Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.

5-05
School of Occupational Therapy Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET

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

Prepared By:
Kamrie Fryer & Sotheavy Moeung

Date Review Completed:
10/2/2014

Clinical Scenario:
Experiencing a mental illness may have devastating effects on young people in society, as
adolescence and young adulthood are pivotal stages in life. During this stage, young people are
trying to establish their identity and having mental or behavioral deficits can only further
complicate this. Mental illnesses can cause a decrease in self-esteem and self-confidence and
often cause withdrawals from social interactions and isolation from peers (Schell, Cotton, &
Luxmoore, 2012).
The magnitude of adolescent and young adult mental health problems have been documented
greatly in literature. Epidemiological findings worldwide have shown that 23% of adolescents
meet the diagnostic criteria for mental health disorder, suicide is the third leading cause of death
in adolescents, and approximately 50% of psychiatric disorders in adults have an adolescent
onset (Kessler, 2007). Some studies have shown that up to 92% of females, and 88% of males,
who are in the juvenile justice system meet the diagnostic criteria for at least one psychiatric
disorder, and 50% meet the criteria for at least two disorders (Murrie, Henderson, Vincent,
Rockett, & Mundt, 2009).
The self-concept of young people has been shown to be highly significant in much of their
behavioral and mental health. Those who see themselves as bad, worthless, and undesirable tend
to act accordingly and those who have deviant self-concept tend to behave in deviant behaviors.
Developing a positive self-concept has been observed as a precursor to the alleviation of
problematic behaviors. Adolescents and young adults with behavioral issues, and labeled at risk,
become troubled individuals with few life goals who possess low self-concept that manifests in
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05
isolation from society and its rules and regulations (Larson, 2007). Additionally, the rates of
adolescent depression have become alarmingly high in the United States, with more than 20% of
adolescents displaying emotional problems and one-third attending psychiatric clinics due to
depression. One in eight adolescent may suffer from depression and only 30% of youth with
emotional and behavioral issues actually receive intervention and treatment (Norton, 2008).
Traditionally, outpatient therapies and psychiatric institutions are examples of intervention
settings used with the population of adolescents and young adults with behavioral and mental
health problems. Wilderness programs has been utilized as an alternative treatment approach for
adolescents with behavioral, emotional, and substance-use problems and is often used as a last
resort for youth who are in or heading for serious trouble. Wilderness programs are typically
considered when the troubled youth do not respond to more traditional treatment modalities and/
or are not successful in improving their problematic behaviors (Russell & Walsh, 2010; Clark,
Marmol, Cooley, & Gathercoal, 2004). Thus, prompting for more holistic interventions such as
wilderness and adventure programs may be more of an impactful option for the troubled youth.

Wilderness therapy (WT) emerged in the 1920s as a rehabilitation program for young people at
risk. It typically involves expedition-based interventions in outdoor wilderness settings away
from home, and through experiential learning, the focus is to change maladaptive behaviors
(Margalit & Ben-Ari, 2014). Historically, there has been some blurring between WT and
wilderness experience (or wilderness adventure) programs since they can be quite similar,
especially with interventions used. For example, both programs utilize the outdoor wilderness
setting and teach survival and daily life skills. Despite the blurring, the intervention strategies
that both programs use have displayed positive outcomes for individuals with a wide array of
behavioral and mental health issues (Clark, Marmol, Cooley, & Gathercoal, 2004). Exploration
of wilderness or adventure experiences in its potential to improve behavioral or self-efficacy
skills of adolescents and young adults with mental health problems is beneficial to the clients
affected, the families involved, and the security of the community.

Summary of Key Findings:
Summary of Levels I, II and III:
-Wilderness and adventure experiences were utilized as an intervention program for a
myriad of diagnoses and problematic behaviors for adolescents and young adults. The
research articles comprised of the following assortment of clinical concerns: substance
abuse, attachment relationships, family functioning, self-concept, self-efficacy,
cognitive autonomy, depression, psychosocial development, conduct problems, and
many other important factors associated with the mental and behavioral health of
adolescents and young adults.

-All the research articles examined showed positive results with the exception of one
article regarding shifts in attachment relationships amongst adolescents which displayed
mixed findings. Positive reports included decreased anger towards parents and increased
emotional connection with parents. However, the adolescents reported reduced sense of
caregivers availability, decreased empathy for caregivers feelings, decreased sense of
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05
security pertaining to understanding the subjects needs and desires, and reduced sense
that parents are sensitive and responsive to emotional states and assist with concerns
(Bettmann & Tucker, 2011).

-Related themes arose from comparison of all eight articles that showed positive
outcomes. Three articles showed improvements in substance-use amongst adolescence
and young adults utilizing wilderness and adventure program interventions. Bettman,
Russell, and Parry (2013) determined that abstinence-focused coping strategies were
effective with decrease in substance-use when used in conjunction with this program
intervention. Norton (2008) showed that wilderness therapy was impactful in decreasing
substance use in their participants. A total of six articles shared positive findings within
the theme of self-concept and cognitive autonomy. Norton (2008) displayed notable
findings within this theme such as increase self-worth, increase confidence (self-esteem
and self-efficacy), and an increase in sense of future. Larson (2007) found statistical
significance in the increase in self-concept amongst 9 to 11 year-olds and Margalit and
Ben-Ari (2014) showed an increase in cognitive autonomy amongst adolescents. Within
the theme of school performance and school status, two articles mentioned noteworthy
gains (Larson, 2007; Norton, 2008). Larson (2007) showed an increase in happiness and
satisfaction amongst the participants while Norton (2008) showed a decrease in
prevalence and rate of depression, elevation in mood and stability in mood, and an
increase in psychosocial health. Other significant findings as a result of wilderness and
adventure programs include increased hope (Russell & Walsh, 2010), and decreased
levels of conduct problems (Lewis, 2013).

-The wilderness and outdoor experiences ranged from the shortest duration at 4 nights
(Margalit & Ben-Ari, 2014) and the longest at 10 weeks (Schell, Cotton, & Luxmoore,
2012). Although there was a difference between the duration of all the interventions, the
findings still resulted in positive outcomes for the subjects. In one study pertaining to
the effects of adventure camp program on the self-concept of adolescents with
behavioral problems, the authors especially noted that the treatment periods were not of
sufficient duration to get statistically significant self-concept differences across all ages
(Larson, 2007). Thus, one can infer that if short periods with wilderness and adventure
experiences showed such positive impact on adolescents with behavioral problems, then
a longer period would show even more positive outcomes. Additionally, Russell and
Walsh (2010) noted the importance of appropriate follow-up and transition services for
youth leaving the wilderness and adventure programs in order to maintain progress on a
clinical and community level.

-Family involvement was utilized in 5 out of the 10 studies examined, displaying a
significant role in the effectiveness of treatment outcomes. Studies including the
assessment of overall family functioning have received minor attention in literature
related to wilderness and outdoor interventions. Experiential-based treatment programs
have been criticized for treating families as add-on elements and not supporting family
involvement in the overall treatment process (Burg, 2001). Bettmann and Tucker (2011)
incorporated family elements throughout the intervention program, which required
families to partake in weekly family therapy at their home, phone calls, as well as
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05
weekly written assignments from parent and adolescents. At the end of the program, the
families traveled to the wilderness site for a 3 day family therapy process that included
therapy exercises, games, solo time, and behavioral contracts. Norton (2008) found a
direct link with the inclusion of family and intervention with depression of adolescents,
noting that positive relationships with parents were a key factor for youth to remain in
remission for depression. Thus, further research should be conducted with family
therapy and/or family involvement utilized in conjunction with wilderness and
adventure programs in helping adolescents and young adults with mental and behavioral
problems.

Summary of Level IV and V:
-Harper, Russell, Cooley, and Cupples (2007) showed many similar findings as the other
articles utilized. Their study conveyed that the participants drug and alcohol usage
declined to a near statistical significance.

- Other significant findings as a result of wilderness and adventure programs include
decrease in suicidal thoughts (Harper, Russell, Cooley, and Cupples, 2007).

- Additionally, transitional planning and after-care was defined as a critical process to
the success of short-term interventions such as wilderness therapy (Harper, Russell,
Cooley, & Cupples, 2007).

- Harper, Russell, Cooley, and Cupples (2007) suggested that more intentional and
direct involvement of families in the change process may be appropriate to help families
address issues preventing effective family functioning. Again, this is important to note
in promoting further research in utilizing family involvement in conjunction with
wilderness and adventure interventions with the population of adolescents and young
adults with mental and behavioral problems in order to improve their behavioral and
self-efficacy skills.

Contributions of Qualitative Studies:
N/A

Bottom Line for Occupational Therapy Practice:
The clinical and community-based practice of OT:
- Wilderness and outdoor experiences are occupation-based interventions that are utilized
with adolescents and young adults who have mental health problems. These wilderness
interventions have significantly improved the participants overall behavioral health, self-
efficacy, and interpersonal relationships.

- Wilderness or outdoor experiences have been proven beneficial for adolescents with
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05
behavioral problems. Adolescents have decreased behavioral dysfunctions, improved
immature defense and maladaptive behavior scores, stabilized problem behavior, and
improved disruptive behavioral patterns (Bettmann, Russell, & Parry, 2013; Clark,
Marmol, Cooley, & Gathercoal 2004; Harper, Russell, Cooley, & Cupples 2007; Lewis,
2013). Thus, wilderness and outdoor interventions have a positive effective on
adolescents with mental health deficits. Interventions greatly enhanced their overall
mental and behavioral health as well as quality of life. Occupational therapists (OTs)
may assist with these interventions, to provide expertise including mental and behavioral
health knowledge. OTs can educate the adolescents to identify positive coping
techniques and behavioral strategies. This will improve their mental, physical,
psychosocial health, and daily occupational performance. Adolescents will have
increased engagement in activities of daily living (ADLs) and instrumental activities of
daily living (IADLs) due to enhanced mental and behavioral health.

- Also participation in wilderness or outdoor experiences has boosted the participants self-
efficacy particularly among male adolescents which similarly lead to improved
behavioral and emotional reactions (Margalit, & Ben-Ari, 2014); as well as improved
daily occupational performance, increased self-acceptance and enhanced social
interactions. Furthermore, psychosocial interventions such as wilderness or outdoor
experiences have been used to treat adolescent depression. Also, results identified
increased self-worth, improved psychosocial health, increased coping skills, and
improved confidence and self-esteem (Norton, 2008). OTs may aid in the facilitation of
mental health interventions in the wilderness setting to decrease adolescents mental
health deficits and improve their occupational performance in IADLs and social
interaction skills. OT can play an active role in assisting other healthcare professionals
with wilderness interventions due to their knowledgeable experience in mental health
practices.

- Furthermore, adolescents who participated in wilderness or outdoor experiences have
reported improved attachment relationships with an increased emotional connection
towards parents (Clark, Marmol, Cooley, & Gathercoal, 2004). Likewise, wilderness
therapy interventions had positive effects on character changes in adolescents with
clinically increased Millon Adolescent Clinical Inventory (MACI) Personality Patterns.
Furthermore, OTs can assist adolescents to improve relationships with parents by
utilizing psychosocial and behavioral intervention strategies and assessment tools. The
OT will educate the parent and adolescent on ways to communicate and express desired
emotions that profoundly affect relationships and IADL performance.

Program development:
- Based upon the findings of the articles examined, more wilderness programs should focus
on strengthening interventions that encourage the development of abstinence-focused
coping strategies (Bettmann, Russell, & Parry, 2013).

- According to the findings, wilderness programs have 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
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05
wilderness interventions (Bettmann & Tucker, 2011).

- While the findings support the effectiveness of wilderness interventions 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 wilderness programs, particularly those that arent licensed by
state agencies (Clark, Marmol, Cooley, & Gathercoal, 2004).

- Improvements in long-term sustainability of systemic family health following wilderness
interventions should also include supportive community resources, since there were
regressions on items in family functioning in 12 months post treatment (Harper, Russell,
Cooley, & Cupples, 2007).

- The findings of the Outdoor Behavioral Health (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 (Lewis, 2013).

- Evidence reported significant cognitive autonomy benefits among male adolescents
following wilderness intervention participation. These findings suggest that wilderness
experiences may provide adolescents with the capacity to tackle decision making
dilemmas in a successful, constructive manner (Margalit & Ben-Ari, 2014).

- 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 (Russell, & Walsh, 2010).

- 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 (Schell, Cotton, &
Luxmoore, 2012).

Societal needs:
- Findings indicate that adolescents fostered better interaction skills with other family
members during the wilderness program. This will allow adolescents to effectively
communicate and interact as active members of society as they return home (Bettmann,
Tucker, 2011). A decrease in maladaptive scores, immature defense responses, disruptive
actions, risky behaviors will enable adolescents to effectively reintegrate into the
community and be more valued members of society (Clark, Marmol, Cooley, &
Gathercoal, 2004; Larson, 2007; Lewis, 2007; Margalit & Ben-Ari, 2014).

- Likewise, adolescents with depression who participated in wilderness or outdoor
interventions showed an increase in self-worth, and improved self-efficacy which will
assist adolescents in integrating back into the community(Norton, 2008; Russell, &
Walsh; 2010). Additionally, OTs may assist with psychosocial adjustments to help
promote acceptance of the adolescents within society.

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05
Healthcare delivery and policy:
- Due to the positive results, more research and health coverage should be considered for
the use of abstinence-focused coping strategies with wilderness and outdoor interventions
when working with adolescents and young adults (Bettmann, Russell, & Parry, 2013).

- Healthcare reimbursements should be considered an option especially for the following
mental and behavioral problems: attachment insecurities, self-efficacy concerns, unstable
mood and depression, and psychosocial concerns (Bettmann & Tucker, 2011; Margalit &
Ben-Ari, 2014; Norton, 2008; Russell & Walsh, 2010; Schell, Cotton, & Luxmoore,
2012).

- Healthcare delivery should also consider coverage for transition planning and after care.
Harper, Russell, Cooley, & Cupples (2007) defined this need as critical to the success of
wilderness and outdoor interventions. OTs can play a prominent role with the adolescents
and young adults as they transition from the wilderness program to their life at home and
community.

- Larson (2007) noted that treatment periods were not of sufficient duration to get
statistically significant differences in self-concept. Greater duration can prompt for better
outcomes for the participants, thus healthcare delivery should consider covering for a
longer duration treatment periods with wilderness and outdoor programs.

Education and training of OT students:
- OT students are educated at a masters and doctorate level in helping those with
behavioral and mental problems engage in occupation-based interventions. Additionally,
OTs are well-educated to accept emerging practice areas as well as traditional therapy
settings. Using a holistic approach, OT students can easily enter into this emerging area
of wilderness and outdoor therapy to provide client-centered approach to helping clients
become independent and gain more life skills. Additionally, OT students are trained to
work with all age groups, a wide variety of diagnoses, as well as take on an
interdisciplinary approach when it comes to treatment. OT students can help with the
actual program implementation, assessments of the participants, as well as with continued
transition planning back to the home and community.

Refinement, revision, and advancement of factual knowledge or theory:
- Study limitations and mixed findings prompt for more refinement and revision of factual
knowledge. Mixed results regarding parent attachment relationships indicate how
complex a parent-adolescent relationship truly is; particularly in consideration of the
context of out-of-home care (Bettmann & Tucker, 2011). Thus, continued research in this
area can provide more information on this behavioral issue.

- Nine to 11 year-olds were the only age group to show statistically significant
improvements with self-concept, as compared to the older participant groups (Larson,
2007). This finding encourages more research to be conducted that introduces
intervention at a younger age to achieve more positive outcomes for self-concept.

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05
- Future research in wilderness and adventure programs should also consider random
assignments to treatment, inclusion of more comparison groups, larger sample size, and
usage of OTs to establish better efficacy of intervention.

- As aforementioned, longer duration treatment periods, involvement of family, and
transition care planning should also be considered for better treatment outcomes for
adolescents and young adults with behavioral and mental problems.

Review Process:
The following process was undertaken to systematically and effectively evaluate the literature:
- The focused question was developed through the selection of possible topics for
systematic reviews from American Occupational Therapy Association (AOTA) research
opportunities table and by preference for the topic of wilderness experiences by both
partners.
- Search terms for applicable population, intervention, and outcome were developed and
databases were used to extrapolate relevant articles.
- Inclusion and exclusion criteria were set and adhered to throughout the literature process.
- Ten articles ranging from level I through level IV were chosen out of twenty articles due
to meeting standards for population, intervention, and outcomes, matched the inclusion
and exclusion criteria, level of evidence, publication date, and written in the primary
language of the researchers (English). Ten articles were eliminated for not meeting the
aforementioned components.
- Ten articles were then evaluated and utilized to summarize key findings, clinical
significance, and implications for occupational therapy in this Critically Appraised Topic.

Procedures for the Selection and appraisal of articles:
Inclusion Criteria:
-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
-Research written in English
-Evidence published after 2003

Exclusion Criteria:
-Adults over age 25 and children under age 12
-Any wilderness or adventure experiences that were residential or community (indoor
rehabilitation settings)
-Articles published prior to 2004
-Dissertations

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05
Search Strategies:
Categories Key Search Terms
Patient/Client Population Adolescents, Mental Health or Behavioral Disorders

Intervention Wilderness, Adventure, or Outdoor experiences

Outcomes N/A


Databases and Sites Searched
CINAHL Plus Ebsco, PsycINFO, CINAHL, Proquest Central, Sage Premier, Health Source
Nursing/ Academic Edition, Pub Med

Quality Control/Peer Review Process:
- Both peers worked in conjunction throughout the whole entire review process
- All ten articles were chosen, evaluated and extrapolated for key findings by both
researchers
- The course instructor was readily on hand to aid in all aspects of the review process
- The course instructor approved each component necessary for the completion of the
Critically Appraised Topic

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of
Evidence
Study Design/Methodology of Selected Articles Number of Articles
Selected
I Systematic reviews, meta-analysis, randomized
control trials
1
II Two groups, non-randomized studies (e.g., cohort,
case-control)
3
III One Group, nonrandomized (e.g., before and after,
pretest, and posttest)
5
IV Descriptive studies that include analysis of outcomes
(single subject design, case studies)
1
V Case reports and expert opinion, which include
narrative literature reviews and consensus statements
0
Other Qualitative Studies 0
TOTAL: 10
Limitations of the Studies Appraised:
Levels I, II, and III
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05
- Level I: Study limitations included that the control group was involved in
behavioral modification treatment during a study period. Also, the study
randomly selected subjects from a population who volunteered to participate in
the intervention also limited the study results (Larson, 2007).

- Level II: The study identified that the sample included only male adolescents
thus limiting viewpoints associated with gender differences in adolescents
cognitive autonomy (Margalit & Ben-Ari, 2014).

- Level II: The study found that those who participated in outdoor adventure group
(OAG) are drawn from the same pool of psychosocial recovery group program
(PRGP) participants. However, there is inherent bias in that those who
participate in the OAG 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 (Schell, Cotton, & Luxmoore,
2012).

- Level II: The study had limited access to the control group thus there were no
results of self-efficacy, hope, and resilience noted for the control group (Russell
& Walsh, 2010).

- Level III: The study limitations include not using random assignment and
control groups. Another limitation was the small sample size which limits
generalizability of the findings. Additionally this 8 week WT intervention used
a specific model thus findings should be interpreted cautiously and
generalizability to other WT programs is not applicable (Bettmann, Russell, &
Parry, 2013).

- Level III: The main limitation of the study was the racial homogeneity of the
sample with 89.6% being white. This limitation then restricts the
generalizability of the findings (Bettmann & Tucker, 2011).

- Level III: The limitations in the study included non-utilization of comparison
group and the analysis of the outcome measures focused on subjects who had
clinically elevated pre-test scores on any of the MACI subscales (Clark, Marmol,
Cooley, & Gathercoal, 2004).

- Level III: 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 at this time
(Lewis, 2013).

- Level III: One limitation was that the subject pool was almost 81% Caucasian in
this study (Norton, 2008).
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Levels IV and V
- Level IV: 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
psychometrically assessed. Caution is expressed for interpretations of these
exploratory results (Harper, Russell, Cooley, & Cupples, 2007).

Other
N/A

Articles Selected for Appraisal:
Bettmann, J., Russell, K., & Parry, K. (2013). How substance abuse recovery skills, readiness to
change and symptom reduction impact change processes in wilderness therapy
participants. Journal of Child & Family Studies, 22(8), 1039-1050. doi:10.1007/s10826-
012-9665-2
Bettmann, J. & Tucker, A. (2011). Shifts in attachment relationships: A study of adolescents in
wilderness treatment. Child & Youth Care Forum, 40(6), 499-519. doi: 10.1007/s10566-
011-9146-6
Clark, J., Marmol L., Cooley, R., & Gathercoal K. (2004). The effects of wilderness therapy on
the clinical concerns (on Axes I, II, and IV) of troubled adolescents. Journal of
Experiential Education, 27(2), 213-232. doi: 10.1177/105382590402700207
Harper, N., Russell, K., Cooley, R., & Cupples, J. (2007). Catherine Freer wilderness therapy
expeditions: An exploratory case study of adolescent wilderness therapy, family
functioning, and the maintenance of change. Child Youth Care Forum, 36, 111-129. doi:
10.1007/s10566-007-9035-1
Larson, B. (2007). Adventure camp programs, self-concept, and their effects on behavioral
problem adolescents. Journal of Experiential Education, 29(3), 313-330.
doi: 10.1177/105382590702900304
Lewis, S. (2013). Examining changes in substance use and conduct problems among treatment-
seeking adolescents. Child & Adolescent Mental Health, 18(1), 33-38. doi:
10.1111/j.1475-3588.2012.00657.x
Margalit, D. & Ben-Ari, A. (2014). The effect of wilderness therapy on adolescents' cognitive
autonomy and self-efficacy: Results of a non randomized trial. Child & Youth Care
Forum, 43(2), 181-194. doi: 10.1007/s10566-013-9234-x
Norton, C. (2008). Understanding the impact of wilderness therapy on adolescent depression and
psychosocial development. Illinois Child Welfare, 4(1), 166-178. Retrieved from
http://www.illinoischildwelfare.org/archives/volume4/icw4-norton.pdf
Russell, K. & Walsh, A. (2010). An exploratory study of a wilderness adventure program for
young offenders. Journal of Experiential Education, 33(4), 398-401.
doi:10.1089/eco.2010.0035
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05
Schell, L., Cotton, S., & Luxmoore, M. (2012). Outdoor adventure for young people with a
mental illness. Early Intervention in Psychiatry, 6, 407-414. doi: 10.1111/j.1751-
7893.2011.00326.x.

Other References:
Burg, J. (2001). Emerging issues in therapeutic adventure with families. Journal of Experiential
Education, 24(2), 118-122. doi: 10.1177/105382590102400209
Kessler, R. (2007). Age of onset of mental disorders: A review of recent literature. Current
Opinion in Psychiatry, 20, 359-364. doi:10.1097/YCO.0b013e32816ebc8c
Murrie, D., Henderson, C., Vincent, G., Rockett, J., & Mundt, C. (2009). Psychiatric symptoms
among juveniles incarcerated in adult prison. Psychiatric Services, 60(8), 1092-2097. doi:
10.1176/appi.ps.60.8.1092.