When Standard DBT Skills Don’t Land: Adapting Distress Tolerance for Neurodivergent Teens

Many standard dialectical behavior therapy (DBT) skills assume a neurotypical way of sensing, processing, and responding to the world. That assumption doesn’t hold for many autistic teens and teens with ADHD, so standard DBT skills may not land, especially at first.

DBT for autism works best when skills are adapted to a teen’s sensory and cognitive needs. Here’s how to adapt three distress tolerance skills (TIPP, ACCEPTS, and IMPROVE) for autistic teens. Many of the same adjustments may also help teens with ADHD.

Why is DBT for autism helpful?

Clinicians who work with autistic teens often find that DBT’s foundations are a strong fit, especially when adapted specifically for neurodiverse brains.

“Many neurodivergent teens feel things intensely and have spent years hearing, and have internalized the message, over time, that their reactions are too big or don’t make sense. DBT begins with validation,” explains Megan Lederman, MA, LPC, Director of Clinical Programming at Charlie Health.

“DBT’s core idea is that emotional sensitivity meeting an environment that doesn’t fit is a real and understandable experience, and that idea is often incredibly helpful to teens who have been invalidated for a long time,” Lederman adds.

Another benefit of DBT for autism: for the most part, DBT is structured and explicit — something that’s more easily digestible for neurodiverse minds rather than more abstract concepts.

Although research on DBT in autistic teens is limited, Lederman says, “research supports optimism, with some caveats.”

Much of the evidence so far comes from adults. For example, a 2025 randomized trial of 63 autistic adults with self-harm or suicidal behavior found DBT reduced emotional dysregulation, with improvements lasting through a six-month follow-up. Furthermore, a 2026 systematic review suggests that DBT can improve emotional regulation, alleviate depression symptoms, and reduce suicidal ideation in people with autism spectrum disorder (ASD).

In a 2025 study of 87 adolescents in a four-week DBT partial hospitalization program, participants improved on most of the DBT outcomes measured, such as emotional and social difficulties, mindfulness, and crisis tolerance. The improvement did not differ significantly between adolescents with elevated autistic traits and those with low or no traits. The study was not a randomized trial, and parents reported the autistic traits, so more controlled research is needed to know how well DBT works for autistic teens.

These studies looked at overall outcomes. They don’t show whether each individual skill works for every teen, and Lederman points to reasons some may not.

Why might standard DBT skills not land with autistic teens?

Some DBT skills rely on sensory experiences or body awareness that may feel uncomfortable or difficult to access. Others use abstract concepts that can be harder for neurodivergent individuals to put into practice. This is why clinicians may need to adapt how they teach and practice individual skills to make them more accessible and effective for each neurodivergent teen.

Lederman points to six factors that might explain why some standard DBT skills don’t land with autistic teens.

Sensory differences

Autistic individuals often experience sensory sensitivities. A common DBT tool is using ice or cold packs, but this isn’t always the right fit for a neurodivergent person. For example, Lederman says that a cold pack that calms down one teen might feel painful for another.

Additionally, they add, “A sensory ‘soothing’ exercise can be incredibly helpful to a sensory-seeking teen, but can be overwhelming to a sensory-avoidant teen who finds sensory silence more regulating.”

Interoception and alexithymia

Autistic people often struggle with interoception, meaning they don’t always sense and interpret internal body signals. Lederman notes that many DBT skills begin with asking someone to notice what their body is doing, and this isn’t something that comes naturally or easily to many autistic people.

Similarly, many autistic people (about 50%) experience alexithymia, which is difficulty identifying and describing one’s own emotions. Lederman says some DBT skills start with rating one’s distress, and again, for someone with alexithymia, this may be very difficult.

Executive functioning difficulties

“Remembering a list of acronyms and choosing among them mid-crisis puts a heavy load on working memory,” says Lederman. This can be especially taxing for those with AuDHD (a community term for co-occurring autism and ADHD).

Abstract or imagery-based instructions

Although many DBT skills are concrete, some are more abstract. Some autistic teens may struggle with this. For example, Lederman explains that the prompt to “picture a safe place” lands differently for a teen who struggles to form or doesn’t form mental images.

Demand sensitivity

Demand sensitivity — or feeling intense distress related to demands — can trigger avoidance, shutdown, or pushback, even when the demand is reasonable, or the task is something the teen would otherwise want to do. “Skills presented as something to do right now can trigger resistance in teens with a strong need for autonomy,” Lederman says. “Choice softens that considerably.”

The impact of masking

Many neurodivergent individuals engage in masking to “camouflage” or blend in with their peers. This can contribute to burnout and exhaustion, which can impede their ability to participate in DBT fully. “A teen who has held it together all day may have little energy left to practice skills in front of a group,” says Lederman.

Does DBT teach autistic teens to mask?

There are concerns that DBT might teach autistic people to suppress their traits, such as stimming, to fit neurotypical expectations. Standard DBT was designed to help people adapt to social environments, often using strategies built around neurotypical norms, so some skills can unintentionally favor fitting in over self-expression. Adapting DBT means starting from the teen’s own sensory profile and preferences, offering choices instead of directives, and including stimming as a way to regulate. None of the adaptations below ask a teen to hide a trait.

How can you adapt DBT skills TIPP, ACCEPTS, and IMPROVE for neurodivergent teens?

Three of the most commonly taught distress tolerance skills are TIPP, ACCEPTS, and IMPROVE. With a few tweaks, each can work well with neurodivergent teens. To adapt the skills, you can plan ahead, make directions concrete, offer choices, and match the teen’s sensory profile.

Below is advice for adapting specific DBT skills.

How to adapt TIPP for neurodivergent teens

TIPP is a DBT skill that stands for temperature, intense exercise, paced breathing, and paired muscle relaxation. It’s designed to quickly lower physical arousal when emotions are running very high.

Here’s how to adapt it:

• Temperature: The original skill uses cold on the face to trigger the dive response. A teen who doesn’t want to submerge their face can hold a cold pack on the eyes and upper cheeks instead, which keeps the same mechanism. If cold on the face is too uncomfortable, Lederman suggests options such as a cold drink, holding an ice cube, or a cool pack on the wrists or neck. These can be soothing, but they are sensory coping strategies, not equivalents of the temperature step. (Screen first for heart or medical conditions, medications that lower heart rate, and other concerns. If you’re unsure whether cold exposure is safe, check with the teen’s medical provider.)
• Intense exercise: This is generally well-suited for ADHD and sensory-seeking teens. Clinicians can help by providing concrete examples of what someone can do for 60 seconds, such as dancing to a favorite song, jumping, or wall push-ups, Lederman says. (Screen for eating disorders, compulsive exercise, or medical conditions before using this component; paced breathing is the alternative.)
• Paced breathing: The task of focusing on breathing can be tough and even increase anxiety for those who struggle with interoception and find internal sensations confusing. In these cases, Lederman suggests pairing the breathing with something external, such as a visual breathing shape. For example, a client can watch a video with graphics that support paced breathing. Or they can use a tactile “breathing ball” that they can physically expand and contract with their breath.
• Paired muscle relaxation: The original skill tenses and releases muscle groups in sequence, paired with the breath. If a teen has difficulty tuning into their body’s sensations, Lederman suggests squeezing a stress ball or firmly pressing palms together. These give the body a concrete, external way to release tension without relying on subtle internal cues, but they don’t replicate the tense-and-release sequence, so they work as a different coping strategy.

How to adapt ACCEPTS for neurodivergent teens

ACCEPTS is a distress tolerance skill that uses distraction to help someone get through a painful moment without making it worse. Lederman has the following recommendations:

• Activities: Use the client’s special interests to their advantage, since they are reliable regulators, Lederman says. You can also write a “menu” ahead of time of options for activities so implementation is easy when the time comes, they add.
• Contributing: Contributing doesn’t have to mean something major or something that involves face-to-face interaction. “Low-social options count, such as caring for a pet, organizing something, or contributing to an online interest community,” Lederman says.
• Comparisons: This step often involves comparing one’s situation to someone who is worse off. “For neurodivergent teens, who can have high justice-sensitivity, comparing themselves to others in order to feel better can feel like punching down, and it’s often not the best approach,” Lederman says. “Comparing a time when things were worse in their own life to gain perspective can be more helpful.”
• Emotions: Planning ahead for this step is often key for neurodivergent teens. “Opposite emotion works best when it’s specific and chosen ahead of time, like a particular playlist or a particular show, so there’s nothing to decide at the moment,” says Lederman.
• Pushing away: “Pushing away” can feel abstract for many neurodivergent teens. Lederman suggests making it concrete and time-limited. For example, they can write the worry down, draw a box around it, and schedule a time to come back to it later.
• Thoughts: Find more concrete ways to redirect thoughts. Lederman suggests offering the options of puzzles, sorting, counting, or learning interest-based facts. All can be strong distractions.
• Sensations: Work with the teen’s sensory profile here and ask them what sensory input feels best for them. Lederman recommends suggesting weighted blankets, textures, deep pressure, music through headphones, and stimming.

How to adapt IMPROVE for neurodivergent teens

IMPROVE is a distress tolerance skill for making a painful moment more bearable. Lederman recommends the following to adapt IMPROVE for neurodivergent teens.

• Imagery: Many neurodivergent individuals struggle to visualize. “For teens with weak or absent imagery, use external anchors like photos, a playlist, a real object, or a place described in words,” says Lederman. “Ask about visual, smell, and taste imagery separately.”
• Meaning: “This skill frames challenging moments in terms of their wider potential meaning,” Lederman says. “Ask what matters to them about getting through this and let the answer come from their own values, interests, or sense of justice.”
• Prayer: This step is only fitting if a teen is spiritual or religious. If they aren’t, Lederman says you can substitute a pause for prayer, such as a grounding phrase or a moment to feel connected to something larger than themselves.
• Relaxation: The best relaxation method for a neurodivergent teen depends on personal sensory preferences. For example, some teens might find movement more relaxing, while others may prefer deep pressure, Lederman explains.
• One thing in the moment: Offer the teen a single sensory task to bring them into the present. For example, Lederman says they can touch a smooth stone or kinetic sand, then focus all their attention on how it feels.
• Vacation: For teens who interpret instructions literally, explain that this step doesn’t mean a true vacation, but a pause in the day. Lederman says you can recommend “a planned, time-limited break, like twenty minutes with headphones and the door closed, with a clear return point so it doesn’t slide into avoidance.”
• Encouragement: This step uses self-talk to feel encouraged. Lederman recommends helping the teen form coping statements in their own words. Some examples are, “This is overload. I know how to intervene. It’s okay to choose rest and restoration. I’ve done this before. My needs deserve good care.”

When should an autistic teen move to a higher level of care?

DBT skills like TIPP, ACCEPTS, and IMPROVE can help autistic teens manage distress, but skills practice isn’t always enough. Watch for signs that a teen’s safety may be at risk, such as talk of self-harm or suicide, self-harm behavior, or a sharp decline in functioning at school, at home, or with friends. Collaborative safety planning with the teen can help identify triggers, effective coping strategies, and steps to take if distress escalates.

When outpatient treatment isn’t enough, clinicians should complete an individualized assessment of symptom severity, safety concerns, functional impairment, treatment response, and available supports. A teen’s ability to take part safely and effectively in the proposed setting matters too. An intensive outpatient program (IOP) may be appropriate when a teen needs more structured therapeutic support but doesn’t need inpatient or other 24-hour care. Care should be adapted to the teen’s communication, sensory, and developmental needs.

Autism and neurodivergent-affirming care at Charlie Health

If an autistic teen you work with needs more than weekly therapy, Charlie Health’s virtual IOP can help.

Charlie Health is a virtual behavioral health provider delivering more than once-weekly high-acuity treatment for kids, teens, and adults facing serious mental health conditions and substance use disorders in a virtual intensive outpatient (IOP) format.

Our innovative treatment model combines clinical expertise, group connection, and measurement-based care to support long-term healing. Charlie Health providers practice neurodivergent-affirming therapy, and clinicians adapt DBT skills (and other therapy modalities) to meet neurodivergent needs. Plus, the program offers dedicated peer groups for neurodivergent members, helping them feel less alone.

If you’re a provider and you have a client who might be a good fit, refer them today.

If your loved one might benefit from Charlie Health’s IOP, fill out this form.