficacy),
competence,
connection, caring,
and identity
achievement.

Negative
Correlation Between
Depression and
Psychosocial
Development:
As psychosocial
health improves,
depression
decreases and vice
versa. Validated
using Pearsons
correlation
coefficient with T-
difference RADS-2
and MPD scores,
which generated
statistically
significant p-value
of .0023.

Other Findings:
Relevant gains in
school performance
improvement,
3 months post-course most youth
still reported more stability in
moods. This retaining of
decrease depression and
stabilization of mood can help
reduction in healthcare and
healthcare associated costs.

Education/Training OT students:
OT students are trained with
psychosocial development and
depression, thus they can play an
important role on the
interdisciplinary team with goal
development with the
adolescents.

Refinement,
Revision/Advancement of
Factual Knowledge or Theory:
The study pointed out that in
addition to wilderness therapy,
intervention with family is
important as well. Creating
opportunities for positive
communication and cohesion in
the family system is important as
well.

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
decreased substance
abuse, and improved
family relationships
(even three months
after).
Russell &
Walsh
(2010)
The aim of the
current study is to
examine the
contributions of
perceived self-
efficacy, resilience,
and hope in youthful
offenders who
participate in a
wilderness
adventure program
and to understand
how these
contributions impact
future recidivism.
Level of Evidence:
Level II

Design:
Non-randomized
Control Trial

Subjects:
33 males and 10
females participated in
treatment group.

Treatment group had
60% white and 40%
nonwhite.

86% were between 14-
17 (average age 15.8)

59% were between 13
and 15 years old when
first involved with
juvenile justice system.
Intervention:
-All participants in the
Wilderness Endeavors
Program between June
2008 and May 2009 were
considered potential
study participants. The
admissions and screening
criteria process followed
by staff was utilized by
the researcher to develop
the sampling frame. All
data were collected upon
admission to the program
during intake procedures
and upon discharge from
the program at
graduation. All
instruments were
administered by a
masters-level therapist.
Probation officers for
both control and
treatment youth were
contacted six
months after release and
interviewed to determine
probationary status and
re-offense rates.


Outcome Measures:
The Perceived
The analysis
showed significant
increases in self-
efficacy, t(42) = -
2.331, p = .02, d =
.35, and hope, t(42)
= -.2.004, p = .05, d
= .30, for
Wilderness
Endeavors Program
graduates. Increases
in resilience were
not significant, t(42)
= -1.100, p = .27,
with a small effect
size (d = .16),
suggesting that
participation in the
Wilderness
Endeavors Program
had no significant
impact on resilience.
Not surprisingly,
hope scores also
increased
significantly due to
participation in the
Wilderness
Endeavors Program.
There was
limited access
to the control
group thus
there were no
results of self-
efficacy, hope,
and resilience
noted for the
control group.

Clinical/ Community Based OT:
This study showed that
appropriate follow up and
transition services for youth
leaving programs such as the
Wilderness Endeavors Program
is needed in order to maintain
progress both clinically and
within the community.

Program Development:
Hope and self-efficacy were
improved but not resiliency upon
completion of the Wilderness
Endeavors Program, thus hope
and self-efficacy should be
continued to be focused on in
future programs.

Societal Needs:
The increase in self-efficacy and
resilience scores helps these
young participants to survive
and contribute more to society.

Healthcare Deliver/ Policy:
Resilience and self-efficacy are
important for youth to have as
they become working adults in
society thus health care
insurances should consider
wilderness programs as a
reimbursable intervention.

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
Competence of
Functioning Inventory
(PCFI) measured self-
efficacy.

The Childrens Hope
Scale measured hope.

The Adolescent
Resiliency Attitudes
Scales measured
resiliency.

Education/ Training OT
students:
Adventure education has been
shown to be quite effective with
troubled youth. OT students can
easily specialize in this field to
help this population.

Refinement,
Revision/Advancement of
Factual Knowledge or Theory:
There was limited access to the
control group thus there were no
results of self-efficacy, hope,
and resilience noted for the
control group. This should be
acknowledged and addressed in
future research.
Schell,
Cotton, &
Luxmoore
(2012)
The aim of the
current study is to
evaluate the efficacy
of an outdoor
adventure for young
people with a mental
illness
Level of Evidence:
Level II

Design:
Non-randomized
Control Trial

Subjects:
21 subjects aged 15-25.
12 control subjects.
Participants were
clients of psychosocial
recovery groups in
Australia. The majority
were female, 18+, and
psychotic illness.
Intervention:
The Outdoor Adventure
Group (OAG) runs 8-10
weeks, once a week for
full day culminating with
3 day & 2 night camp.

The group comprises of
max 10 clients w/ 2
clinicians and 1 or 2 Out
Doors, Inc. staff.

Curriculum involves
series of incremental
challenges in difficulty in
which participants must
rely on one another to
persevere.

Participants in OAG
improved in self-
esteem (p=.001) and
mastery (p=.001)
which were not
observed in control.

Total of 80 personal
goals (3.81 per
person).
Performance
significantly
improved in 66
goals (82.5%). Most
common goal
related to self-
improvement and
social skills
development.
Those who
participate in
OAG are
drawn from
the same pool
of the
Psychosocial
Recovery
Group
Program
(PRGP)
participants.
However,
there is
inherent bias
in that those
who
participate in
the OAG
Clinical/ Community Based OT:
This study contributes to the
early intervention literature
regarding exciting and creative
ways of engaging young people
in treatment and is a unique and
effective approach to
psychosocial recovery.

Program Development:
Adventure therapy programs
have been implemented in a
variety of settings across
different age ranges, and within
both clinical and mainstream
populations. However, it has
been shown to be most
successful with the adolescent
population.

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
Outcome Measures:
The Rosenburg 10 items
measure varying aspects
of self-esteem.

The Pearlin 7 items
assess the extent to which
one regards life chances
as being under ones own
control in contrast to
being fantastically-ruled.

The Social
Connectedness
20 items measures how
an individual perceives
his or her interpersonal
closeness with the social
world.

The Personal Goals
include goal settings
adapted from the COPM.
group are
required to
have
prerequisite
characteristics
based on the
multi-variant
demands of
the group and
for safety
reasons. These
characteristics
may introduce
potential bias
in favor of the
OAG as they
may be more
motivated,
engaged and
committed,
and they may
be further
along in their
psychosocial
recovery than
the control
group.


Societal Needs:
The adventure component allows
young people to engage in
appropriate risk taking
behaviors, in a group context
that closely approximates social
situations that may be
encountered outside the
program, and that skills learned
in this way may be generalized
beyond the program setting.

Healthcare Deliver/ Policy:
Adventure Therapy showed to
improvements in many
psychosocial areas. Thus, it can
be suggested to healthcare
providers to be a reimbursable
intervention.

Education/Training OT students:
Personal goals were an outcome
measure and part of the
intervention. Once personal
goals were established by the
clients, their performance
significantly improved. OT
students can be trained on aiding
with establishment of goals for
participants to further better
performance.

Refinement,
Revision/Advancement of
Factual Knowledge or Theory:
This is one of the only controlled
studies examining the efficacy of

Author/
Year
Study Objectives Level/Design/ Subjects Intervention and
Outcome Measures
Results Study
Limitations
Implications for OT
an adventure therapy group for
adolescents with mental illness.
It is also one of the only known
adventure therapy studies that
examines the change of self-
rated personal goals.



References
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