Scoping Review Of Acceptance And Commitment Therapy For ADHD

Acceptance and Commitment Therapy (ACT) is a form of cognitive-behavioral therapy (CBT) that aims to improve psychological flexibility by fostering mindfulness, acceptance, and value-driven action.

ACT teaches individuals to observe and accept their thoughts and feelings without trying to change them, while committing to behaviors that align with their personal values.

For people with ADHD, ACT may help manage symptoms like inattention, impulsivity, and disorganization by increasing awareness of internal experiences, reducing experiential avoidance, and promoting purposeful action.

By cultivating a more flexible and accepting relationship with ADHD-related challenges, ACT can improve functioning and quality of life.

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). https://doi.org/10.1016/j.heliyon.2021.e07842

Key Points

• This scoping review found that acceptance and commitment therapy (ACT) is a relatively new but promising treatment approach for individuals with attention deficit hyperactivity disorder (ADHD).
• ACT was used to treat a variety of behavioral and psychosocial outcomes in people with ADHD, including reducing core ADHD symptoms like inattention and impulsivity, as well as associated issues like poor quality of life, academic procrastination, depression, anxiety, and psychological maladjustment.
• ACT appears to be a flexible approach that can be adapted to deliver targeted treatment of ADHD symptoms as well as more general psychosocial issues, and can be provided in both individual and group formats.
• While the initial findings are encouraging, the research is still quite limited, with only 6 studies published between 2015-2020 that had small sample sizes and methodological weaknesses. More rigorous randomized controlled trials with larger samples are needed to confirm ACT’s effectiveness for ADHD.
• Exploring new treatment options like ACT for ADHD is important given the high worldwide prevalence of the disorder and the need for alternatives or adjuncts to standard medication and behavioral therapies.

Rationale

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder affecting 2-7% of the global population (Polanczyk et al., 2007).

It is characterized by traits of inattention, hyperactivity, and impulsivity that persist into adulthood and can significantly impact functioning (APA, 2013).

Stimulant medications are considered a first-line treatment, especially for stronger cases in children and adolescents (Conners, 2002; Faraone et al., 2006).

Behavioral therapies used in combination with medication appear to be superior to either treatment alone (Catala-Lopez et al., 2017). However, the utility of newer cognitive-behavioral approaches like acceptance and commitment therapy (ACT) for ADHD is still ambiguous and understudied (Faraone et al., 2006).

ACT has shown promise in treating various mental health issues like anxiety, depression, chronic pain, and aggression (A-tjak et al., 2015; Byrne & Ghrada, 2019; Graham et al., 2016; Swain et al., 2013).

By fostering psychological flexibility through mindfulness, acceptance, cognitive defusion, self-as-context, values, and committed action, ACT aims to neutralize maladaptive psychological processes underlying distress and promote adaptive behavior (Hayes et al., 2006; Luoma et al., 2007).

Considering that ACT encourages broad and flexible behavioral repertoires, it may have utility for some of the challenges that may be seen in ADHD.

The present scoping review, therefore, aimed to synthesize the current research on the effectiveness of ACT approaches for treating individuals with ADHD. B

y providing an overview of this emerging literature, the review can inform clinicians about the potential applications of ACT and guide future studies to address gaps in the evidence base.

Method

This scoping review followed the Joanna Briggs Institute guidelines (Peters et al., 2015) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards (Moher et al., 2009).

A comprehensive search was conducted across eight electronic databases: Medline, Embase, PsycInfo, ScienceDirect, PubMed, Emcare, Scopus, and Google Scholar, from inception to January 2021.

Using Boolean operators, truncation, Medical Subject Headings terms, wildcard features, and synonymic keywords, a broad search strategy was employed to capture all relevant studies.

The inclusion criteria were: 1) empirical studies reporting on ACT treatment for individuals with ADHD; 2) ACT as a standalone or adjunctive therapy based on at least 2 of the 6 core processes; 3) at least one outcome measure of treatment effectiveness; 4) quantitative, qualitative, mixed-methods, or case studies; 5) published in English. Exclusion criteria were: 1) non-empirical papers like reviews or book chapters; 2) non-English studies; 3) ACT techniques not clearly used.

Titles and abstracts were screened by one author, with full-text reviews done independently by two authors who discussed discrepancies to reach consensus. Data was extracted using a pre-designed coding table that captured key study characteristics.

A formal quality appraisal was not conducted, as is typical of scoping reviews. A narrative synthesis of the findings was performed using thematic analysis.

Meta-analysis was precluded by the heterogeneity of the included studies. No additional subgroup or sensitivity analyses were conducted.

Results

Study Characteristics:

The 6 included studies were published between 2015-2020, with 2 each from Iran and Italy, and 1 each from the USA and UK. There were 4 experimental studies and 2 quasi-experimental designs.

Sample sizes ranged from 9 to 45 participants aged 8 to 23 years, totaling 142 individuals (63 males, 16 females). Three studies used a group therapy format and two used individual sessions, with varying treatment lengths.

Comparison of ACT with Other Treatments:

Two studies compared ACT to dialectical behavior therapy (DBT) and token economy plus parent training.

Bayat et al. (2019) found that 12 individual ACT sessions and DBT were both more effective than control in reducing ADHD symptoms and improving quality of life in 45 participants. DBT showed greater effects on ADHD symptoms at follow-up, while ACT outperformed DBT on quality of life measures.

Vanzin et al. (2019) evaluated a 9-month group ACT program adjunctive to token economy and parent training in 31 children.

Significant improvements were seen in parent-rated ADHD symptoms, impairments, and clinical severity, which held after controlling for medication use and demographics.

ADHD Symptoms Based on Pre-Post Designs:

Four studies examined pre-post changes in ADHD symptoms and associated outcomes using various designs.

Fullen et al. (2020) piloted a brief phone/video-delivered individual ACT manual to support psychosocial adjustment during COVID-19 lockdown in 12 adults. Three sessions led to improved mood, anxiety, coping, and treatment acceptability at 2-week follow-up.

Murrell et al. (2015) provided 8 weekly group sessions to 9 children with ADHD, learning disorders, and disruptive behaviors, finding behavioral improvements in a third of the sample.

Vanzin et al. (2020) assessed cognitive outcomes of a 9-month, 26-session group ACT program in 29 children compared to untreated ADHD controls, but found no significant benefits.

Gholipour et al. (2019) showed that 10 sessions reduced hyperactivity/impulsivity and academic procrastination in 16 adolescents.

Insight

This scoping review offers a synthesis of the developing research on ACT for ADHD, revealing some key insights:

1. ACT appears to be a flexible and feasible approach for addressing both core ADHD symptoms and associated psychosocial difficulties in children, adolescents, and adults. The ability to adapt ACT for different developmental stages and target multiple domains of impairment is promising.
2. ACT can be delivered effectively in both individual and group formats, and even remotely via teletherapy, increasing its potential reach and accessibility. Brief protocols may be sufficient to produce meaningful changes.
3. Preliminary evidence suggests ACT is efficacious in reducing inattention, hyperactivity/impulsivity, disruptive behaviors, mood issues, academic procrastination, and quality of life difficulties in people with ADHD. Some studies show comparable or superior effects to established treatments like DBT and token systems.
4. Not all studies found significant benefits of ACT on cognitive functioning or ADHD symptoms, highlighting the need for more well-controlled trials to clarify its effects and boundary conditions. Tailoring ACT to the specific neurocognitive profile of ADHD may enhance outcomes.
5. Integrating ACT with other evidence-based practices like behavioral parent training could yield synergistic effects and warrants further study. Teaching ACT skills to parents may help them cope with their own distress and facilitate their child’s progress.

Overall, this review extends the literature by demonstrating the utility of ACT across the lifespan for both symptomatic and functional outcomes in ADHD. While encouraging, the findings are tempered by the small, heterogeneous evidence base.

Replication in larger samples with active control groups, long-term follow-up, analysis of mechanisms and moderators, and development of manualized protocols are important future directions to establish ACT as an empirically-validated option for ADHD management.

Strengths

The review had several methodological strengths:

1. Comprehensive search of 8 databases using a broad strategy to minimize omission of relevant studies
2. Independent screening and data extraction by multiple authors to ensure consistency
3. Adherence to PRISMA guidelines and Joanna Briggs Institute standards for scoping reviews
4. Inclusion of a range of study designs, outcome measures, treatment formats, and sample characteristics to provide a comprehensive overview of the topic

Limitations

However, some limitations should be noted:

1. The small number and heterogeneity of included studies precluded meta-analysis and definitive conclusions about ACT’s effectiveness for ADHD
2. Half the studies were published in non-indexed journals, potentially indicating lower methodological rigor
3. Lack of information about participants’ medication status and other treatments limit interpretations
4. No formal quality assessment was conducted, as is typical of scoping reviews, so risk of bias is unknown
5. Narrow geographic representation (only 4 countries) and skewed gender ratio (predominantly male) constrain generalizability
6. English language restriction may have excluded pertinent research

Implications

Despite the limitations, this review has important implications:

1. ACT may offer a viable alternative or adjunct to gold-standard pharmacological and behavioral treatments for ADHD, especially when adapted developmentally
2. Training clinicians in ACT could expand the repertoire of evidence-based practices for ADHD and allow more individualized, multimodal treatment planning
3. Disseminating ACT in scalable and accessible ways, like group or online delivery, could help meet the global burden of ADHD
4. Identifying which individuals with ADHD are most likely to benefit from ACT based on personal characteristics, comorbidities, and baseline functioning could optimize outcomes
5. Examining how ACT interfaces with other therapies, support systems, and contexts relevant to ADHD can guide integrated care models
6. Elucidating the mechanisms by which ACT improves symptoms and functioning in ADHD, such as through targeting specific psychological flexibility processes, can refine interventions
7. Incorporating stakeholder perspectives on the acceptability, feasibility, and outcomes of ACT can enhance its real-world utility for ADHD management

In sum, this scoping review suggests ACT is a promising therapy for ADHD that merits more rigorous research and clinical application. By providing an accessible overview and identifying key gaps, this review can stimulate further scientific inquiry and evidence-based practice regarding ACT for this impairing neurodevelopmental disorder.

References

Primary reference

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). https://doi.org/10.1016/j.heliyon.2021.e07842

Other references

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

A-tjak, J. G., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A., & Emmelkamp, P. M. (2015). A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84(1), 30-36. https://doi.org/10.1159/000365764

Byrne, G., & Ghráda, Á. N. (2019). The application and adoption of four ‘third wave’ psychotherapies for mental health difficulties and aggression within correctional and forensic settings: A systematic review. Aggression and violent behavior, 46, 45-55. https://doi.org/10.1016/j.avb.2019.01.001

Catalá-López, F., Hutton, B., Núñez-Beltrán, A., Page, M. J., Ridao, M., Macías Saint-Gerons, D., Catalá, M. A., Tabarés-Seisdedos, F., & Moher, D. (2017). The pharmacological and non-pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: a systematic review with network meta-analyses of randomised trials. PloS one, 12(7), e0180355. https://doi.org/10.1371/journal.pone.0180355

Conners, C. K. (2002). Forty years of methylphenidate treatment in Attention-Deficit/Hyperactivity Disorder. Journal of Attention Disorders, 6(1_suppl), 17-30. https://doi.org/10.1177/070674370200601S04

Faraone, S. V., Biederman, J., Spencer, T. J., & Aleardi, M. (2006). Comparing the efficacy of medications for ADHD using meta-analysis. Medscape General Medicine, 8(4), 4.

Graham, C. D., Gouick, J., Krahé, C., & Gillanders, D. (2016). A systematic review of the use of Acceptance and Commitment Therapy (ACT) in chronic disease and long-term conditions. Clinical psychology review, 46, 46-58. https://doi.org/10.1016/j.cpr.2016.04.009

Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour research and therapy, 44(1), 1-25. https://doi.org/10.1016/j.brat.2005.06.006

Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT: An acceptance & commitment therapy skills-training manual for therapists. New Harbinger Publications.

Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Prisma Group. (2010). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. International journal of surgery, 8(5), 336-341. https://doi.org/10.1371/journal.pmed.1000097

Peters, M. D., Godfrey, C. M., Khalil, H., McInerney, P., Parker, D., & Soares, C. B. (2015). Guidance for conducting systematic scoping reviews. JBI Evidence Implementation, 13(3), 141-146. https://doi.org/10.1097/XEB.0000000000000050

Polanczyk, G., De Lima, M. S., Horta, B. L., Biederman, J., & Rohde, L. A. (2007). The worldwide prevalence of ADHD: a systematic review and metaregression analysis. American journal of psychiatry, 164(6), 942-948. https://doi.org/10.1176/ajp.2007.164.6.942

Swain, J., Hancock, K., Hainsworth, C., & Bowman, J. (2013). Acceptance and commitment therapy in the treatment of anxiety: a systematic review. Clinical psychology review, 33(8), 965-978. https://doi.org/10.1016/j.cpr.2013.07.002

Keep Learning

Here are some potential discussion questions for a college class on this paper:

1. How does ACT differ from other established psychosocial treatments for ADHD, and what are its proposed advantages? What ADHD-related difficulties seem most amenable to ACT techniques?
2. The reviewed studies included participants across the lifespan, from children to young adults. What developmental considerations are important when adapting ACT for different age groups with ADHD? How might ACT be tailored to the neurocognitive profile of ADHD?
3. Several studies delivered ACT in a group format or integrated it with other therapies like parent training and token economies. What are the potential benefits and challenges of these alternate delivery models compared to standard individual therapy? How can ACT complement or synergize with other modalities?
4. The COVID-19 pandemic has accelerated the shift toward telehealth and digital mental health interventions. How might technology be leveraged to increase the scalability, accessibility, and personalization of ACT for ADHD? What are some examples of ACT-informed digital tools or programs that could be developed and tested?
5. Many studies in this review had small sample sizes, lacked control groups, and used parent- or self-report measures. What are some key methodological limitations of the current evidence base and how can future research address them to draw stronger causal conclusions about ACT’s efficacy for ADHD?
6. ACT targets psychological flexibility processes like mindfulness, acceptance, cognitive defusion, self-as-context, values, and committed action. Which of these mechanisms do you think are