Successful stream rehabilitation requires a shift from narrow analysis and management to integrated understanding of the links between human actions and changing river health. At study sites in the Puget Sound lowlands of western Washington State, landscape, hydrological, and biological conditions were evaluated for streams flowing through watersheds with varying levels of urban development. At all spatial scales, stream biological condition measured by the benthic index of biological integrity (B‐IBI) declined as impervious area increased. Impervious area alone, however, is a flawed surrogate of river health. Hydrologic metrics that reflect chronic altered streamflows, for example, provide a direct mechanistic link between the changes associated with urban development and declines in stream biological condition. These measures provide a more sensitive understanding of stream basin response to urban development than do treatment of each increment of impervious area equally. Land use in residential backyards adjacent to streams also heavily influences stream condition. Successful stream rehabilitation thus requires coordinated diagnosis of the causes of degradation and integrative management to treat the range of ecological stressors within each urban area, and it depends on remedies appropriate at scales from backyards to regional storm water systems.

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