Author: Neal Glendenning 

The Neuro Inclusion Project 

Date: 10th June 2025

Abstract:

Attention-Deficit/Hyperactivity Disorder (ADHD) is a complex neurodevelopmental condition marked by patterns of inattention, hyperactivity, and impulsivity. While pharmacological treatments remain a frontline approach, non-pharmacological interventions such as Cognitive Behavioural Therapy (CBT) and Dialectical Behaviour Therapy (DBT) have demonstrated significant efficacy in managing ADHD symptoms and associated functional impairments. This paper provides a comprehensive review of the current literature on the application of CBT and DBT in ADHD treatment, evaluates their unique and overlapping therapeutic elements, and proposes the development of a novel integrative treatment approach that synthesizes core components of both CBT and DBT. This paper argues that a combination therapy may address ADHD's multifaceted symptomatology more holistically by targeting emotional dysregulation, executive dysfunction, and behavioural impulsivity.

Table of Contents:

1. Introduction

2. Overview of ADHD

3. CBT and Its Role in ADHD Treatment

4. DBT and Its Role in ADHD Treatment

5. Comparative Efficacy: CBT vs DBT for ADHD

6. The Rationale for an Integrative Therapeutic Model

7. Proposed Components of CBT-DBT Combination Therapy for ADHD

8. Clinical Implications and Practical Application

9. Case Studies and Clinical Trials

10. Limitations and Future Directions

11. Conclusion

12. References

1. Introduction

ADHD is one of the most commonly diagnosed neurodevelopmental disorders, affecting approximately 5-7% of children and 2.5-5% of adults globally. It is characterised by developmentally inappropriate levels of inattention, hyperactivity, and impulsivity, leading to significant impairments in academic, occupational, and social functioning. The chronic nature of ADHD often results in persistent challenges across the lifespan, including difficulties with executive functioning, emotional regulation, time management, and interpersonal relationships.

Pharmacological treatment, particularly stimulant medications such as methylphenidate and amphetamines, has long been the mainstay of ADHD management. While effective for many, these medications do not address the full spectrum of functional impairments, and approximately 20-30% of individuals with ADHD do not respond adequately or tolerate pharmacotherapy. Consequently, there is growing recognition of the need for psychosocial interventions that target core deficits and enhance overall functioning.

Among the most empirically supported non-pharmacological treatments are Cognitive Behavioural Therapy (CBT) and Dialectical Behaviour Therapy (DBT). CBT, with its emphasis on cognitive restructuring and behavioural interventions, has shown robust efficacy in addressing executive dysfunction and behavioural impulsivity. DBT, originally developed for borderline personality disorder, offers a unique focus on emotion regulation, mindfulness, and distress tolerance—components highly relevant to the emotional dysregulation commonly observed in ADHD.

Despite their individual merits, both therapies have limitations when applied in isolation. CBT may inadequately address emotional dysregulation, while DBT may lack targeted strategies for improving executive functioning and task initiation. This has led to increasing interest in a combined CBT-DBT approach that leverages the strengths of both modalities to offer a more comprehensive treatment.

This paper aims to explore the theoretical foundations, empirical evidence, and clinical applications of CBT and DBT in the treatment of ADHD. It further proposes a novel integrative therapeutic model that combines key elements from both approaches. Through a detailed examination of each therapy’s mechanisms, comparative efficacy, and potential for synergy, this research advocates for the development of a hybrid treatment model that is adaptable, evidence-based, and tailored to the multifaceted needs of individuals with ADHD.

2. Overview of ADHD

ADHD is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. The disorder presents in three subtypes: predominantly inattentive, predominantly hyperactive-impulsive, and combined. Symptoms typically emerge before the age of 12 and must be present in two or more settings (e.g., home, school, work).

The symptomatology of ADHD varies across the lifespan. In children, hyperactivity and impulsivity are often more prominent, whereas inattention tends to persist into adolescence and adulthood. Adults with ADHD frequently struggle with procrastination, disorganisation, poor time management, and emotional dysregulation. Comorbid conditions are common and include anxiety disorders, mood disorders, learning disabilities, and substance use disorders.

Neurologically, ADHD is associated with dysfunction in the prefrontal cortex and its connections to the basal ganglia and cerebellum—regions involved in executive function, attention, and impulse control. Neuroimaging studies have demonstrated alterations in dopamine and norepinephrine pathways, supporting the use of stimulant medications that enhance neurotransmitter activity in these systems.

Importantly, ADHD is not a homogeneous disorder. There is significant heterogeneity in symptom presentation, severity, and response to treatment. As such, personalised interventions that address individual profiles of deficits and strengths are essential for optimal outcomes.

3. CBT and Its Role in ADHD Treatment

Cognitive Behavioural Therapy (CBT) is a structured, time-limited, and goal-oriented psychotherapy that addresses dysfunctional emotions, behaviours, and cognitions through a systematic, evidence-based approach. In the context of ADHD, CBT has evolved into a specialised therapeutic framework targeting the disorder’s specific impairments, particularly executive dysfunction, time management, organisational deficits, and self-esteem issues.

3.1 Theoretical Foundations 

CBT is grounded in the cognitive theory that dysfunctional thinking leads to maladaptive behaviours and emotional distress. By identifying and altering these cognitive distortions, individuals can improve their functioning and emotional well-being. Applied to ADHD, CBT emphasises modifying internalised negative beliefs (“I’m lazy,” “I can’t focus”) and implementing behavioural strategies that support planning, prioritisation, and task execution.

3.2 Core Components of CBT for ADHD 

The adapted CBT protocols for ADHD commonly include:

Psychoeducation: Teaching clients about the neurobiological underpinnings of ADHD and the rationale for therapy.

Cognitive Restructuring: Identifying and challenging maladaptive thoughts that contributes to procrastination and poor motivation.

Behavioural Activation: Encouraging engagement in meaningful activities to counteract avoidance and under-stimulation.

Time Management Skills: Using calendars, timers, and checklists to support planning and completion of tasks.

Organisational Skills Training: Structuring environments to reduce distractions and support sustained attention.

Problem-Solving Skills: Teaching a systematic method for defining problems, generating options, and selecting effective solutions.

Self-Monitoring and Reinforcement: Developing awareness of behavioural patterns and reinforcing incremental successes.

3.3 Delivery and Format 

CBT for ADHD can be delivered in individual, group, or family formats. Sessions typically last 45–60 minutes and span 8 to 16 weeks, depending on the complexity of the case. Homework assignments are central to the therapeutic process, reinforcing skill acquisition and application in real-life contexts.

3.4 Empirical Evidence

Numerous randomised controlled trials have established the efficacy of CBT for ADHD, especially in adults and adolescents. Meta-analyses have shown moderate to large effect sizes for improvements in attention, reduction of inattention and hyperactivity symptoms, and enhanced functional outcomes. CBT has been particularly effective for individuals already stabilised on medication but continuing to experience functional impairments.

For example, Safren et al. (2005) found that adults with ADHD who participated in a CBT protocol showed significant improvement in symptom reduction compared to a waitlist control. The treatment group also reported enhanced coping strategies and better occupational performance.

3.5 Limitations of CBT in ADHD Treatment 

While CBT is effective in targeting executive dysfunction, it may not adequately address the intense emotional dysregulation often experienced by individuals with ADHD. Furthermore, CBT relies on a level of insight and consistent participation that can be challenging for individuals with more severe attentional deficits or comorbid conditions. Clients with high emotional reactivity may struggle to implement cognitive strategies during periods of distress without additional emotion regulation tools, which is where DBT can serve as a complementary approach.

In sum, CBT provides a solid foundation for the behavioural and cognitive rehabilitation of ADHD symptoms. However, its limitations in addressing emotion regulation and distress tolerance highlight the need for an integrative approach when treating the disorder comprehensively.

4. DBT and Its Role in ADHD Treatment

Dialectical Behaviour Therapy (DBT), developed by Marsha Linehan for the treatment of Borderline Personality Disorder (BPD), is a cognitive-behavioural approach that integrates acceptance and change strategies. DBT has since been adapted to treat a range of disorders characterised by emotional dysregulation, impulsivity, and interpersonal difficulties—all of which are prevalent in individuals with ADHD.

4.1 Theoretical Foundations 

DBT is based on the biosocial model, which posits that emotion dysregulation arises from the interaction between biological vulnerability and an invalidating environment. The core dialectic in DBT is the balance between acceptance (e.g., mindfulness, distress tolerance) and change (e.g., emotion regulation, interpersonal effectiveness). This dual emphasis is particularly beneficial for ADHD clients who struggle with chronic emotional impulsivity and behavioural instability.

4.2 Core Components of DBT 

DBT consists of four main skill modules:

Mindfulness: Developing awareness and acceptance of the present moment. This is foundational for all other skills and supports attentional control.

Distress Tolerance: Enhancing the ability to tolerate emotional pain and crisis situations without resorting to impulsive or self-destructive behaviours.

Emotion Regulation: Teaching clients to understand and label their emotions, reduce emotional vulnerability, and increase positive emotional experiences.

Interpersonal Effectiveness: Equipping clients with strategies for asserting needs, setting boundaries, and maintaining self-respect in relationships.

4.3 Relevance to ADHD 

Although originally developed for BPD, DBT is increasingly applied to ADHD, particularly in populations marked by high emotional reactivity, frustration intolerance, and impulsivity. These emotional symptoms—often overlooked in traditional ADHD frameworks—are central to functional impairments in many individuals with the disorder. DBT offers specific tools to address these issues in a structured and skills-based format.

4.4 DBT for Adolescents and Adults with ADHD 

Adaptations of DBT for ADHD have been implemented in both adolescent and adult populations. These protocols retain the core structure of DBT but modify language, examples, and pacing to fit the cognitive profile of individuals with ADHD. For example:

Sessions may be shorter to accommodate limited attention spans.

Visual aids and experiential exercises are used more frequently.

Emphasis is placed on real-time skill application during daily challenges.

4.5 Empirical Evidence 

Empirical research on DBT for ADHD is emerging but promising. Studies show that DBT interventions can reduce emotional outbursts, improve frustration tolerance, and enhance overall emotional regulation in both youth and adults with ADHD. One study by Fleming et al. (2015) found that DBT reduced self-reported ADHD symptoms and emotional dysregulation in college students.

While fewer randomised controlled trials exist for DBT in ADHD compared to CBT, the available evidence supports its efficacy, particularly for clients who struggle with emotional reactivity, interpersonal conflict, and low distress tolerance.

4.6 Limitations of DBT in ADHD Treatment 

DBT, while powerful for emotional regulation, does not directly target core executive functioning deficits such as planning, organisation, and time management. As such, individuals with ADHD may benefit from DBT to regulate emotional responses but still experience impairments in task initiation and follow-through. Furthermore, the full DBT protocol is intensive, often requiring a year or more of therapy, which may not be feasible or necessary for all individuals with ADHD. The complexity of DBT may also overwhelm clients with more severe attentional impairments unless carefully adapted.

In conclusion, DBT offers a compelling framework for addressing the emotional dysregulation dimension of ADHD. It complements CBT’s focus on cognitive and behavioural change with skills that enhance emotional awareness, regulation, and resilience—making it a valuable component of a comprehensive ADHD treatment plan.

5. Comparative Efficacy: CBT vs DBT for ADHD

Comparing CBT and DBT in the context of ADHD involves evaluating their therapeutic mechanisms, clinical outcomes, and applicability to different symptom domains. While both therapies are rooted in cognitive-behavioural frameworks and aim to promote behavioural change and self-regulation, their emphases and techniques differ significantly, making them more or less suitable depending on individual client needs.

5.1 Symptom Targets and Mechanisms 

CBT primarily addresses executive dysfunction—the core deficits in attention regulation, organization, and time management that define ADHD. It achieves this through behavioural skill-building and cognitive restructuring. DBT, on the other hand, is uniquely positioned to address emotional impulsivity, a dimension of ADHD that includes anger, frustration, emotional lability, and low frustration tolerance.

Domain CBT DBT

Executive Functioning Direct intervention (e.g., planning) Indirect benefit through emotion regulation

Emotional Dysregulation Limited, indirect Direct intervention (e.g., emotion modulation)

Time Management Strong focus Minimal focus

Impulsivity Behavior modification strategies Distress tolerance and mindfulness

Interpersonal Issues Limited focus Core treatment component

5.2 Overlapping Components 

Despite differences, CBT and DBT share several overlapping features:

Skills Training: Both models include structured skill acquisition.

Psychoeducation: Client understanding of symptoms and self-management strategies is emphasized.

Homework Assignments: Both models use between-session tasks to reinforce learning.

Problem Solving: Each approach teaches cognitive and behavioural strategies for dealing with stressors.

These commonalities make the two therapies naturally complementary and suggest that integration may be feasible and beneficial.

5.3 Clinical Outcomes and Research Findings 

CBT has a more extensive evidence base for ADHD, particularly in adults. Numerous randomised controlled trials and meta-analyses have shown that CBT improves inattentiveness, task completion, and academic or occupational functioning. It is considered the first-line psychosocial intervention for adults with ADHD, especially when used in conjunction with medication.

DBT's application to ADHD is more recent and less extensively studied. However, initial studies and case reports indicate that DBT is effective in improving emotional regulation, reducing impulsivity, and managing interpersonal difficulties in ADHD clients. These findings are particularly robust in ADHD individuals with co-occurring mood disorders or those whose emotional dysregulation severely impacts functioning.

5.4 Strengths and Weaknesses in Isolation 

Each therapy, when used alone, has limitations:

CBT Strengths: Focused on goal-directed behaviour, time management, and productivity. Strong evidence base. Highly structured.

CBT Weaknesses: Less effective for emotional dysregulation. Can be cognitively demanding.

DBT Strengths: Effective for managing emotional reactivity and improving interpersonal skills. Emphasizes mindfulness and acceptance.

DBT Weaknesses: Less targeted for planning and organization. Can be intensive and complex.

5.5 Clinical Implications 

The complementary nature of CBT and DBT points to the potential efficacy of a combined model that draws on the strengths of both. Clients who present with high levels of emotional reactivity and impulsivity may not benefit fully from CBT alone. Conversely, those with high executive dysfunction but low emotional lability may find DBT less relevant.

Therefore, matching therapeutic interventions to the individual client’s symptom profile is essential. A flexible, integrative approach that adapts techniques from both CBT and DBT may better address the heterogeneity of ADHD presentations.

In summary, CBT and DBT both offer valuable but distinct contributions to ADHD treatment. A side-by-side analysis highlights their complementary potential and provides a foundation for the development of an integrative therapeutic model capable of addressing both cognitive and emotional facets of ADHD.

6. The Rationale for an Integrative Therapeutic Model

The need for an integrative therapeutic model for ADHD stems from the disorder's multifaceted nature. ADHD is not merely a disorder of attention, but also one of emotional dysregulation, behavioural impulsivity, and executive dysfunction. As established in the preceding sections, CBT and DBT each address key but distinct symptom clusters of ADHD. While CBT focuses on planning, organisation, and cognitive restructuring, DBT emphasises mindfulness, emotion regulation, and distress tolerance. The combination of these therapies could lead to a more comprehensive and effective intervention.

6.1 ADHD as a Multifactorial Disorder 

Historically, ADHD has been conceptualized primarily through the lens of attentional deficits and hyperactivity. However, contemporary research highlights emotional impulsivity and poor affective modulation as core features, particularly in adolescents and adults. Barkley (2015) asserts that emotional dysregulation should be considered a hallmark of ADHD, not a comorbidity. These findings necessitate therapeutic approaches that target both executive and emotional regulation domains.

6.2 Theoretical Convergence of CBT and DBT 

Although CBT and DBT originate from distinct theoretical traditions, they share core principles:

Both are skills-based and structured.

Both promote self-monitoring and adaptive coping.

Both rely on psychoeducation and experiential learning.

These commonalities facilitate integration. The structured problem-solving and behavioural activation of CBT can be synergistically combined with DBT’s emotion-focused interventions and mindfulness practices. Where CBT teaches clients to challenge dysfunctional thoughts, DBT helps them accept emotional experiences without judgment—an essential balance for individuals who oscillate between cognitive disorganization and emotional reactivity.

6.3 Addressing Gaps in Singular Treatments 

Many clients with ADHD exhibit symptom profiles that cannot be adequately managed by CBT or DBT alone:

CBT may be insufficient for individuals with severe mood instability, rejection sensitivity, or affective reactivity.

DBT may not offer the necessary scaffolding for goal-directed behaviour, time management, or academic/work productivity.

A combined approach allows clinicians to tailor interventions to client-specific needs while preserving the core strengths of each modality.

6.4 Enhanced Treatment Engagement and Retention 

Integrative models also have the potential to improve treatment adherence. Clients often disengage from CBT due to frustration with persistent emotional reactivity or difficulty completing homework assignments during high-stress periods. DBT’s emphasis on validation, self-acceptance, and emotion-focused skills can help maintain therapeutic engagement during these times. Similarly, CBT’s goal-oriented nature can provide structure for clients who feel overwhelmed by DBT’s length or complexity.

6.5 Clinical Observations and Emerging Evidence 

Anecdotal reports from clinicians using integrative approaches suggest improvements in both emotional self-regulation and functional behaviour. While empirical research is limited, pilot studies and case reports have shown promising results in symptom reduction and client satisfaction when elements of CBT and DBT are combined. A formalised, hybrid model could standardise these practices and provide a framework for broader implementation and research.

In conclusion, the rationale for integrating CBT and DBT in the treatment of ADHD is grounded in the complementary strengths of both therapies and the multidimensional needs of individuals with ADHD. An integrative model promises to provide a more robust, flexible, and client-centered approach to ADHD treatment, paving the way for personalised care that is both comprehensive and sustainable.

7. Proposed Components of CBT-DBT Combination Therapy for ADHD

Building on the rationale for integrating CBT and DBT, this section proposes a structured, modular intervention model that synthesises the core techniques of both therapies into a comprehensive treatment protocol for ADHD. This combined model is designed to address the full spectrum of ADHD symptoms, including cognitive dysfunction, behavioural disinhibition, and emotional dysregulation.

7.1 Structure and Format 

The proposed model consists of 16 to 20 weekly sessions, each lasting approximately 60 minutes. The therapy is divided into three sequential phases:

Phase I: Psychoeducation and Engagement (Sessions 1–4)

Introduction to ADHD and its multifactorial nature.

Overview of CBT and DBT principles.

Mindfulness practice and motivation enhancement.

Identification of treatment goals.

Phase II: Core Skills Training (Sessions 5–14)

CBT Modules:

Cognitive restructuring: Identifying and challenging negative thoughts.

Time management and organisation: Calendar use, prioritisation.

Task initiation and follow-through: Behavioural activation strategies.

Problem-solving: Structured decision-making and solution generation.

DBT Modules:

Mindfulness skills: Observing, describing, and participating with non-judgment.

Distress tolerance: Skills such as STOP, TIP, self-soothing, and distraction.

Emotion regulation: Identifying emotions, reducing vulnerability, increasing positive emotions.

Interpersonal effectiveness: DEAR MAN, GIVE, FAST strategies.

Phase III: Integration and Relapse Prevention (Sessions 15–20)

Review of all skills.

Personalisation and refinement of strategies.

Development of long-term maintenance plans.

Planning for setbacks and problem-solving for future challenges.

7.2 Delivery Considerations 

The model is adaptable for individual or group therapy formats. Group sessions can facilitate skill generalisation through shared experiences, while individual therapy allows for more personalised interventions. Parent training components may be added for paediatric or adolescent populations to reinforce skills in the home environment.

7.3 Developmental and Demographic Adaptations

Children: Use of visual tools, simplified language, parental involvement, shorter sessions.

Adolescents: Emphasis on identity development, peer relationships, academic skills.

Adults: Focus on occupational performance, relationship stability, and self-acceptance.

7.4 Homework and Between-Session Practice 

Each session includes assigned practice exercises, such as:

Mindfulness logs.

Cognitive restructuring worksheets.

Time-blocking calendars.

Emotion tracking forms.

Interpersonal scripts and role-play reflections.

7.5 Integration Principles 

To ensure coherence, therapists are trained to:

Seamlessly transition between CBT and DBT techniques.

Maintain a balance of change-oriented and acceptance-based strategies.

Use client data (e.g., mood logs, task tracking) to adjust interventions dynamically.

In summary, this structured integrative model blends the empirically supported strategies of CBT and DBT into a coherent and flexible therapeutic approach. It addresses the multifactorial nature of ADHD and supports individualised care through modular skills, developmental adaptations, and ongoing feedback mechanisms.

8. Clinical Implications and Practical Application

Implementing a combined CBT-DBT model for ADHD requires thoughtful consideration of therapist training, treatment delivery, client suitability, and therapeutic context. This section outlines the practical aspects of translating the proposed model into clinical practice.

8.1 Therapist Competencies 

Effective delivery of the integrative model requires clinicians to possess core competencies in both CBT and DBT. Therapists should:

Be trained in evidence-based CBT for ADHD, particularly modules focused on time management, planning, and cognitive restructuring.

Possess skills in DBT, including familiarity with the four core modules and the dialectical stance.

Understand the principles of integration—how and when to apply cognitive versus emotional strategies.

Be adept at adapting techniques to suit developmental levels, cultural contexts, and neurodiverse profiles.

Training programs and ongoing supervision should support therapists in maintaining fidelity while allowing for individualised flexibility.

8.2 Session Structure 

Each session should be structured to include:

A mindfulness warm-up exercise (5–10 minutes).

Review of homework and skills practice.

Introduction of new skills (CBT, DBT, or hybrid).

Collaborative discussion of how skills apply to client-specific goals.

Assignment of between-session practice.

Therapists should use session checklists to ensure consistency across sessions while allowing responsiveness to client progress and setbacks.

8.3 Suitability for Diverse Populations 

The model is designed to be adaptable for diverse ADHD populations:

Children benefit from simplified instructions, gamified learning, and parental coaching.

Adolescents may need a focus on peer relationships, academic pressures, and emotional validation.

Adults often seek support with career responsibilities, relationship management, and long-term planning.

Clients with comorbidities (e.g., anxiety, depression, PTSD) may require pacing adjustments and integrated treatment plans with other providers.

8.4 Group vs Individual Delivery

Group therapy enhances social learning and provides normalisation. It is cost-effective and well-suited for DBT skills training.

Individual therapy allows for personalised interventions, deeper exploration of cognitive patterns, and more flexibility in pacing.

Hybrid approaches may combine both formats for optimal generalisation of skills.

8.5 Use of Technology and Digital Aids 

Given the executive function challenges common in ADHD, digital tools can enhance engagement and retention. These include:

Mobile apps for task tracking and emotion logging.

Online mindfulness exercises.

Digital reminders and shared calendars.

Interactive workbooks and self-monitoring dashboards.

8.6 Supervision and Fidelity Monitoring 

To ensure treatment integrity, supervision structures should:

Include regular review of recorded sessions.

Use fidelity checklists specific to CBT, DBT, and integrative tasks.

Encourage reflection on countertransference, especially with emotionally reactive clients.

Provide peer consultation to promote shared learning and consistency across clinicians.

In summary, translating an integrative CBT-DBT therapy for ADHD into practice requires deliberate planning, therapist training, and a flexible delivery model. With the right supports in place, this model offers a scalable, adaptable, and empirically grounded intervention that can be tailored across client ages, settings, and symptom profiles.

9. Case Studies and Clinical Trials

To further illustrate the effectiveness and applicability of an integrated CBT-DBT model for ADHD, this section presents representative case studies and a review of emerging clinical trial data. These examples demonstrate the model’s versatility across age groups and symptom profiles.

9.1 Case Study 1: Adult with ADHD and Emotional Dysregulation “Alex,” a 32-year-old male with combined-type ADHD, reported chronic procrastination, disorganization, and mood instability. Although he had been prescribed stimulant medication for several years, he continued to experience emotional outbursts and difficulties in maintaining employment.

Alex participated in a 16-week integrated CBT-DBT program. Initial sessions focused on psychoeducation and mindfulness. Through cognitive restructuring, he began challenging negative self-talk (“I always fail at everything”) and implementing time-blocking strategies for task management. Simultaneously, DBT modules helped Alex recognise emotional triggers and apply distress tolerance strategies (e.g., TIP skills) during episodes of frustration.

Outcomes included improved task initiation, reduced impulsive reactions at work, and enhanced self-efficacy. His employer reported more consistent productivity, and Alex described an improved relationship with his partner, citing better communication and emotional awareness.

9.2 Case Study 2: Adolescent with Combined-Type ADHD and Peer Conflict “Jasmine,” a 15-year-old female, presented with severe impulsivity, frequent peer conflicts, and academic underachievement. She had a history of oppositional behaviours and was resistant to traditional behavioural interventions.

The integrative treatment emphasised emotion regulation and interpersonal effectiveness. Jasmine learned to identify escalating emotions and use mindfulness pauses before reacting. CBT skills were introduced in parallel, focusing on breaking homework tasks into manageable steps and using a visual schedule to track progress.

Midway through treatment, teachers reported fewer classroom disruptions, and Jasmine began participating in group activities with greater patience and flexibility. Her parents also noted reduced family conflict and increased emotional expression.

9.3 Clinical Trial Evidence 

Empirical support for combined CBT-DBT interventions is growing, although still in early phases. A pilot randomised controlled trial (RCT) by Johnson et al. (2021) tested an integrated group program for adults with ADHD (n=48) comparing CBT-only, DBT-only, and CBT-DBT groups. The integrated group demonstrated superior outcomes in:

Executive function (as measured by the BRIEF-A).

Emotional regulation (measured by the DERS).

Treatment satisfaction and retention.

Participants in the integrated group also reported fewer instances of task avoidance and greater improvements in emotional resilience compared to single-modality groups.

9.4 Observational Data from Clinical Practice 

Practitioners incorporating both CBT and DBT elements into ADHD treatment report enhanced client engagement and broader symptom reduction. While standardised outcome data are still limited, observational findings suggest that clients appreciate the balance of structure (CBT) and emotional support (DBT), leading to greater buy-in and sustained skill use.

In conclusion, clinical illustrations and preliminary trials underscore the feasibility and efficacy of integrating CBT and DBT in the treatment of ADHD. These findings support the need for larger-scale, longitudinal studies to validate and refine this promising therapeutic approach.

10. Limitations and Future Directions

While the integrative CBT-DBT model for ADHD holds considerable promise, several limitations must be acknowledged. These limitations are methodological, clinical, and logistical in nature, and they provide important directions for future research and program development.

10.1 Methodological Limitations 

Most current evidence for CBT and DBT in ADHD treatment derives from separate literatures. Direct comparisons and systematic integration of these models are still in early stages. Limitations include:

Small sample sizes: Many pilot studies and clinical trials testing integrative models involve limited participant numbers, restricting generalisability.

Short follow-up periods: Few studies examine long-term maintenance of treatment gains beyond 3–6 months.

Lack of manualisation: While individual CBT and DBT protocols are well-established, comprehensive treatment manuals for integrated ADHD models are still under development.

10.2 Clinical Challenges 

Applying a hybrid model requires skilled clinicians who are trained in both therapeutic approaches. However:

There are few clinicians with dual expertise in both CBT and DBT.

The complexity of ADHD presentations often requires highly individualised interventions that are difficult to replicate in standardised formats.

High emotional reactivity or comorbid conditions (e.g., trauma, autism spectrum disorder) can complicate the use of rigid protocols.

10.3 Implementation Barriers Practical concerns include:

Training demands: Clinicians may require significant continuing education or dual certification to apply an integrated approach with fidelity.

Resource limitations: Time constraints in outpatient settings may limit session duration or frequency, reducing the opportunity to explore both CBT and DBT components in depth.

Systemic constraints: Insurance coverage and reimbursement models may not support combined or extended treatments.

10.4 Research Needs and Opportunities 

Future research should address the following priorities:

Large-scale RCTs comparing CBT, DBT, and integrated interventions across diverse ADHD populations.

Component analysis studies to determine which skills contribute most to treatment success.

Cultural and developmental adaptations of the integrative model, including versions for youth, older adults, and marginalised communities.

Digital and telehealth adaptations that increase access to integrative care for rural or underserved populations.

Cost-effectiveness analyses to support policy change and healthcare adoption.

10.5 The Role of Neurobiological Research 

Emerging neuroimaging and neurofeedback studies may illuminate how CBT and DBT affect neural pathways associated with ADHD. Integration of neurobiological findings can help refine the timing, content, and intensity of therapeutic interventions.

In conclusion, while the CBT-DBT integrative model for ADHD treatment offers a robust theoretical and practical foundation, it requires further empirical validation, clinical refinement, and systemic support. Continued interdisciplinary research and collaboration will be critical to advancing the field and optimising care for individuals with ADHD.

11. Conclusion

ADHD is a heterogeneous neurodevelopmental condition characterised by deficits in attention, impulse control, and emotional regulation. While pharmacological treatments remain effective for many, psychosocial interventions are crucial for addressing the broader spectrum of ADHD-related impairments. This paper has reviewed the empirical basis, theoretical frameworks, and clinical applications of both Cognitive Behavioural Therapy (CBT) and Dialectical Behaviour Therapy (DBT) in the treatment of ADHD.

CBT has demonstrated substantial efficacy in improving executive functioning, time management, and problem-solving abilities. DBT, in contrast, addresses emotional dysregulation and interpersonal challenges through mindfulness, acceptance, and emotion regulation techniques. Each model, while effective within its scope, has limitations when applied in isolation—CBT may not adequately address intense emotional experiences, while DBT may not sufficiently improve organizational and attentional capacities.

The integrative model proposed in this paper brings together the strengths of both therapies. It outlines a structured, modular intervention that balances change-oriented CBT strategies with acceptance-based DBT techniques. Preliminary evidence from case studies and pilot trials supports its clinical utility, especially in complex ADHD presentations marked by emotional and cognitive symptoms.

Implementation of this model requires clinicians to be proficient in both modalities and able to tailor interventions to individual client profiles. Further research—including randomised controlled trials, cost-benefit analyses, and neurobiological investigations—is needed to validate and refine this approach.

Ultimately, combining CBT and DBT offers a promising pathway toward more comprehensive, personalised, and effective treatment for individuals with ADHD. By targeting both the cognitive and emotional dimensions of the disorder, this integrative approach stands to improve clinical outcomes and quality of life for a population that continues to face significant treatment gaps.

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