Cognitive behavioral therapy (CBT) is a vetted, evidence-based psychosocial treatment for adult ADHD.

Such evidence-based status is established chiefly by way of randomized controlled clinical trials. Such studies examine structured, manualized, session-by-session approaches tailored to address the key issues for managing adult ADHD compared to other standard treatments. This approach is the current gold standard for quality control.

After achieving evidence-based status, free-range humans with ADHD of all flavors and complexities will seek out such specialized help they’ve long been hoping to find—including people whose complexities would have excluded them from the original studies.

The clinician-researchers who developed the treatment manuals openly acknowledge that their use in day-to-day clinical practice requires a balance of adhering to their core elements and a degree of flexibility to tailor them to the needs of adults with ADHD with various life complexities.

Trends in CBT That Have Potential Benefits for the Treatment of Adult ADHD

With the demands of treatment of more complex cases, there are ongoing adjustments to approaches for adult ADHD within the CBT family tree that aim to augment the current evidence-supported foundation to broaden its effectiveness. Below is a review of some promising advances.

Dialectical Behavior Therapy (DBT)/Acceptance and Commitment Therapy (ACT)

To date, the most recognized CBT approaches adapted for adult ADHD are representative of the “second wave” of the behavioral therapy school in which cognitions—thoughts, beliefs, attitudes—were established as influential factors affecting functioning and well-being and not merely as learned mental behaviors that could be shaped like any other behaviors. It might seem obvious now, but this was a really big deal.

The original success of CBT for depression led to its modifications for anxiety and other diagnoses and complexities. Such refinements included helping clients manage extreme emotionality by way of directly understanding it and using distress tolerance strategies, as well as learning to tolerate and accept these emotions and other discomforts without necessarily eradicating them and still being able to engage in valued life roles, relationships, and other cherished endeavors. Over the past few decades, DBT [1] and ACT [2] have forged this “third wave” expansion of behavioral therapy. These treatment approaches have been adapted to and are being researched in terms of the benefits they have to offer adults with ADHD, and many of their elements are woven into existing CBT approaches for adult ADHD [3,4,5].

**Process-Based CBT **

A positive side effect of this ongoing evolution of behavioral therapy is appreciating how many of the beneficial features of its different waves are, in fact, complementary. That is, thoughts, emotions, and behaviors each affect and are affected by the others. An emerging “process-based” CBT approach seeks to reconcile this common ground [6]. It’s not a simple mash-up but an assimilation of complementary approaches tethered by evolutionary science and guided by network modeling of conceptualizations of common life difficulties to personalize treatments with ever more sophistication. It’s way too early to understand how it might help with adult ADHD, but it’s a promising direction.

4E Cognition

4E cognition [7] is another interesting way to understand how much our brain’s work occurs outside its membrane. This view drives home the importance of many existing coping strategies for ADHD as being central for well-being, such as externalization of time, motivation, and information. 4E cognition views the brain and its processes as embodied in the senses and visceral experiences; embedded in the surrounding context and culture; enactive through experiences and problem-solving; and extended via the use of tools and devices. This understanding emphasizes how the brain developed to make use of extra-neural resources to survive and, in our modern world, store and utilize information outside itself. Such outside-the-brain thinking facilitates and enhances mental and emotional processing, including that such spatial cognition is a foundation for our ability to conjure abstract ideas. What’s more, in terms of managing ADHD, such action-oriented, hands-on options support coping and well-being in ways that are good fits for adults with ADHD.

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Conclusion

There are a range of developments in CBT for treating adult ADHD. DBT and ACT have already been adapted to adult ADHD and are establishing their place. 4E cognition helps make sense of the usefulness of many existing coping strategies for adult ADHD and may perhaps uncover some new ones. Process-based CBT is still in early stages, but considering the intersection of executive functions and evolution and the need for tailored psychosocial strategies for adults with ADHD, it may be the next step forward in providing specialized care.

References

1. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford.

2. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. Guilford.

3. Spradlin, S., & Spradlin, M. (in press). The Dialectical Behavior Therapy skills workbook for adult ADHD. New Harbinger.

4. Munawar, K., et al. (2021). Acceptance and commitment therapy for individuals having attention deficit hyperactivity disorder (ADHD): A scoping review. Heliyon, 7(8). https://doi.org/10.1016/j.heliyon.2021.e07842

5. Ramsay, J. R. (2024). The adult ADHD & anxiety workbook. New Harbinger.

6. Hayes, S., & Hofmann, S. (Eds.) (2018). Process-based CBT. Context Press.

7. Newen et al. (Eds.) (2020). The Oxford handbook of 4E cognition. Oxford University Press.