Blue prescription for children with ADHD in coastal marine settings: design of a paediatric health intervention

Abstract

Background: Attention-Deficit/Hyperactivity Disorder (ADHD) is a prevalent neurodevelopmental condition associated with a high socioeconomic burden. While the current multimodal treatment is the gold standard, it presents limitations regarding long-term efficacy and costs. Concurrently, modern lifestyles have exacerbated the ‘nature deficit’, potentially worsening symptoms. Although Paediatric Environmental Health (PEH) identifies blue spaces as health assets, their therapeutic potential through structured Blue Prescription remains underexplored in children, despite promising evidence regarding psychological restoration and physical activity in marine environments and the proven efficacy of nature-based activities in green spaces. Aim: To evaluate whether a structured, sea-based Blue Prescription intervention of 8 weeks, compared with Treatment as Usual (TAU), improves attention capacity in children aged 8 to 10 years diagnosed with ADHD. Secondary objectives include assessing impacts on ADHD symptomatology, sleep quality, medication dosage, quality of life, and connection with nature, as well as evaluating family satisfaction, adherence, and perceived feasibility. Methods: A prospective, multicentre, single-blind, parallel-group randomised controlled trial (RCT) will be performed. The sample will comprise 160 children (aged 8-10) with a confirmed diagnosis of ADHD, recruited from six public hospitals in the coastal region of Catalonia. Participants will be randomly assigned (1:1) to an experimental group (receiving the 8-week sea-based programme + TAU) or a control group (TAU only). The primary outcome, attention capacity, will be measured using the CARAS-R test. Secondary outcomes will be evaluated using validated scales (ADHD-RS-5, SDSC, PedsQL 4.0, IINS, CNI), medication logs, and a satisfaction survey across the established study time points (baseline, post-intervention, and at 3- and 6-month follow-ups). Data will be analysed following the Intention-to-Treat (ITT) principle

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