Neuroaffirming ACT with adults who have ADHD

October is ADHD awareness month, a good moment to look at what the evidence says about acceptance and commitment therapy (ACT) with adults who have ADHD, and at what it takes to make ACT work neuroaffirming.

Start with the language in the room

Neuroaffirming practice starts from the view that ADHD is a neurodevelopmental difference with real costs, and that many of those costs come from the fit between a brain and its environment. Some people describe strengths such as intense focus on things that matter and quick links between ideas, though the same traits can cost them in other settings. Not every client recognises these in themselves, and strengths-talk should never be used to skip past what is hard.

That shows up in small choices. Some clients prefer identity-first language such as “ADHDer” or “autistic ADHDer” because ADHD is part of who they are, and others prefer “person with ADHD”, so it is worth asking. “Differences” works for how a brain works and “difficulties” for what a particular environment makes hard, in place of “deficits”. A diagnosis, formal or self-identified, can be treated as an explanation that sometimes arrives late and says nothing about character.

The concern goes deeper than tone. In a 2021 scoping review of 221 documents, Champ and colleagues found that current treatments for adult ADHD draw on a single theoretical perspective, cognitive behavioural theory, which the authors describe as promoting a deficit-focused characterisation of ADHD. They noted that this single perspective limits research into accommodating context and variation between individuals, and recommended research into alternative theoretical characterisations of ADHD.

Neurodivergent people also differ from one another. A client may think differently from what the textbook assumed, from other ADHDers and from you, whether or not you are neurodivergent yourself.

What adult presentation often looks like

Some adults who reach a therapist’s door were diagnosed in adulthood, or are still working out whether to pursue a diagnosis, and some are also autistic. Girls and women are recognised less often: a UK expert consensus statement (Young et al., 2020) attributes the gap in diagnosis, at least in part, to lack of recognition and referral bias, and notes that compensatory strategies can mask how ADHD shows up. By the time clients reach a clinic they may have spent years building workarounds. Some are ordinary and useful, such as alarms, lists and working alongside another person. Others involve hiding, because hiding can keep people safe at school or at work. Years of being told you are lazy or “not living up to your potential” can leave a mark, and some clients arrive with a very harsh internal critic and a small sense of what they are allowed to need. Sustained masking can also be exhausting, so rest deserves as much attention as strategies.

Rejection sensitivity is an experience many clients describe, and according to Rowney-Smith and colleagues it remains relatively unexplored in ADHD. Their 2026 qualitative study ran focus groups with five undergraduates who have ADHD. The students described how perceived rejection or criticism brought on intense distress, how they masked to cover it, and how the masking left them feeling cut off from themselves and from other people. Five students is a small sample, so the study offers a window into the experience and cannot speak for everyone with ADHD. It resembles what some clients describe in therapy. Masking can be a sensible response to an environment that punishes difference, so it is worth asking what it protects a client from before suggesting they put it down.

A related finding comes from Bodalski and colleagues (2023), who surveyed 3,720 undergraduates online. Students with more ADHD symptoms (the authors’ term) tended to judge themselves harshly for falling short while reporting lower standards, not higher ones. The authors note that targeting this harsh self-judgement with cognitive behavioural therapy or ACT may be beneficial. That is useful because it points away from “try harder”. It leaves room for the client’s relationship with their own mind and also for the question of what the environment is asking of them.

Where ACT fits

None of the points in this section comes from a trial. They are clinical reasoning, offered for you to test against your own clients.

• Acceptance as self-acceptance. ACT often talks about making room for difficult feelings. With ADHD clients the weight can go somewhere else first: accepting how their brain works, including the parts that are inconvenient in a world built for other brains. That is a different request from asking someone to put up with things that should change. A client who accepts that sitting through a two-hour meeting without notes is brutal for them can ask for the agenda in advance. You can help them rehearse the request and plan for a refusal, and you can add weight yourself, for example with a supporting letter or by talking to the employer or school with the client’s consent. Sometimes the values-consistent move is to push for a formal adjustment or to change the role. Acceptance and advocacy work well together, and any ACT formulation that leaves a client absorbing an environment that does not fit deserves some wariness.
• Defusion from the old verdicts. Many adults with ADHD carry a long list of verdicts from teachers, bosses and relatives. “Lazy” and “scatty” are two common ones. These verdicts were real, and they often came from people with power over the client, so validate that first. Some of what the client was told was unfair, and some pointed at something real that was misread. Defusion lets a client separate the verdict from what is true underneath it. “Lazy” is a label. “Starting boring tasks is very hard for me” is information. After that, “there’s the lazy label again” is easier to say than to argue with, and it keeps open the question of who handed the label over and why.
• Values as direction. Many ADHD clients describe importance as not driving their behaviour the way it seems to drive other people’s. Interest and urgency often do more of the work, a pattern clients commonly report but one that is not established as a mechanism. Values can still help, because they describe what a person wants to move towards, but check whether a value still feels alive when it is only an idea. If it does not, ask what would make it present today, which might be a person, a deadline or a shared task.
• Mindfulness with the pass mark changed. Mindfulness is often the point where clients decide they are failing. If the skill is defined as holding attention on the breath, a mind that drifts often counts as a failure. If the skill is defined as noticing that you have drifted and choosing where to go next, a drifting mind gives you plenty of practice. Eyes-open and movement-based practices both count, and it is worth asking clients what works for them instead of assuming. Some clients find mindfulness unpleasant or pointless, and it is fine to drop it and work on defusion or values instead.

Adapting how you deliver it

None of the suggestions below has been tested in trials, so treat them as things to try and adjust with the client in front of you.

• Offer a choice of format. Some clients like a one-page values sheet and some want to talk it through, so ask which suits them this week.
• Put some of the structure on the outside. Share your screen, use a whiteboard, send a written summary after the session, and let the client photograph the notes.
• Let people move, doodle, pace or fidget. If a client is working harder to look attentive than to think, the session has lost its point. Camera-off and in-person options matter for the same reason.
• Ask about the sensory side of the setting, such as lighting, noise, smells and seating, and about the ways a client prefers to communicate between sessions.
• Plan for lateness and missed appointments as part of how the service runs. A text reminder before the session and a clear, kind cancellation policy both help. For many clients a flexible plan for a bad week is something to build together, and a late arrival can count as a session that started late and not a failed one.
• If a client takes medication, ACT can sit alongside it. Ask how it is going and what they notice, and leave prescribing questions with the prescriber.
• Ask early and often what is helping and what is not, and change what you do when they tell you.

What does the research say?

The evidence is promising and still thin. Searches of PubMed in October 2026 found no published randomised controlled trial of ACT for adults with ADHD. ClinicalTrials.gov lists one registered randomised trial of a mindfulness, acceptance and commitment group for adults with ADHD (NCT03806569, status unknown, no results found), so any claim of a completed trial deserves caution.

For wider context, Ostinelli and colleagues (2025) published a network meta-analysis of 113 randomised trials of treatments for adults with a formal ADHD diagnosis, 28 of them testing psychological therapies in 1,116 participants. Stimulants and atomoxetine were the only treatments with evidence of reducing core symptoms on both self-rated and clinician-rated scales at around 12 weeks. Cognitive behavioural therapy, mindfulness and psychoeducation did better than placebo on clinician-rated measures only, and the authors describe the effects of non-drug approaches as inconsistent across raters. These are researcher-chosen symptom ratings, which count behaviours that others find difficult and say little about how a person’s life is going. The authors also note that medications were not shown to improve other outcomes such as quality of life. The abstract does not name ACT as a separate component, so the review describes the field and says nothing direct about ACT.

Munawar and colleagues (2021) published a scoping review of six small studies, with between 9 and 45 participants each. Two were quasi-experimental and four were experimental, and the designs included single-arm open-label studies. None was a randomised controlled trial, and the studies included children and adolescents as well as adults. The authors concluded that ACT showed preliminary promise for outcomes the researchers chose, including inattention and impulsivity, quality of life, depression and anxiety, and that it could be delivered individually or in groups. They called for more research, which is fair.

Fullen and colleagues (2020) ran a small single-group open trial of a brief, three-session ACT-based manual that also drew on compassion-focused and cognitive behavioural exercises. It was delivered remotely during the 2020 lockdown to young adults with ADHD, with a mean age of about 22. Of the 13 who started, 12 completed, and they showed improvements in mood, anxiety and psychosocial adjustment. The authors took the low dropout as a sign that the approach was acceptable, and they call for larger samples with waitlist and treatment comparison groups.

More recently, Seery and colleagues (2024) evaluated the Understanding and Managing Adult ADHD Programme (UMAAP), a six-session online group that combines psychoeducation with ACT and is run by a charity. In an uncontrolled study, 257 adults with diagnosed or self-identified ADHD completed baseline measures. Quality of life, self-acceptance and knowledge of ADHD improved after the programme, and the improvements were still there at three months. Only 96 people (37% of the original group) gave three-month data, so the follow-up is a weaker guide than the headline numbers suggest. Psychological flexibility did not change straight away but had risen significantly by three months. With no control group, the study cannot show what caused the changes.

A companion paper (Seery et al., 2023) analysed open-ended survey feedback from 49 participants. Two of the four themes were “an epiphany of awareness” and “accepting and affirming ADHD”. The other two were that the content could feel like too much for an introductory programme, and the costs and benefits of an online format. It is good to see a study that asked people what the experience was like for them.

One laboratory study speaks to the core ACT process. Matthies and colleagues (2014) randomly assigned 36 adults with ADHD to accept or to suppress their feelings while watching a film clip that induced sadness. Two minutes later, feeling overwhelmed by the emotion was still elevated in the suppression group, whereas it had decreased in the acceptance group. This was emotion-regulation acceptance and not a course of ACT, and it was a single brief laboratory exercise, so it hints at a mechanism and says nothing about treatment.

One more study sits next to this literature. Pahnke and colleagues (2023) ran a randomised pilot trial of an ACT group adapted for autistic adults (NeuroACT), with 20 people in the ACT group and 19 receiving usual care. The ACT group did better on the two primary outcomes, stress and quality of life. There were no significant differences between the groups in depression, anxiety or executive difficulties (the trial’s term), and dropout was slightly higher in the ACT group. The first author is an instructor in the method and has a financial interest in it, so the result needs independent replication. The participants were autistic adults, so the study speaks to adapting ACT for autistic adults and says nothing direct about ADHD.

Most of these outcomes were chosen by researchers. Far less is known about whether clients themselves think their lives got better in the ways that matter to them, which is the question the next round of studies most needs to ask.

Bringing it together

ACT may be a good fit for many adults with ADHD, and the early evidence is encouraging enough to try it, with the caveat that none of the ADHD evidence is controlled evidence of benefit. The version worth offering treats the way a client’s brain works as information about what they need, and works on the environment as well as the person. Shame is something learned, and it can be unlearned. If a client leaves your room feeling more like themselves and less like a problem to be managed, you are on the right track.

A longer reading list on ACT and ADHD, including work with children and young people, is on our ACT for ADHD useful links page.

References

• Bodalski, E. A., Abu-Ramadan, T. M., Hough, C. E., Lefler, E. K., Meinzer, M. C., & Antshel, K. M. (2023). Low standards yet disappointed: ADHD symptoms and experiential avoidance in college students. Journal of Contextual Behavioral Science, 28, 180-184. https://doi.org/10.1016/j.jcbs.2023.04.002
• Champ, R. E., Adamou, M., & Tolchard, B. (2021). The impact of psychological theory on the treatment of attention deficit hyperactivity disorder (ADHD) in adults: A scoping review. PLOS ONE, 16(12), e0261247. https://doi.org/10.1371/journal.pone.0261247
• Fullen, T., Galab, N., Abbott, K. A., & Adamou, M. (2020). Acceptance and commitment therapy for adults with ADHD during COVID-19: An open trial. Open Journal of Psychiatry, 10(4), 205-215. https://doi.org/10.4236/ojpsych.2020.104017
• Matthies, S., Philipsen, A., Lackner, H. K., Sadohara, C., & Svaldi, J. (2014). Regulation of sadness via acceptance or suppression in adult attention deficit hyperactivity disorder (ADHD). Psychiatry Research, 220(1-2), 461-467. https://doi.org/10.1016/j.psychres.2014.07.017
• Munawar, K., Choudhry, F. R., Lee, S. H., Siau, C. S., Kadri, N. B. M., & Sulong, R. M. B. (2021). Acceptance and commitment therapy for individuals having attention deficit hyperactivity disorder (ADHD): A scoping review. Heliyon, 7(8), e07842. https://doi.org/10.1016/j.heliyon.2021.e07842
• Ostinelli, E. G., Schulze, M., Zangani, C., Farhat, L. C., Tomlinson, A., Del Giovane, C., Chamberlain, S. R., Philipsen, A., Young, S., Cowen, P. J., Bilbow, A., Cipriani, A., & Cortese, S. (2025). Comparative efficacy and acceptability of pharmacological, psychological, and neurostimulatory interventions for ADHD in adults: A systematic review and component network meta-analysis. The Lancet Psychiatry, 12(1), 32-43. https://doi.org/10.1016/S2215-0366(24)00360-2
• Pahnke, J., Jansson-Fröjmark, M., Andersson, G., Bjureberg, J., Jokinen, J., Bohman, B., & Lundgren, T. (2023). Acceptance and commitment therapy for autistic adults: A randomized controlled pilot study in a psychiatric outpatient setting. Autism, 27(5), 1461-1476. https://doi.org/10.1177/13623613221140749
• Rowney-Smith, A., Sutton, B., Quadt, L., & Eccles, J. A. (2026). The lived experience of rejection sensitivity in ADHD: A qualitative exploration. PLOS ONE, 21(1), e0314669. https://doi.org/10.1371/journal.pone.0314669
• Seery, C., Leonard-Curtin, A., Naismith, L., King, N., O’Donnell, F., Byrne, B., Boyd, C., Kilbride, K., Wrigley, M., McHugh, L., & Bramham, J. (2024). Feasibility of the Understanding and Managing Adult ADHD Programme: Open-access online group psychoeducation and acceptance and commitment therapy for adults with attention-deficit hyperactivity disorder. BJPsych Open, 10(5), e163. https://doi.org/10.1192/bjo.2024.743
• Seery, C., Leonard-Curtin, A., Naismith, L., King, N., Kilbride, K., Wrigley, M., Boyd, C., McHugh, L., & Bramham, J. (2023). The Understanding and Managing Adult ADHD Programme: A qualitative evaluation of online psychoeducation with acceptance and commitment therapy for adults with ADHD. Journal of Contextual Behavioral Science, 29, 254-263. https://doi.org/10.1016/j.jcbs.2023.08.005
• Young, S., Adamo, N., Ásgeirsdóttir, B. B., Branney, P., Beckett, M., Colley, W., Cubbin, S., Deeley, Q., Farrag, E., Gudjonsson, G., Hill, P., Hollingdale, J., Kilic, O., Lloyd, T., Mason, P., Paliokosta, E., Perecherla, S., Sedgwick, J., Skirrow, C., Tierney, K., van Rensburg, K., & Woodhouse, E. (2020). Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/hyperactivity disorder in girls and women. BMC Psychiatry, 20, 404. https://doi.org/10.1186/s12888-020-02707-9