A functional contextualist process model of ADHD

George Horne1*, Benjamin Sharpe2,

1 Seeds of Science Research Collective; ORCID: 0000-0001-6888-0313

2 Institute of Psychology, Business, and Human Sciences, University of Chichester; ORCID:

0000-0001-8539-9935

*Corresponding Author: [email protected]

Keywords: ADHD; Self Regulation; Functional Contextualism; Behaviour; Process

Abstract

ADHD is one of the most prevalent neurodevelopmental disorders and represents one extreme of

self-regulation within any population. However, no theory of ADHD yet explains the

behavioural processes behind its common symptoms, holistically accounts for how contextual

changes impact beahviour, or explains cases where people with ADHD perform better than their

neurotypical peers. Instead, existing theories overemphasise ADHD’s neurological differences

and arguably encourage pharmaceutical treatment of them. In this paper, we extend current

process theories of self-regulation to clinical self-regulation issues within ADHD: ADHD

behaviour is characterised as faster changes in goal-directed behaviour across tasks, and

dependent on an individual’s context. We use this model to explain basic and complex ADHD
symptoms, differentiate ADHD from a different process related to sluggish cognitive tempo, and

suggest practical, non-pharmaceutical alternatives to manage ADHD symptoms Future research

is needed to test the generalisability of goal-directed behaviour processes from neurotypical to

ADHD populations across different contexts.

Attention-deficit hyperactivity disorder (ADHD) is a one of the most prevalent

neurodevelopmental disorders (American Psychiatric Association, 2013). It is currently

diagnosed by symptoms of inattention, hyperactivity, and impulsivity. Approximately from 5-8%

of children have clinical levels of ADHD symptoms (Ayano et al., 2023; Polancyzk et al., 2007;

Polanczyk et al., 2014), with another 5% experiencing issues with attention and impulsivity at

subclinical levels (Sayal et al., 2018), and approximately 2.5% of adults have clinical levels of

ADHD symptoms (Simon et al., 2009; Song et al., 2021). ADHD is associated with issues in

interpersonal relationships (Wymbs et al., 2021), education (Berchiatti et al., 2022), and

employment (Fuermaier et al., 2021), as well as frequently being comorbid with other

neurodevelopmental issues such as autism spectrum disorder (Hours et al., 2022), and dyslexia

(Boada et al., 2012).

ADHD symptoms vary as a trait within clinical and non-clinical populations. ADHD is highly

genetic, with a high heritability of approximately .75-80 across children and adults (Brikell et.,
2015; Faraone et al., 2005; Larsson et al., 2014). Genetic risk factors for ADHD exist within the

general population and people with ADHD have more of these risk factors than neurotypicals

(Martin et al., 2014; Stergiakouli et al., 2015). Additionally, regardless of symptom severity in

the individual, ADHD symptoms have similar relationships with other psychological variables

such as anxiety and personality traits (Li et al., 2019). Together these findings suggest that

clinical ADHD diagnoses are only one extreme of the normal variation in ADHD symptoms

within a population.

Mainstream ADHD theories and research are based within neuro- and cognitive psychology and

follow the biomedical, syndromes-focused paradigm. This paradigm categorises and defines

maladaptive behaviour as discrete illnesses with standardised symptoms and treatments (Hayes

et al., 2019). Some notable theories are the executive dysfunction theory (e.g., Barkley, 1997,

2011, 2022), the cognitive-energetic model (Sergeant, 2000), catecholamine dysfunction theory

(Prince, 2008), Sagvolden et al. (2005)’s dynamic developmental theory, synaptic gating theory

(Levy, 2004), and theories related to glial cell activity (Russell et al., 2006; Zhang et al., 2022).

However, these theories are arguably incomplete; without an underlying theory of behaviour

(e.g., Horne & Swettenham, 2024), they fail to account how their ADHD-related dysfunctions

integrate with other contextual factors, such as a person’s social environment and learned

experiences, to effect symptom expression. While in some cases other contextual factors are

somewhat considered (e.g., Sagvolden et al., 2005), there remains no clear underlying theory or

mechanism for how they influence behaviour. Overreliance on these neurocognitive theories

leads to issues in diagnosing, predicting, and treating ADHD behaviour (Champ et al., 2021), as

we will discuss below.

Firstly, using neurocognitive theories to define maladaptive behaviour leads to two diagnostic

issues: ADHD becomes a catchall diagnosis for a variety of neurological deficits with similar

symptoms, and people with similar neurological deficits may receive different diagnoses if their

behaviour is more functional. However, ADHD research suggests that there is not only a variety

of causal factors associated with the disorder (Nigg et al., 2005; Sagvolden et al., 2005), but also

that contextual factors may affect how ADHD neurology leads to behaviour. For example, not all

people with ADHD have executive function deficits (Willcutt et al., 2005), and researchers have

argued that those who only experience inattentive symptoms may instead have a different

underlying deficit (Barkley, 2001; Milich et al., 2001). Additionally, higher IQ (Kosaka et al.,

2019; Soares et al., 2022), higher fitness levels (Mehren et al., 2019), better nutrition (Hawkey &

Nigg, 2014; Ligezka et al., 2021), and mindfulness-based cognitive-behavioural therapy

(Cairncross & Miller, 2020) have all been linked to lower ADHD symptoms. Therefore, people

that have or do these things may experience differing diagnoses to people that do not, even if

their underlying genetic ADHD risk factors are similar.

Secondly, neurocognitive ADHD theories are also limited in explaining differences in

performances between people with and without ADHD. Take the following examples: Jylkkä et

al. (2023) found that people with ADHD do not perform worse on computer simulated everyday

tasks (d = 0.02, p = .862) but do worse in task efficacy (d = − 0.28, p = .015) and measures of

efficiency (e.g., empty clicks, d = .44, p <.001); and Boot et al. (2020) found that people with

ADHD reported more creative achievements (d = 0.71, p = .001) and that ADHD symptoms

were positively correlated with more original ideas on the alternative uses task (r = .28, p < .01).
Within the context of these experiments, overall performances of people with ADHD were equal

to, or better, than people with less severe/ non-clinical ADHD symptoms. While current theories

describe neurocognitive deficits associated with ADHD, they are unable to explain their

downstream effects on behaviour, especially in combination with other contextual factors.

Finally, the neglect of context within neurocognitive theories may inappropriately prioritise

pharmaceutical interventions for ADHD. Currently, the neurological and cognitive deficits

associated with the order (Barkley, 1997; Prince, 2008; Sagvolden et al., 2005), at least in some

cases (Willcutt et al., 2005), provide a practical therapeutic target for pharmaceutical treatment:

reduced dopamine signalling (Prince, 2008; Sagvolden et al., 2005) can be treated with stimulant

medication which increases dopamine signalling. However, current ADHD medications often

have side effects (Barnard-Brak & Kudesy, 2022; Pan et al., 2022; Wynchank et al., 2017), and

are not always effective (Michielsen et al., 2021; Ophir, 2022). Recent studies have even

suggested that, despite potential withdrawals and a lack of other treatment options, most people

try to stop taking ADHD medication (Ophir, 2022), with 42.7% of people being successful in a

different sample (Michielsen et., 2021). Without a holistic, behavioural understanding of ADHD,

health professionals may continue to prioritise pharmaceutical treatments, instead of first

adopting a more contextual approach to improve functional behaviour with far fewer side effects.

In summary, neurocognitive ADHD theories overemphasise neurological differences and

underemphasises contextual factors that also influence ADHD symptom expression. At best,

these theories overlook the potential advantages of ADHD (e.g., Boot et al., 2020). At worst, the

neurological focus of these theories may promote misdiagnosis and clinical malpractice (BBC

Panorama, 2023), and cause shortages of ADHD medication (ADHD UK, 2024), as potentially
ineffective and harmful medications (Michielsen et al., 2021; Ophir, 2022), remain the first main

treatment option for adults and some children (Hertfordshire Partnership NHS, 2017), with other

treatment options often only being recommended after starting medication (e.g., Psychiatry UK,

2024).

In this paper, we look to refocus ADHD conceptualisation and treatment towards a holistic

model of behaviour, where medication is one, but the not the only option to manage ADHD

symptoms. We model ADHD behaviour as a contextually-bound process dependent on both a

person’s biopsychosocial environment, including ADHD-related neurology, and their past

learned experiencess (relational frames; Hayes et al., 2001; Hayes et al., 1999; Horne &

Swettenham, 2024). As ADHD is one extreme of self-regulation behaviour (Martin et al., 2014;

Stergiakouli et al., 2015), we generalise behavioural self-regulation theory to the clinical self-

regulation issues linked with ADHD, and argue that ADHD symptoms are a result of faster

contextually-bound changes in goal-directed behaviour (attention, emotion, motivation) which

lead to more frantic, inefficient behaviour (Jylkkä et al., 2023) as people switch faster between

new goals and ideas (Boot et al., 2020). We also differentiate this behavioural process from

another behavioural process associated with sluggish cognitive tempo (SCT; Becker, 2021;

Becker et al., 2016), and explain how theoretically both processes could contribute to inattentive

symptoms within an individual. Based on this contextual understanding of ADHD, we then make

contextual recommendations to help people with ADHD live lives they value. In doing so, we

aim to provide practical alternatives for first-line ADHD treatment, especially for people who

cannot access medications, or experience severe side effects from them.

 The process model of ADHD

Our theory of behaviour

Before introducing our process model of ADHD behaviour, we must first introduce our

underlying model of human behaviour and the philosophy behind it. It is best practice for both

clinical and sport and exercise psychology practitioners to use an underlying philosophy and

theory of behaviour to inform their work (Hughes, 2018; Poczwardowski et al., 2004; Tod &

Eubank, 2020). Doing so allows practitioners to integrate different interventions within a holistic

treatment program (e.g., Horne & Swettenham, 2024). To our knowledge, this is something that

no theory of ADHD currently does: neurocognitive deficits remain the priority while their

downstream effects on behaviour, in combination with other contextual factors, comparatively

seem like an afterthought. This over-emphasises the role of the neurology shared among people

with ADHD and neglects the individual-level differences that may either worsen or reduce their

symptoms.

Our process model of ADHD behaviour instead is underpinned by functional contextualism and

relational frame theory (Hayes et al., 1999; Hayes et al., 2001; Horne & Swettenham, 2024; see

Figure 1). Within the model, behaviours (both internal thoughts, feelings and emotions, and

external, observable actions) are reciprocally dependent on an individual’s context, consisting of

their environment (physical, social, physiological and neurological), and their relational frames.

Relational frames are webs of language-driven formed connections between different stimuli and

are how we learn as humans. Relational frames form verbal knowledge and rule-governed
behaviour. As we develop, behaviour becomes evermore mediated by our relational frames as we

behave according to our past experiences. Generally, Figure 1 argues that our behaviour is

dependent on our current environment and how we have learnt to perceive it, and our behaviour

can change our environment and provide new experiences to be learnt from.

Figure 1.

Our theory of behaviour based on Functional Contextualism and Relational Frame Theory

Within this theory of behaviour, existing ADHD theories document parts of an individual’s

context. Together, existing neurocognitive theories suggest that reduced dopamine signalling

associated with ADHD leads to a reduced functioning reward system (Prince, 2008; Sagvolden et

al., 2005); this relates to an individual’s neurocognitive environment in the model. Over time, the

reduced reward and satisfaction in life encourages people with ADHD to prioritise immediately

rewarding tasks over effortful work towards their long-term goals (Barry & Kelly, 2006;

Sagvolden et al., 2005); this relates to an individual’s the relational frames in our model.
However, while these theories model an individual’s context, they neglect the behaviour itself.

For example, while these theories argue that someone with ADHD would be more impulsive,

they do not describe how this impulsivity occurs in terms of motivational, attentional, and

emotional processes; they do not describe how these processes may be different from people

without ADHD; and they do not describe under what conditions and contexts this impulsive

behaviour will occur. Our contextually-bound process model below looks to solve these issues.

The ADHD process model

Elsewhere, there has been a growing call for a contextual, process-based understanding of

ADHD behaviour. As many of the neurocognitive ADHD theories were being published, there

was initial doubt around whether neurocognitive-level theories were the best suited for

understanding the disorder (Nigg et al., 2005). More recently too, there have been calls for a

holistic, contextual understanding of how psychiatric disorders affect maladaptive behaviour

processes (Hayes et al., 2019); instead of trying to reduce psychological symptoms that are

deemed problematic (e.g., anxiety), a greater emphasis should be given to how these conditions

prevent people living the lives they value (Hayes et al., 2019). Recent voices in scientific

journalism have also proposed that a more process-based understanding of neurodiversity is

needed (Timms, 2022): having a particular diagnosis, such as ADHD, is neither definitive nor

comprehensive in defining an individual’s life experiences or behaviour, a more nuanced

explanation is needed.
Where behavioural implications are touched upon, existing ADHD theories describe it as a

disorder of goal-directed behaviour and self-regulation. Barkley (1997, 2011, 2022) relates his

executive dysfunction to self-regulation and goal-directed behaviour, specifically through issues

in task persistence and fluency. Additionally, Sagvolden et al. (2005) describe how neurological

signalling and learning impairments lead to impulsiveness, aversion towards waiting and delays,

and preferential hyperactivity towards immediately gratifying and novel situations. While a

mechanism for this action is not identified in either theory, together these results suggest that

people with ADHD will struggle to persist on long-term goals where they are uncomfortable,

boring, and presented with a more gratifying alternative.

In contrast, self-regulation in positive and cognitive psychology theories do provide process

models of goal-directed behaviour over time in general populations. Recent models of self-

regulation and self-control model it as a process (Inzlicht et al., 2014; Inzlicht et al., 2021), rather

than a resource (Inzlicht & Schmeichel, 2012): instead of a self-regulation being something that

can be trained, depleted and replenished, self-regulation is dependent on shifts in motivation,

attention, and emotion over time between long-term and short-term goals (Inzlicht et al., 2014),

within a particular environment. Once an individual engages in a long-term goal-orientated task

that requires self-regulation, effort becomes increasingly unattractive, as an individual’s

motivation, attention, and emotions become more directed at immediately rewarding short-term

goals instead. While Inzlicht et al. (2014) only accounted for one task, we model self-regulation

across multiple tasks, with (long-term) goal-directed behaviour (attention, motivation, and

emotion) functioning as a wave (see Figure 2).

Figure 2

Goal-directed behaviour towards a particular goal in people with and without ADHD

We assert that individuals with ADHD experience faster changes in goal-directed behaviour

(attention, motivation, and emotion) towards any given goal, either short- or long-term.

Consequently, not only does goal-directed behaviour decline more swiftly for individuals with

ADHD than their neurotypical peers, but it also returns faster too, provided an individual's

context allows these changes. Figure 2 shows this process towards one long-term goal over time.

Faster changes in goal-directed behaviour leads to more erratic and chaotic behaviour, where

individuals with ADHD switch between different thoughts, ideas, and tasks more often. In
experimental environments such as Boot et al. (2020) and Jylkkä et al. (2023), this franticness

can lead to a faster generation of new ideas and creativity as attention to different things changes

more quickly (Boot et al., 2020), but these faster changes can also lead to inefficient

performances on singular tasks (Jylkkä et al., 2023). However, in different contexts where task-

irrelevant novelty is available (in conversations with others, or on social media, as examples)

performance on a particular task may decline.

This process reframes traditional ADHD symptoms of inattention and hyperactivity-impulsivity.

Instead of being simply issues of attention control and self-regulation, now these symptoms mark

the shifts in goal-directed behaviour within different contexts. As attention, motivation, and

emotion declines at a faster rate for people with ADHD, current tasks become more unengaging,

boring, and burdensome more quickly, while a new task they could be doing instead becomes

more captivating, exciting, and fun. Hyperactive-impulsive behaviour occurs when individuals

follow these faster changes in attention, whereas inattentive behaviour occurs when people

cannot, or choose not to, change their actions due to contextual restraints. In such cases,

attention, motivation, and emotion remain directed towards different tasks, as they think about

other things, but their observable actions only reflect a disengagement with the current activity.

This process also provides insights into more complex behaviour associated with ADHD, such as

the ADHD paralysis. In our model of behaviour (see Figure 1), behaviour is both observable

actions, as well as thoughts, feelings and emotions, and all this behaviour can be goal-directed.

Paralysis associated with ADHD, referred to colloquially as ADHD paralysis (ADDA Editorial

Team, 2022; Enright, 2021) or scientifically as analysis-classification-paralysis (Carminati et al.,

2023), describes when people with ADHD symptoms get stuck in a mental loop of thinking

about, but not beginning tasks, when they are faced with lots of information and jobs to do. This

paralysis behaviour can be seen as an extreme of the ADHD model shown in Figure 2. In

situations with much information and many tasks to do and little motivation, persistence may be

so low because goal-directed behaviour is limited to only thoughts on a particular task, and does

not extend to observable actions. Therefore, an individual’s thoughts may switch to a new task

before they have had the chance to start action on the one before.

Contextual factors within our model

Contextual factors affect goal-directed behaviour. In any given situation, an individual’s

attention and subsequent behaviour are inherently bound by the context and their tasks within it

(Horne & Swettenham, 2014). As a result, contextual changes can be used to functionally

improve behaviour, whether that be environmental changes (Duckworth et al., 2014, 2016;

Duckworth et al., 2018), or through new learned experiences forming new relational frames

(Hayes et al., 1997). In our model’s biopsychosocial conceptualisation of environment (Horne &

Swettenham, 2024), an ADHD brain is one environmental factor which can affect behaviour, as

shown in Figure 2. However, other changes in context, whether social, physiological, or

experiential can also affect behaviour.

For example, developmental changes in ADHD symptom expression are tied with contextual

changes over time. While initial hyperactive and impulsive behaviour are common in children

with ADHD, these external behaviours are often replaced with internal symptoms of inattention
in adulthood (Kumperscak, 2013). This delay in inhibiting observable ADHD symptoms can be

linked to delays in brain maturation (e.g., Shaw et al., 2007), but also the impaired learning of

social norms and rules over time (Barry & Kelly, 2006; Sagvolden et al., 2005); these represent

an individual’s environment and relational frames in Figure 1, respectively. Learning these social

norms prevents the faster changes in thoughts, motivations, and emotions being externalised into

impulsive, hyperactive actions. Children with ADHD and higher IQ, another contextual factor,

may learn these social norms faster and mask their symptoms better due to less delays in brain

development (De Zeeuw et al., 2012) and less impaired cognitive skills (Milioni et al., 2017).

Additionally, contextual differences can affect task persistence through different initial levels of

goal-directed behaviour (Hayes et al., 1997; Hayes, 2001; Horne & Swettenham, 2024). On the

one hand, positive past experiences of an environment or task may improve future task

persistence through increasing future motivation: Taylor et al. (2020) found that high motivation

towards an exercise endurance task led to increased persistence, while goal-directed behaviour

declined similarly across high and low motivation groups, as initial differences were maintained

the higher motivation group persisted longer. On the other hand, effortful, cognitively

demanding tasks have been linked with increased hyperactivity behaviour for people with

ADHD (d= 1.39), far more than in low cognitive load environments (d = .036; Kofler et al.,

2021). Intuitively, but contrary to neurocognitive ADHD theory, these results suggest that

ADHD-related hyperactivity is context dependent: task persistence is worse for uncomfortable,

unmotivating situations, especially for people with ADHD. In our process model (see Figure 2),

engaging or demanding contexts would then lead to differing goal-directed behaviour peaks.
Furthermore, contextual, physiological changes during and after exercise can slow the changes in

goal-directed behaviour associated with the disorder. Exercise programs aim to improve the

management of goal-directed behaviour (Ng et al., 2017; Silva et al., 2015). At a neurocognitive

level, these treatments help to minimise the deficits which have been found in some, but not all

people with the disorder (e.g., Mehren et al., 2019; Willcutt et al., 2005). At a behavioural level,

exercise has led to improved sustained attention for people with ADHD (Rassovsky & Alfassi,

2019), and neutralised possible effects of ADHD on goal valuation (Horne et al., 2024). Other

contextual, physiological changes which reduce inattentive and hyperactive-impulsive

symptoms, such as omega-3 supplementation (Chang et al., 2018; Hawkey & Nigg, 2014), or

even transcranial direct current stimulation (Breitling et al., 2016; Salehinejad et al., 2020) could

similarly help slow changes in goal-directed behaviour for people with ADHD.

Distinctions between ADHD and SCT

Our process model is distinct but interlinked with other processes within neurodiversity and

mental illness. Our model argues that ADHD behaviour such as inattention and hyperactivity-

impulsivity are due to faster changes in goal-directed behaviour (attention, motivation and

emotion). However, this is not the only process that exists within neurodiversity, nor is it even

the only process that contributes to inattention. People with ADHD may experience multiple

processes at once, and these processes combine to reach clinical threshold levels of inattentive

behaviour.
One example distinction is between ADHD and Sluggish Cognitive Tempo (SCT) processes.

SCT (Barkley, 2012; Becker, 2021; Becker et al., 2016), predominantly inattentive ADHD

(Barkley, 1997; Milich, 2001), and depression (Kroenke et al., 2001) lead to symptoms of

apathy, lethargy, brain fog, and inattention, but crucially not hyperactivity-impulsivity. There is

huge overlap between ADHD and SCT both diagnostically and behaviourally in terms of

inattention, but they are distinct disorders with different functional problems (Barkley, 2012;

Becker et al., 2020; Lee et al., 2016; Lee et al., 2014). Approximately half of adults with clinical

levels of ADHD also have clinical levels of SCT, and vice versa (Barkley, 2012).

We propose that SCT is related to lower initial goal-directed behaviour (attention, motivation,

and emotion) towards any goal (see Figure 3). Unlike our ADHD process, goal-directed

behaviour does not change faster, but is generally lower. Due to lower levels of goal-directed

attention and motivation, overall but task persistence and attention towards it will still be

impaired (Taylor et al., 2020). Therefore, people who only experience this second process would

still display inattentive behaviour quicker than healthy, neurotypical populations, but the loss of

attention and motivation towards one activity would not be replaced by attention and motivation

towards another.

Figure 3.

Goal-directed behaviour towards one task in people with and without SCT
A combination of ADHD and SCT processes helps to explain links between ADHD and fatigue.

Fatigue is a common comorbidity with ADHD; people with the disorder are more likely to feel

clinical levels of fatigue than healthy populations (62% to 26%) and only marginally less than

people diagnosed with chronic fatigue syndrome (86%; Rogers et al., 2017). Additionally,

ADHD and depressive symptoms, have both been shown to be unique predictors of fatigue

intensity (Sáez-Francàs et al., 2012). Our process models of ADHD (Figure 2) and SCT (Figure

3) could uniquely contribute to this fatigue both through doing more inefficient and frantic goal-

directed behaviour to complete the same task, and general feelings of lethargy, apathy and

amotivation, respectively.
 Model limitations and future directions

This model assumes that poor self-regulation linked with ADHD is an extreme of poor self-

regulation in neurotypical people. This assumption is based on genetic research findings that

people with ADHD just have more ADHD risk factors than people without ADHD (Martin et al.,

2014; Stergiakouli et al., 2015), and allows us to generalise self-regulation theory and goal-

directed behaviour changes from population samples to clinical ADHD samples. To our

knowledge, however, no experiment has investigated how ADHD is linked to goal-directed

behaviour changes and task persistence other than Horne et al. (2024). Further research is needed

to test differences in goal-directed behaviour between people with and without ADHD across

different environments and tasks.

Recommendations

We now make some recommendations on how an individual’s context, in both their environment

and relational frames (see Figure 1), can be manipulated to help people with ADHD manage

their symptoms and live meaningful lives. While theories of ADHD’s neurocognitive deficits

may promote pharmaceutical treatments which directly target them, these are not always

effective, and can lead to serious side effects (e.g., Michielsen et al., 2021). In contrast, our

model encourages people with ADHD to integrate many different, more accessible and

sustainable treatments either as an alternative or to complement pharmaceutical interventions.

Our aim here is to promote more holistic treatment plans for ADHD, rather than defaulting on

prescribing legal stimulants (e.g., Psychiatry UK, 2024).

Where possible, work environments can be manipulated to best suit the strengths of ADHD.

Above, we have shared results that suggested that people with ADHD have more creative

achievements and novel ideas (Boot et al., 2020) and are able to switch in goal-directed

behaviour while maintaining a level of performance on one task (Jylkkä et al., 2023). Due to

their faster changes in goal-directed behaviour, especially during cognitively demand tasks

(Kofler et al., 2016), people with ADHD may benefit from having multiple tasks at once which

they can switch between at will when they have a new, novel idea, or get bored. While Jylkkä et

al. (2023) showed that people with ADHD perform similarly to neurotypicals at one task within

an experimental context, people with ADHD may thrive in jobs and contexts where goal-directed

behaviour towards a secondary task is still productive; what was inefficient, irrelevant behaviour

in Jylkkä et al. (2023) could be a groundbreaking new idea for a side project.

Environmental changes should also be used to manage the downsides of the disorder. While

faster changes in goal-directed behaviour can be useful for creativity, they can often lead to

forgetfulness and make it harder for people with ADHD to stay on track. Using a notepad or

other note-taking device to write down both goals and novel thoughts before attention is diverted

can both maintain organisation and goal-directed behaviour, while also making sure creativity is

not lost (Boyer et al., 2015; Duckworth et al., 2018; Fleming & McMahon, 2012; Murphy,

2005). People could also change their working environments so that potential distractors, such as

online devices, are harder to access (Duckworth et al., 2018). These extra barriers may reduce

initial motivation for the distraction, so goal-directed behaviour may revert back into the original

task quicker.
Other factors related to individuals’ physiological health, diet, and recovery should also be

prioritised to manage fatigue and work sustainably. Many alternative treatments to ADHD have

already been intensively researched and many have been shown effective to manage ADHD.

Exercise programs are arguably the most effective behavioural ADHD treatment and many

reviews have shown them to reduce ADHD symptoms (e.g., Sun et al., 2022 SMD = −0.60).

Other behavioural interventions promoting sleep have also been shown to reduce ADHD

symptoms (SMDs = −0.02 to −0.40; Larsson et al., 2023). And even small changes in diet, such

as omega-3 supplementation, moderately reduce ADHD clinical scores (g = 0.38; Chang et al.,

2018), with probiotics treatments showing promising, but preliminary findings too (Nahidi et al.,

2024). These treatments, which can be combined, are all comparative to medication efficacy (d =

.65; Mészáros et al., 2009), but without the potential side effects.

Finally, psychological, cognitive behavioural interventions can establish new relational frames to

encourage long-term functional behaviour. For example, Acceptance and Commitment Therapy

looks to encourage valued, meaningful, long-term behaviour, through mindfulness, acceptance,

and behavioural interventions (Hayes et al., 1999). These interventions look to change how

people notice and relate to their thoughts, feelings and emotions through developing more

adaptive relational frames and verbal rules. For ADHD specifically, these new relational frames

could help counteract existing ones associated with the disorder which may prioritise short-term,

immediately gratifying avoidance behaviours (Hayes et al., 1999; Sagvolden et al., 2005).

Mindfulness-based cognitive behavioural therapies such as acceptance commitment therapy have

been shown to reduce inattention (d = -.66) and hyperactivity/ impulsivity symptoms (d = -.53;

Cairncross & Miller, 2020).

 Conclusion

In this paper, we present a contextually-bound process model of ADHD underpinned by a theory

of behaviour. We then differentiate this process from SCT, a different behavioural process that

while interlinked with ADHD and inattentive symptoms, is itself distinct. Not only do we hope

this paper promotes a process-based understanding of neurodiversity which assesses functional

behaviour, not symptoms, but we also hope our context-based recommendations encourage a

holistic management of ADHD symptoms, where medication is one option, rather than the only

option, for healthcare providers. Through our contextual recommendations for people with

ADHD, we hope to help people with the disorder play to their strengths, and around their

weaknesses, to achieve a life they value.

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