This programme is a treatment manual intended for mental health professionals. It presupposes clinical training, experience of working with adults, and a supervision framework. It replaces neither your clinical judgement nor your ethical responsibility. The diagnostic criteria are reformulated in our own words, never reproduced: refer to the original manuals for the letter of the text.
1. The programme at a glance
Indication. Attention deficit hyperactivity disorder in adults: inattention, disorganisation, impulsivity and inner restlessness, present since childhood, in at least two contexts, with an occupational, relational or financial impact.
Reference model. The cognitive and behavioural therapies evaluated in this disorder: the organisational skills training protocol of Safren et al., the group meta-cognitive therapy of Solanto et al., and the work of Barkley and Ramsay on the deficit of implementation. The whole rests on the executive model, on the motivational model of sensitivity to delay, and on the analysis of learned avoidance.
Format. Fourteen individual sessions of 50 minutes: weekly until session 8, then every two weeks. Two booster sessions, at one month and then at three months.
Mechanism targeted. Not to make the patient attentive, but four changes: to put the organisation into the environment rather than into their head, to make consequences immediate, to undo the avoidance that has settled over twenty years, and to repair a self-image built on reproach.
| Session |
Object |
Product of the session |
| 1 |
Feedback, measures, record |
Record installed |
| 2 |
Explaining the disorder, rereading one's life |
Written case formulation |
| 3 |
The external system: capturing |
Single list in place |
| 4 |
The calendar and time |
Single diary, durations quantified |
| 5 |
Getting started |
Written starting procedure |
| 6 |
Space, paperwork, money |
Three automatisms installed |
| 7 |
Procrastination |
Two avoidances treated |
| 8 |
Emotions |
Signal and de-escalation protocol |
| 9 |
Impulsivity |
Written delay rules |
| 10 |
Work |
Adjustments requested |
| 11 |
The people close to them |
One conversation prepared and held |
| 12 |
Sleep, screens, substances |
Bedtime held |
| 13 |
Self-image |
List of contrary evidence |
| 14 |
Review, plan, and what follows |
Plan written in the patient's own hand |
What the patient takes away. Seven printable worksheets, listed in section 35 and downloadable from this page: my record, my single list, my diary, my starting procedure, my avoidance situations, my thermometer, my plan.
What distinguishes this programme from organisational coaching. Coaching teaches methods. This programme does three further things: it treats avoidance, which is the reason the known methods are not applied; it treats emotional regulation, which decides a large part of the relational impact; and it works on self-image, without which the patient gives up at the first failure.
2. Before you begin
Who this programme is for
This text is addressed to psychologists, psychiatrists, neuropsychologists, psychotherapists and doctors trained in cognitive behavioural therapy with adults. It presupposes that you can conduct a structured diagnostic interview, that you know the presentations that must be ruled out, and that you know how to work with a prescriber.
It is not intended for patients. It contains the procedures, the thresholds and the criteria of non-response, and it raises questions — medication, misuse, prognosis, non-response — that must be put differently when one is addressing the person concerned.
The prior question: is this really ADHD?
It is the most important decision in this manual, it is harder than in paediatrics, and it is not made in one session.
This programme accompanies an established ADHD in an adult, that is, a picture of inattention and disorganisation, with or without hyperactivity-impulsivity, present since childhood, in at least two contexts, with a real impact, and not explained by something else.
It does not treat an overloaded life. An adult managing three children, a demanding job and an unshared mental load presents exactly the picture: forgetting, scattering, irritability, the sense of never finishing. Look at what is being asked of them before concluding about what they cannot do.
It does not treat a recent onset. It is the rule that settles the matter most often, and it is simple: ADHD does not begin at thirty-five. A patient who describes a disorganisation that appeared two years ago has something else — a depression, an exhaustion, a sleep disorder, a substance use, a life event. Section 10 gives the method for establishing onset.
It does not treat the presentations that must be ruled out first: lack of sleep and apnoea, depression, bipolar disorder, anxiety disorders, substance use, borderline personality disorder, autism spectrum disorder, learning disorders, and certain medical causes. Section 7 is devoted to them, and it is not optional.
It does not replace a medical opinion. The diagnosis may be made by different professionals depending on the country, but the question of medication is a doctor's business, and so is the physical work-up.
A difficulty particular to this period
Many patients arrive with a diagnosis they have made themselves, often from online content. That calls for a precise position, and it is neither contempt nor acquiescence.
What is true: the disorder has been massively underdiagnosed in adults, in particular in its inattentive form and in women, and many of these patients are right. A recognition that arrives through online content is still a recognition.
What is also true: the descriptions in circulation are not very specific, they describe experiences almost everyone has, and a patient who recognises themselves in a list does not thereby meet the criteria — in particular those of early onset and impact.
What you do: you do not argue with the hypothesis, you assess it. Say so in those terms from the first interview — "we are going to look at this seriously, and I will tell you what I find, including if I find something else". A patient who is promised an honest assessment accepts a negative conclusion very well; a patient who is met with doubt from the outset does not come back.
What this programme is not
It is not attention training. See section 34.
It is not a drug treatment, and it does not take its place. The place of medication is stated in section 13, clearly and without circumlocution.
It is not productivity coaching. The aim is not output, and a manual aiming at that would miss the essence of what this disorder costs: relationships, money, and self-esteem.
It is not a therapy of origins. The past is reread in session 2, once, in order to give the history a meaning — not in order to be explored at length.
How to use it
Read the whole before the first session, in particular sections 7, 10, 13 and 31: the differential, the retrospective diagnosis, medication, and external organisation. Those are the four places where one goes wrong.
Each session is described within the same frame: the objective, the step-by-step run-through, what you say, the frequent errors, and the criterion for moving on.
A warning particular to this disorder. Your patient will forget sessions, arrive late, and not do the agreed tasks. That is not resistance and it is not a failure of alliance: it is the presenting complaint manifesting itself in your consulting room. Section 15 says how to take account of it in the frame, and that is what decides whether the follow-up ends prematurely or not.
3. The clinical picture in adults
What patients describe
They rarely describe inattention. They describe a gap: between what they are worth and what they produce, between what they intended to do and what they did.
The sentences that recur: "I know perfectly well what needs doing, I cannot do it", "I start ten things and finish none", "I need an emergency in order to start", "I have tried every diary there is", and "I feel I have wasted what I had". That last one is the most important.
They also describe something that makes them doubt themselves: on what fascinates them, they hold out for six hours without lifting their head. That sentence is almost always spoken, often in the tone of a confession, and it is the one to explain first — see section 4.
What has changed since childhood
Visible hyperactivity has gone, and has become an inner restlessness: a difficulty in sitting still without occupying one's hands, a need to move, a sense of an engine running, the impossibility of doing nothing.
Inattention and disorganisation have persisted, and they cost more than before, because nobody structures the adult's environment in their place any more. School gave a frame; adulthood gives none.
Compensations have accumulated. Many of these patients have developed costly strategies — working at night, doing everything in a rush, choosing highly stimulating jobs, relying on a very organised partner. They hold as long as a balance holds, and they give way at a change: a promotion, a birth, a divorce, a move to remote working.
That is the most frequent reason for a first consultation at thirty-five or forty, and it must be said to the patient: it is not the disorder that has appeared, it is the compensation that has given way.
The three dimensions in adults
Inattention. Difficulty sustaining attention on what is not immediately interesting, losing the thread in a conversation or a meeting, forgetting, losing objects, careless mistakes, an inability to proofread. It is the dimension most stable with age and the most closely tied to occupational impact.
Disorganisation. To be treated as a dimension in its own right in adults, because it is the one that produces the most concrete damage: unprocessed paperwork, missed appointments, overrun deadlines, late payments, a cluttered home.
Impulsivity. Interrupting, deciding fast, buying, resigning, breaking off, taking risks at the wheel. It is the dimension least visible in consultation and the most costly in real consequences.
Motor hyperactivity is still noted, but it tells you little in adults. Record the other three separately.
The dimension that is not in the criteria
Emotional dysregulation. It is not in the diagnostic criteria, it is present in a large majority of adults with ADHD, and it is very often the real reason for consulting — even when the stated reason is organisation.
What it produces: reactions that rise within seconds, an intensity out of proportion to the event, a rapid return to normal, a low tolerance of frustration, and a marked sensitivity to rejection and criticism.
What it costs: couple conflicts, jobs left on impulse, damaged friendships, and a reputation for being difficult.
It has its session in this programme — session 8 — and it is not an extra: in many patients it is the part that changes the most.
The layer the child does not yet have
Learned avoidance. Twenty years of repeated failure on the same tasks produce a stable avoidance, and that avoidance becomes an autonomous problem, independent of the deficit that created it.
Concretely: the patient no longer opens their post, no longer looks at their bank account, puts off administrative calls, lets deadlines pass whose date they nevertheless know. That is no longer a problem of attention, it is a problem of anxiety and avoidance, and it is treated as such.
Spotting this layer is decisive: an organisational programme applied to an untreated avoidance produces nothing, because the patient already knows the methods and does not apply them.
What adult ADHD is not
It is not an attention deficit in the strict sense. The patient can concentrate intensely on what interests them. The problem is regulation: allocating attention according to importance and not according to interest.
It is not a lack of intelligence. Many of these patients are highly able, and that is precisely what delayed the diagnosis: they compensated until the demands exceeded their capacity to compensate.
It is not a lack of will. It is the most important sentence of the feedback, and it must be supported by the model rather than by an assertion.
It is not an excuse. Say that too, and say it early. The diagnosis explains the difficulties, it does not exempt from the consequences, and a patient who uses it in order to change nothing will not get better. That sentence is said with warmth and it is not taken back afterwards.
What makes the picture worse
Lack of sleep, which imitates and worsens the disorder. Alcohol and cannabis, very frequently used as evening regulators. Environments with no imposed structure — self-employment, full remote working, periods of unemployment. Heavy administrative burdens. And the accumulation of failures, which produces avoidance and then demoralisation.
Epidemiology, in three useful figures
The prevalence of ADHD in adults is estimated at around two and a half to three per cent, with figures that vary according to the definition of persistence adopted.
A substantial proportion of children diagnosed retain a significant picture in adulthood, often in a different form — visible hyperactivity decreases, inattention and disorganisation persist.
The diagnosis is markedly less frequent in women, and that gap is largely due to under-recognition of the inattentive form and to earlier social compensation. In a woman of forty, the absence of a childhood diagnosis is not an argument against.
4. The model that guides this programme
Three levels, to be explained to the patient
It is the most profitable explanation of the programme, and it takes twenty minutes in session 2. It makes comprehensible what has been baffling the patient for years.
The executive level. What is affected is not knowledge of the rules, it is the capacity to apply them at the right moment: inhibiting a response, keeping a goal in mind while doing something else, remembering the next step, resisting a distraction, estimating time.
A useful formula: it is not a disorder of knowing, it is a disorder of doing. The patient knows what needs doing; they do not do it at the moment when it needs doing. That is why the organisational advice, all of which they know, has never changed anything.
The motivational level. The adult with ADHD is more sensitive than others to the delay of reward. A deadline three weeks away does not reach them; the same deadline tomorrow sets them in motion. That explains functioning by emergency, which is not a character trait but the only condition in which the system starts up.
The learned level. After twenty years, a third layer has been added: avoidance of the tasks on which they have failed, and a set of beliefs that goes with it — "I am incapable", "there is no point trying", "I work better under pressure", "if I start I shall get it wrong". That layer is not in the deficit, it is in the history, and it is the one most accessible to treatment.
What these three levels imply
They give the four principles of the programme, and they must be written down with the patient.
The organisation is put outside. Not in their head: in the environment, at the point of use, in a form they do not need to remember. Anything that rests on memory will fail.
Consequences are made immediate. A distant deadline does not work; a deadline manufactured this week does. It is a design constraint, not a lack of seriousness.
Work is broken up. Short units, planned breaks, visible steps, and a first step small enough to be ridiculous.
Avoidance is treated as avoidance. With the tools that work on avoidance: breaking down, graded exposure, behavioural experiments — and not with more method.
What the model explains to the patient
Why they hold out for six hours on what fascinates them. Immediate feedback, constant novelty, calibrated difficulty. It is not proof that they could if they wanted to, it is a demonstration of the model.
Why they only start at the last minute. The emergency supplies the immediacy that the system does not manufacture on its own. The programme does not take that crutch away: it teaches them to produce urgency earlier and at less cost.
Why they know every method and apply none. Because the problem has never been knowledge, and because each failed attempt has added a layer of avoidance.
Why they forget what matters and retain what does not. The allocation is not made according to importance.
Why they function well in a crisis and badly in calm. It is the same mechanism, seen from the other side.
What the model implies not doing
Do not aim at discipline. It has already been tried, hundreds of times, and it is the failure of those attempts that produced the demoralisation.
Do not pile up tools. A system with five applications is a system that will be abandoned in three weeks.
Do not remove the supports because things are going better. They are going better because the supports are there.
Do not confuse avoidance with laziness, including when the patient calls it laziness themselves.
5. The DSM-5-TR criteria, reformulated
The criteria below are a reformulation in our own words, for the purposes of a reminder. They do not replace the manual: refer to the DSM-5-TR (American Psychiatric Association, 2022) for the letter of the text and the application notes.
The disorder presupposes the following elements.
A set of manifestations of inattention and/or hyperactivity-impulsivity, persistent, that interferes with functioning or development.
On the inattention side: not paying attention to detail or making careless mistakes; having difficulty sustaining attention; seeming not to listen when spoken to; not following instructions through and not finishing; having difficulty organising tasks; avoiding tasks that demand sustained mental effort; losing necessary objects; being easily distracted; forgetting daily activities.
On the hyperactivity-impulsivity side: fidgeting, squirming; leaving one's seat when one is expected to remain seated; feeling restless in situations where that is not appropriate; being unable to be still in leisure; being often on the go; talking a great deal; answering before questions are finished; having difficulty waiting one's turn; interrupting or intruding.
At least five manifestations in one of the two registers from the age of seventeen — six before that age —, persisting for at least six months, to a degree that does not match the developmental level.
Onset before the age of twelve, with several manifestations present before that age.
Presence in at least two contexts — home, work, studies, relationships, other activities.
A clear impact on social, academic or occupational functioning.
The absence of a better explanation by another mental disorder, and the absence of occurrence exclusively during a psychotic disorder.
The useful specifiers
The DSM-5-TR distinguishes three presentations: combined, predominantly inattentive, predominantly hyperactive-impulsive. In adults, the inattentive presentation is by far the most frequent, including in patients who were hyperactive as children.
It also allows severity and a state of partial remission to be specified. That last mention is useful in adulthood: a treated and well-compensated patient still carries the disorder.
The three points that cause difficulty in adults
The threshold of five manifestations was lowered for adults, and it remains debated: some data suggest it is still too high in patients with a high level of compensation, whose impact is real with four manifestations rated.
Onset before the age of twelve is the criterion hardest to establish retrospectively and the one most often rushed. Section 10 is devoted entirely to it.
The examples in the criteria are written for children. "Leaving one's seat in the classroom" does not transpose as it stands. Rate the adult equivalent, and tell the patient explicitly that you are doing so — otherwise they will answer no to questions to which the answer is yes.
What these criteria do not say and what must be assessed
They do not mention emotional dysregulation, which is nevertheless present in the majority of adults and often in the foreground.
They do not measure executive functions, and a normal neuropsychological assessment does not exclude the diagnosis — that is a frequent source of error, and more frequent still in adults.
They say nothing about sleep, which must be assessed systematically.
They say nothing about the compensations in place, which can mask the impact in a patient heavily supported by their partner or by their post.
Frequent questions
The patient arrives with a diagnosis they have made themselves.
Do not argue with the hypothesis: assess it, and say so in those terms from the first interview. Many of these patients are right, because the disorder has been massively underdiagnosed in adults. And many recognise themselves in descriptions that are not very specific. The method of section 9 settles it, and a patient who is promised an honest assessment accepts a negative conclusion very well.
How do you establish onset before the age of twelve in someone who is forty?
See section 10. In order: school reports, a parent, a sibling, then memories structured by concrete anchors. And when no source exists, one looks for continuity rather than for onset, and writes the limitation into the conclusion. What is not acceptable is not to look.
They did well at school and have a good job. Does that rule out the diagnosis?
No. It obliges you to document the impact differently: extra hours worked, personal life sacrificed, anticipatory anxiety, exhaustion, and what happens when the compensation disappears. Many of these patients consult precisely because a promotion or a birth has broken a balance that had held for twenty years.
Is medication necessary?
It is the best-evaluated treatment for this disorder, and it teaches nobody anything — both sentences are true and both must be said. The decision belongs to the patient and to the doctor. Your role is to inform, to pass on elements useful to the prescriber, and to measure the effect. See section 13.
They forget one session in three. Should the follow-up be stopped?
No: it is the presenting complaint manifesting itself in your consulting room. Put in place what section 15 describes — reminder the day before, fixed slot, policy on missed sessions announced without reproach — and tell them explicitly to call back after a missed session. A patient who feels ashamed does not call back, and that is how these follow-ups end.
They know every organisational method and apply none.
That is the most reliable sign of an installed avoidance, and it is not treated by one more method. Do the sorting of session 7 on real tasks, write the prediction beforehand, run the experiment, compare. If you add a tool to that picture, you add a failure.
They change application every two months, enthusiastically.
Name it: changing tool gives the sensation of progress at no cost, and it is a form of avoidance. The rule is that of section 31 — one support, as simple as possible, and it is not changed during the programme.
His partner is exhausted from managing everything.
It is the most frequent configuration, and the solution is not to ask the partner to stop reminding while counting on goodwill. The human reminder is replaced by the system: the partner stops when something else does it, not before. See session 11, and offer a couple session.
They say it is too late, that they have wasted their life.
Do not reassure. Acknowledge the grief, which is legitimate — there really are lost years. Then bring things back to what is measurable: what has changed since session 1, dated. In these patients, recent evidence is worth more than any argument, and that is why session 13 comes late in the protocol.
Should one tell them it is not an excuse?
Yes, and on the day of the feedback — not three months later on the occasion of a reproach. Said at the outset, with the sentence from section 11, it is received and it protects the follow-up. Said afterwards, it is experienced as the withdrawal of something that had been granted.
Is a neuropsychological assessment needed?
Not to make the diagnosis: in a highly able adult, normal tests are the rule and exclude nothing. It is useful for something else — spotting a learning disorder, documenting a need for adjustment, clarifying a profile. Ask for it when it will change something in the management.
Should they tell their employer?
That is not for you to decide. Help them weigh the benefit — formalised adjustments — against the risk, which is real and which varies a great deal by sector. And think of the intermediate options, too little used: asking for an adjustment without naming the diagnosis, or going through occupational health, who are bound by confidentiality.
Fourteen sessions, is that enough?
What counts is not the number of sessions, it is the number of supports actually installed and used. A patient who leaves after eight sessions with a single list kept every day, a starting ritual and a delay rule is better treated than a patient who has heard everything in fourteen. And plan the boosters: they are what decides whether it is maintained.