The rationale for turning to nature rests on a growing but still incomplete body of evidence. Conventional care for ADHD typically relies on medication and, in some cases, parent training or cognitive behavioural approaches, yet post-diagnostic support within NHS services remains inconsistent and often stretched thin. Nature-based interventions, which involve guided activities in green or natural settings, have shown promise for mental wellbeing across a range of populations, but they remain under-researched specifically for children with ADHD as an adjunct to standard treatment. The CONIFAS2 team argues that this evidence gap matters, because families need timely, accessible options that complement rather than replace existing care. By embedding the intervention within NHS neurodiversity services rather than treating it as a standalone lifestyle recommendation, the researchers hope to test something that could realistically become part of routine clinical practice.

A distinctive feature of the study is its co-production ethos. Rather than designing the intervention behind closed doors and presenting it to families as a finished product, the researchers developed the programme collaboratively with the people who will actually use it, including children with lived experience of ADHD, their parents, and NHS practitioners. Co-production of this kind is increasingly recognised in health services research as a way to ensure that interventions are not only theoretically sound but also practical, culturally appropriate, and engaging for the families expected to complete them. For a population in which daily routines are often difficult to sustain, the difference between an activity schedule that feels imposed and one that families helped to shape could determine whether the programme is followed at all.

The design of the trial itself follows the established architecture of a feasibility study. Children who have received a diagnosis of ADHD and their parent or guardian will be recruited as a dyad, meaning the pair is treated as the unit of participation, from NHS neurodiversity services. This dyad structure reflects the reality that a home-based intervention for a child necessarily involves parental support and supervision. After completing a baseline assessment, each dyad will be randomised to one of two arms. The intervention arm receives a programme of structured daily nature-based activities accompanied by psychoeducational support, delivered alongside usual treatment. The control arm receives treatment as usual only. Randomisation ensures that differences observed between the groups in engagement, outcomes, or data completeness can be attributed to the intervention pathway rather than to pre-existing differences between families.

What exactly does the intervention involve? The protocol describes structured daily nature-based activities, which in practice means deliberately planned engagements with the natural environment carried out at or near home, paired with psychoeducational components that help children and parents understand ADHD and the reasoning behind the activities. The home-based delivery model is a deliberate choice with important implications for equity and scalability. Clinic-based programmes often exclude families who cannot travel regularly, whereas a home-based format could, in principle, reach a much broader population. At the same time, home delivery raises its own questions about fidelity, which is the technical term for whether the intervention is delivered as intended. A family that completes only a fraction of the prescribed activities, or completes them in a substantially altered form, weakens the researchers’ ability to interpret results. Assessing intervention fidelity is therefore one of the trial’s explicit feasibility objectives.

The primary purpose of CONIFAS2 is to measure feasibility and acceptability across several dimensions. The team will track recruitment, asking whether enough eligible dyads can be enrolled through NHS services and whether the recruitment pathway itself functions smoothly. They will measure retention, meaning how many families remain in the trial from baseline through follow-up, a critical concern in any study requiring sustained daily activity from children with a condition characterised by difficulties with attention and routine. They will also evaluate whether the planned data collection procedures work in practice, and whether both the intervention and the trial design are acceptable to participants. Acceptability is not a soft outcome; interventions that families find burdensome, stigmatising, or impractical fail in real-world implementation regardless of what efficacy trials suggest.

Beyond the core feasibility outcomes, the study incorporates a mixed methods process evaluation, a design element that separates thoughtful feasibility work from simple pilot testing. Quantitative data alone can show that families dropped out or failed to complete activities, but they cannot explain why. The process evaluation will combine qualitative and quantitative approaches to refine a programme theory, essentially a structured account of how the intervention is supposed to produce its effects, and to identify the barriers and facilitators that shape delivery, engagement, and eventual implementation. Interviews and other qualitative methods can reveal, for example, whether parents struggled with time constraints, whether children found particular activities motivating or tedious, and whether NHS staff encountered practical obstacles in referring families. These insights directly inform the design of a future definitive trial, potentially saving substantial resources by preventing a large-scale study built on flawed assumptions.

The protocol also includes a feasibility health economic evaluation, an element that reflects the growing expectation that health interventions demonstrate value for money as well as clinical benefit. Before a full cost-effectiveness analysis can be conducted in a definitive trial, researchers must establish that the necessary data can actually be collected from participating families. The CONIFAS2 team will therefore assess the feasibility of gathering information on resource use, such as contacts with health services and use of medications, on costs, and on health-related quality of life. If families find these questionnaires too burdensome or the data too incomplete, a future economic evaluation would be unreliable, and this needs to be known before a large trial commits resources to it. Health-related quality of life measures are particularly important because they allow the benefits of an intervention to be compared across different conditions and treatments using a common metric.

The study is registered with the ISRCTN trial registry under identifier ISRCTN15490570, providing transparency about its design before results are known. The research team brings together expertise spanning environmental science, health sciences, health economics, and clinical practice, with authors including Peter A. Coventry, Piran C. L. White, Sarah Sumpter, Susan Griffin, Chao Huang, and Hannah A. Armitt, among others, reflecting the genuinely interdisciplinary nature of nature-based health research. This breadth matters because such interventions sit at the intersection of environmental psychology, paediatric healthcare, and health service delivery, and no single discipline can evaluate them alone.

The implications of this work extend well beyond ADHD. If CONIFAS2 demonstrates that a co-produced, home-based nature intervention can be feasibly delivered through NHS neurodiversity services, it would clear the path for a definitive trial capable of establishing clinical and cost-effectiveness. More broadly, the study exemplifies a methodological trend in health research: testing deliverability and acceptability rigorously before investing in large efficacy trials, and involving patients and families as genuine partners in intervention design. For the families of children with ADHD who currently face long waits and limited post-diagnostic options, the prospect of a low-cost, accessible support programme built around daily contact with the natural world is an appealing one. The findings, which will be disseminated through peer-reviewed publications, conference presentations, and community partners, will determine whether that prospect advances toward the rigorous evidence needed to change clinical practice.

Subject of Research: Feasibility of a co-produced home-based nature-based intervention for children with ADHD

Article Title: CO-produced Nature-based Intervention Feasibility for children with ADHD Study: The CONIFAS2 study protocol

Article References: Date, K. L., Cohen, J., Coventry, P. A., Dorey, T., Green, N., Griffin, S., Huang, C., Kingsley, E. N., Marlow, M., Sumpter, S., Twiddy, M., White, P. C. L., Woolley, K., & Armitt, H. A. (2026). CO-produced Nature-based Intervention Feasibility for children with ADHD Study: The CONIFAS2 study protocol. PLOS One, 21(10), e0359206. https://doi.org/10.1371/journal.pone.0359206

Image Credits: AI Generated

DOI: 10.1371/journal.pone.0359206

Keywords: ADHD, children, nature-based intervention, feasibility trial, randomised controlled trial, NHS, co-production, psychoeducation, process evaluation, health economics, PLOS One, neurodiversity