DBT can help individuals with ADHD manage emotional dysregulation, impulsivity, and interpersonal difficulties.
By teaching skills such as mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, DBT can help those with ADHD better cope with their symptoms and improve overall functioning, making it a valuable complementary treatment approach although alternative management methods should be considered.
Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by persistent symptoms of inattention, hyperactivity, and impulsivity that interfere with daily functioning, according to the American Psychiatric Association.
While pharmacological treatments are often the first-line approach for managing ADHD symptoms, psychosocial interventions can provide additional support and help individuals develop coping strategies.
Dialectical Behavior Therapy (DBT) is one such intervention that has shown promise in addressing the challenges faced by individuals with ADHD.
What is Dialectical Behavior Therapy?
DBT is a cognitive-behavioral treatment developed by Marsha Linehan in the late 1980s for people with intense, hard-to-manage emotions, often meeting criteria for borderline personality disorder.
Its organizing idea is the dialectic. Treatment holds two truths together: that a person is doing the best they can, and that they still need to build new skills.
The therapy combines cognitive-behavioral techniques with mindfulness and acceptance strategies to help individuals regulate their emotions, tolerate distress, and improve interpersonal relationships. Acceptance strategies mean validating that a client’s reactions make sense given their history, rather than rushing straight to change.
Key components of DBT include:
- Mindfulness: Learning to be present in the moment and non-judgmentally observe thoughts, feelings, and sensations.
- Distress tolerance: Developing skills to cope with difficult situations and emotions without making them worse.
- Emotion regulation: Understanding and managing intense emotions more effectively.
- Interpersonal effectiveness: Communicating assertively, setting boundaries, and maintaining healthy relationships.
How Can DBT Be Applied to ADHD?
DBT was not designed specifically for ADHD. Many of its skills can still be adapted to help manage ADHD symptoms and the wider challenges the condition brings day to day.
As ADHD specialist Russell Barkley notes, the two conditions are substantially comorbid and may share around half their genetic liability. Both conditions center on one shared difficulty: regulating emotion. DBT was built to treat that dysregulation, so its skills transfer naturally to ADHD’s own emotional ups and downs.
Common difficulties experienced by individuals with ADHD that DBT can target include:
- Emotional dysregulation: Many individuals with ADHD struggle with managing their emotions, leading to impulsivity, mood swings, and interpersonal conflicts. DBT skills such as mindfulness, emotion regulation, and distress tolerance can help individuals better understand and cope with their emotions.
- Impulsivity: Impulsive behavior is a core symptom of ADHD and can lead to negative consequences in various domains of life. DBT’s emphasis on mindfulness and distress tolerance can help individuals pause before acting on impulses and make more thoughtful choices.
- Interpersonal difficulties: ADHD can impact social functioning, leading to challenges in maintaining relationships and communicating effectively. The interpersonal effectiveness skills taught in DBT can help individuals navigate social situations more successfully.
Examples of DBT Strategies for ADHD
Below are some examples of DBT strategies that could be used to help someone manage their symptoms of ADHD:
Mindfulness exercises
Practicing mindfulness through activities such as deep breathing, body scans, or guided meditations can help individuals with ADHD focus their attention, reduce stress, and manage impulsivity.
DBT organizes this practice into three “what” skills: observing, describing, and participating in the present moment. It also teaches three “how” skills. These mean acting non-judgmentally, one thing at a time, and in whatever way actually works. For ADHD, this can help counter a mind that jumps between tasks.
Behavior chain analysis
This DBT technique involves identifying the sequence of events, thoughts, and feelings leading up to a problematic behavior (e.g., an impulsive outburst).
The analysis also looks at “vulnerability factors”: anything that made a person more likely to react that way, such as poor sleep or a stressful day. The goal is to find the exact point where a different choice could have interrupted the chain.
By understanding these patterns, individuals can develop alternative coping strategies.
Opposite action
When faced with intense emotions that may lead to impulsive behaviors, DBT encourages individuals to act opposite to their emotional urges.
For example, if feeling angry and wanting to lash out, the opposite action might be to take a break and engage in a calming activity.
The effect here is physiological, not just mental. Acting against an emotional urge can directly shift the emotion itself, rather than only changing how a person thinks about it. For fear, this often means gently approaching a safe situation rather than avoiding it, since avoidance keeps needless fear alive.
DEAR MAN
DEAR MAN is a DBT acronym for assertive, effective communication:
- Describe: State the facts of the situation, without judging them.
- Express: Say how you feel about it, clearly and simply.
- Assert: Ask directly for what you need.
- Reinforce: Explain what the other person gains by cooperating.
- Mindful: Keep your attention on the one goal you are pursuing.
- Appear confident: Speak and act as though you believe in your own request.
- Negotiate: Stay willing to find a middle ground if needed.
Effectiveness of DBT for ADHD
Research on the use of DBT for ADHD is still emerging, but several studies have shown promising results:
- Adults: A randomized controlled trial found that adults with ADHD who received a 14-week DBT-based group treatment had significantly greater improvements in executive functioning, ADHD symptoms, and quality of life compared to those receiving treatment as usual. These improvements were maintained at a 6-month follow-up.
- Adolescents: A study explored moderators of long-term treatment outcomes in adolescents with ADHD who participated in a DBT-based skills training group. It was found that participants with elevated symptoms of hyperactivity/impulsivity, conduct problems, and emotional dysregulation benefited more from the DBT-based intervention than from a psychoeducational control group.
- College students: A pilot randomized controlled trial investigated DBT group skills training for college students with ADHD. While the study had a small sample size, results indicated improvements in self-reported ADHD symptoms, quality of life, and executive functioning.
Limitations and Considerations
While the research on DBT for ADHD shows promise, there are some limitations and considerations to keep in mind:
- Limited research: More large-scale, well-controlled studies are needed to establish the effectiveness of DBT for ADHD across different age groups and presentations of the disorder.
- Adaptation of DBT: DBT was originally developed for borderline personality disorder, and adaptations for ADHD are still being refined. More research is needed to determine which specific DBT skills and strategies are most effective for individuals with ADHD.
- Complementary treatment: DBT should not be considered a replacement for other evidence-based treatments for ADHD, such as medication management. Instead, it can be used as a complementary approach to address specific challenges and improve overall functioning.
- Access to trained providers: DBT requires specialized training, and not all mental health professionals may be adequately prepared to deliver the treatment. Individuals seeking DBT for ADHD should look for providers with experience in both DBT and ADHD.
ADHD specialist Russell Barkley cautions that DBT is not itself considered ADHD’s established first-line psychological treatment. He points instead to a different form of cognitive behavioral therapy aimed at executive-function difficulties such as organization and time management, ADHD’s own first-line therapy.
Conclusion
Dialectical Behavior Therapy offers a promising approach for addressing the emotional, behavioral, and interpersonal challenges often experienced by individuals with ADHD.
By teaching skills such as mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, DBT can help individuals with ADHD better manage their symptoms and improve their overall functioning.
While more research is needed to establish the effectiveness of DBT for ADHD, the existing evidence suggests that it can be a valuable addition to a comprehensive treatment plan.
Key Takeaways
- Origins: Marsha Linehan developed DBT in the 1980s for borderline personality disorder, not ADHD, but its skills can be adapted.
- Core skills: DBT teaches mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, which map onto common ADHD difficulties like emotional dysregulation and impulsivity.
- Evidence: Small randomized trials in adults, college students and adolescents with ADHD report gains in executive functioning and emotional control, though the evidence base is still limited.
- Complementary: DBT works best alongside first-line ADHD treatments such as medication, not instead of them.
- Access: Providers trained in both DBT and ADHD are scarce, which can make this therapy harder to access than medication or standard CBT.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425787
Fleming, A. P., McMahon, R. J., Moran, L. R., Peterson, A. P., & Dreessen, A. (2015). Pilot randomized controlled trial of dialectical behavior therapy group skills training for ADHD among college students. Journal of attention disorders, 19(3), 260-271. https://doi.org/10.1177/1087054714535951
Halmøy, A., Ring, A. E., Gjestad, R., Møller, M., Ubostad, B., Lien, T., Munkhaugen, E. K., & Fredriksen, M. (2022). Dialectical behavioral therapy-based group treatment versus treatment as usual for adults with attention-deficit hyperactivity disorder: a multicenter randomized controlled trial. BMC Psychiatry, 22(1), Article 738. https://doi.org/10.1186/s12888-022-04356-6
Hirsch, O., Chavanon, M., Riechmann, E., & Christiansen, H. (2018). Emotional dysregulation is a primary symptom in adult Attention-Deficit/Hyperactivity Disorder (ADHD). Journal of affective disorders, 232, 41-47. https://doi.org/10.1016/j.jad.2018.02.007
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
Meyer, J., Zetterqvist, V., Unenge Hallerbäck, M., Ramklint, M., & Isaksson, J. (2022). Moderators of long-term treatment outcome when comparing two group interventions for adolescents with ADHD: who benefits more from DBT-based skills training?. BMC psychiatry, 22(1), 767. https://doi.org/10.1186/s12888-022-04435-8
Wehmeier, P. M., Schacht, A., & Barkley, R. A. (2010). Social and emotional impairment in children and adolescents with ADHD and the impact on quality of life. Journal of Adolescent health, 46(3), 209-217.https://doi.org/10.1016/j.jadohealth.2009.09.009
