There are certain conversations that stay with you long after the session has finished, and over the last few years, I’ve found myself coming back to one in particular. It isn’t about one specific young person or one particular family. It’s a pattern I’ve started noticing more and more in my work with autistic and ADHD children and young people, and it has made me think quite differently about what we actually mean when we talk about therapy being successful.
Imagine a young person who, a few months ago, was barely managing school. They were becoming overwhelmed by the smallest changes, avoiding activities they used to enjoy and spending most evenings melting down after holding everything together all day. Their parents were exhausted and increasingly worried about how restricted their child’s world had become.
Fast forward a few months and things look very different. They’re attending school more consistently, they’ve started going back to activities they had stopped, and home is calmer. Their parents tell you they understand their child in a completely different way now. The young person can recognise when they’re becoming overwhelmed, explain what they need and ask for support rather than getting to the point where everything explodes. They’re recovering more quickly when plans change and they’re starting to understand that their brain works differently rather than believing there is something wrong with them.
From a clinical perspective, there is so much to celebrate here.
Then you look at the anxiety questionnaire.
The score has barely moved.
And that’s where I think things get interesting.
Has therapy fallen short, or are we measuring success in a way that doesn’t always capture the changes that actually matter to this young person and their family?
I certainly don’t have a definitive answer to that. This is much more of a question I’ve found myself sitting with through clinical practice, conversations with families and my own ongoing thinking about what neuroaffirmative CBT should look like in reality.
CBT has never promised perfection
One of the things I love about CBT is that it is practical. We work collaboratively to understand what is keeping difficulties going, identify patterns and experiment with different ways of responding. Ultimately, we’re trying to reduce distress and help people build lives that feel meaningful to them.
For many difficulties, symptom reduction is absolutely the right goal.
If I’m working with a young person with OCD, I want those intrusive thoughts to lose their power and I want compulsions to stop dictating their day. If someone is experiencing PTSD, I want traumatic memories to become less distressing and less disruptive. If depression has gradually taken away their motivation, confidence and enjoyment, I want to help them reconnect with the things that matter to them.
In those situations, measuring symptoms makes complete sense because the symptoms themselves are a huge part of what we are trying to change.
Working with neurodivergent young people has made me think more carefully about what happens when the picture is a little more complicated.
Not every source of anxiety needs to disappear
One of the conversations I have regularly with parents is about their child’s response to change.
A parent might tell me that their child becomes extremely distressed when a teacher is absent, the school timetable changes or somebody makes an unexpected alteration to the plans. They might say, “Can we get them to stop being so anxious when things change?”
I completely understand why they ask.
If you watch your child become incredibly distressed because something unexpected has happened, you want to know that therapy can make that easier for them.
What I often find myself explaining is that therapy might not make their brain suddenly love uncertainty. It can, however, change what happens around that anxiety.
For some autistic people, predictability genuinely matters. An unexpected change can require a huge amount of mental effort, particularly when there are already sensory, social or executive functioning demands going on in the background. ADHD can bring its own challenges with emotional regulation, impulsivity, working memory and managing transitions.
Those differences aren’t simply unhelpful thoughts that need challenging out of existence. They are part of how that person experiences and processes the world.
That doesn’t mean therapy has nothing to offer. Quite the opposite.
We can work on the fear that develops around anxiety, the shame that can build after years of being told you’re overreacting, the avoidance that gradually makes someone’s world smaller and the belief that you simply can’t cope.
We can help a young person recognise their early signs of overwhelm, understand what helps them regulate, communicate their needs more clearly and build confidence in their ability to get through difficult moments.
A young person might still feel their stomach drop when they walk into school and realise the usual teacher isn’t there. The difference might be that they now know what is happening, know what they need and know that they can get through it without immediately going home.
That is a pretty significant therapeutic outcome, even if the anxiety score doesn’t tell us much about it.
The question I keep coming back to
There are times when I finish a session feeling incredibly proud of the progress a young person has made, while also having a tiny part of me wondering whether I should have been able to do more.
I think that probably comes from caring about the people we work with.
I wish I could make the world quieter for the child who is completely overwhelmed by sensory input. I wish I could make uncertainty feel easier for the young person whose nervous system seems to be constantly searching for what is going to happen next. I wish I could remove the social misunderstandings, the pressure to fit in and the exhaustion that can come from spending all day trying to navigate an environment that doesn’t always feel designed with you in mind.
Of course, I can’t do those things.
No therapist can.
What I can do is help someone understand themselves better, develop strategies that genuinely work for them and build a life that feels more manageable and more theirs.
I think that’s why I’ve become increasingly interested in the difference between reducing symptoms and reducing suffering.
They overlap, but they aren’t always the same thing.
Are we asking the right questions?
I’m a big believer in routine outcome measures. They give us useful information, help us track change and can highlight when somebody isn’t progressing in the way we would hope. I don’t think we should throw them out.
I do think we need to be careful about assuming that one score can tell us the whole story.
Imagine two young people who both score highly on an anxiety questionnaire.
One is barely leaving the house, has stopped attending school and genuinely believes they are incapable of coping.
The other still feels anxious when plans change, still gets overwhelmed and still needs time to process unexpected situations, but they are attending school, seeing friends, taking part in activities they enjoy and asking for sensory adjustments when they need them. They can tell you what happens in their body when they’re becoming overwhelmed and they have learned that feeling anxious doesn’t automatically mean they have to escape the situation.
Those are two very different clinical pictures.
Yet if we only look at the anxiety score, we might miss some of the most important differences between them.
I think most therapists would look at the second young person and feel encouraged by that progress. Their family probably would too.
So why can we still find ourselves questioning whether therapy has worked when the anxiety itself hasn’t disappeared?
Recovery might look different
I don’t think neuroaffirmative practice means lowering expectations or deciding that symptom reduction doesn’t matter.
Autistic and ADHD clients can absolutely recover from anxiety disorders, depression, OCD and PTSD, and where reducing symptoms is appropriate, we should continue to aim for meaningful change.
What I think neuroaffirmative practice asks us to do is become more thoughtful about what exactly we are trying to change.
Are we trying to eliminate every anxious feeling?
Or are we trying to help someone build a life that isn’t controlled by anxiety?
Those are two very different goals.
I’ve started to think about recovery a little more broadly.
Recovery might look like understanding your own nervous system rather than feeling ashamed of it. It might look like recognising the early signs that you’re becoming overwhelmed and knowing what actually helps. It might mean asking for an adjustment at school rather than masking until you get home and completely fall apart. It might mean going to the birthday party even though you’re nervous because you trust yourself to cope with the discomfort. It might mean realising that needing headphones, movement, preparation or a quiet space isn’t a personal failing.
It might even mean a young person saying, “I’m really anxious about this, but I know what to do.”
For me, that sentence can represent enormous progress.
What are we actually measuring?
When we talk about therapeutic outcomes, we tend to think about things we can easily quantify. Anxiety score down. Depression score down. Panic attacks reduced. School attendance up.
There is huge value in that information, but I wonder whether we also need to become better at capturing the things that can be harder to put into a questionnaire.
Can this young person understand themselves better than they did six months ago? Can they recognise what they need and communicate those needs? Are they spending more time doing things they actually enjoy? Are they less frightened of their own emotions? Has the shame reduced? Are they masking less? Do they believe they are capable of coping? Are they making choices based on what they actually want rather than what anxiety tells them they should avoid?
These are the changes I often hear families talking about when they describe therapy helping their child.
They might tell me, “They still get anxious, but they understand what’s happening now.”
Or, “They still get overwhelmed, but we know what to do.”
Or, “They actually told their teacher what they needed instead of just refusing to go into school.”
Those conversations tell us something that a questionnaire score alone can’t always show.
Broadening the conversation
I don’t think this means replacing traditional outcome measures or deciding that we’ve been measuring therapy incorrectly all this time.
It feels more like an opportunity to broaden the conversation.
Our understanding of neurodivergence has changed enormously, so perhaps our understanding of what recovery can look like needs to keep developing too.
A young person who understands their own needs, feels less ashamed of who they are, can ask for support and is gradually taking back parts of their life that anxiety had taken away is showing us something important, even if their anxiety questionnaire still suggests they have quite a lot of anxiety.
Perhaps we don’t need to choose between symptom reduction and these wider outcomes. We can value both and use them alongside each other to build a much fuller picture of whether therapy is actually helping.
So what does success actually look like?
I still celebrate the anxiety score that comes down. I celebrate the young person who tells me they haven’t had a panic attack in three months. I celebrate the young person with OCD who realises they have gone an entire day without completing a compulsion. I celebrate the teenager who starts leaving the house again after months of avoiding it.
Those changes are huge.
At the same time, some of the most meaningful work I’ve done hasn’t involved making anxiety disappear completely.
It has involved helping a young person stop organising their entire life around it.
There is something incredibly powerful about a child who can say, “I know this is going to be hard, but I know what I need.”
There is something equally powerful about a parent saying, “I finally understand what’s happening for them.”
And there is something pretty special about watching a young person move from believing their brain is the problem to understanding themselves well enough to work with it.
That has left me with a question I suspect I’ll keep coming back to.
For some neurodivergent young people, could recovery be less about the absence of anxiety and more about the absence of unnecessary suffering, shame and restriction?
If the answer is yes, perhaps one of the challenges for us as therapists isn’t changing CBT itself. Perhaps it is becoming better at recognising, measuring and celebrating the progress that is already happening right in front of us.