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Managing ADHD in Couples – Attending When Attending is the Problem

Jenny Sanbrook, Accredited Mental Health Social Worker, Certified Gottman Therapist  

Managing ADHD in couples – Attending When Attention is the Problem.

The diagnosis of ADHD has evolved and changed over the years, originally called a Hyperkinetic Reaction of Childhood (DSM-II, 1968) and redefined as Attention Deficit Disorder- with and without hyperactivity, (the DSM-III, 1980). Renamed again as Attention Deficit Hyperactivity Disorder in the DSM III-R and IV. Most recently the DSM-5 (2013) diagnostic changes included among other things, modifications on definitions for older adolescents and adults, see Epstein and Loren (2013).  Although research on ADHD has expanded in the last decade,  there are currently no guidelines for treating ADHD challenged couples.  One of the first books published on this titled ADHD-Focused Couples Therapy (Barkley 2016) provides some guidance on this by blending three areas: Empirically supported principles where one partner has a psychiatric diagnosis, understanding ADHD related contributions to distress and couple oriented modifications of strategies already established for treating individuals with ADHD.   Other authors have expanded on these ideas identifying common impacts and patterns in couples with recommendations for therapists.  This article aims to give a brief overview of how ADHD effects couple relationships and outline management strategies for treating this. 

Definition, Statistics and Prevalence

ADHD is defined in the DSM-5 as a persistent pattern of inattention/and or hyperactivity-impulsivity that interferes with functioning or development.  This can be classified as a combined presentation, predominantly inattentive presentation or predominantly hyperactive presentation.  The diagnosis fits under the Neurodevelopmental section of the DSM-5 along with other conditions such as Autism Spectrum Disorder and Learning Disorder.  Symptoms of ADHD include inattention/distractibility, poor sustained attention, poor executive functioning (self-regulation, mood swings) hyperfocus, disorganisation, forgetfulness and impulsivity.

Much has been written on the causes of ADHD (too much to cover and outside my area of expertise), however major causes fall into the realm of neurology and genetics (biological causation) with no evidence that social factors alone account for the condition (Barkley, 2017).  There is now greater focus on ADHD to be a reward deficiency syndrome created from a deficit of pleasure neurotransmitters (mostly dopamine but also serotonin and endorphins) (Ratey, 2005).  Without these chemical indicators of reward people with ADHD have trouble completing tasks that reward only after a long period of time such as studying at school to obtain a university entrance, or engaging in more boring and repetitive tasks such as household duties, repetitive tasks, completing taxes etc.

A large study in Missouri of 9380 subjects aged between 7-19 showed the overall prevalence in the community to be  9.2% (any subtype), in children 11.7%, and a decline in prevalence in adolescence at 9.7%,  and adults at 6.4%.  This was consistent with the research showing ADHD symptoms decrease with brain maturation.  (Ramtekkar, U et.al 2010).  

The issue of gender differences is also tricky with research differing however males have been more likely to be diagnosed with ADHD than females  with a male to female ratio of approximately 4:1  (Ramtekkar, U et.al 2010), however these statistics vary on the subtypes assessed and age of assessment along with effect size of the study.  Gender differences around diagnosis may have implications for couples work as couples tend to present with the male partner having the diagnosis of ADHD.  The study also showed a higher prevalence in males however this was in the younger age group.  Males tend to be diagnosed with ADHD at higher rates than females however this is complex because in clinical setting females are often under referred.  (Ramtekkar, U et.al 2010). 

Impact on relationships and implications for couples therapy 

According to Biederman et. al. (2006) a person with ADHD is twice as likely to be divorced as someone without ADHD.  Some studies show that 96% of all spouses of adults with ADHD reported that their partner’s symptoms make it harder for them to manage their household and raise kids. More than 90% said they had to do more to make up for their spouse’s difficulties in these areas Webmed (2022).  Barkley et.al (2016) also propose from several studies that more than 80% of adults with ADHD have at least one other condition – current depression between 16-31%, anxiety 24-43%, ODD 24-35%, conduct disorder 17-25% and alcohol dependence 21-53%.  Indeed ADHD has been associated with less satisfaction and success in romantic relationships and sufferers often have short lived and discordant romantic relationships (Wymbs, B et al. 2021).  

ADHD impacts far  more than attention, research shows it is a disorder of executive functioning which involves the five areas of:  time management, organization, motivation, concentration and self discipline/ emotion regulation Weir (2012).    The presence of these pose particular challenges for couples, considering that healthy relationships require partners to be attentive, connected, reliable, and trustworthy.   The tendency towards impulsivity and mood swings is also challenging.   Orlov (2022) points out, “the issue with ADHD emotional hyperarousal is that it is de-stabilising for relationships – if negative responses are unpredictable the other partner is walking on eggshells” (Orlov 2022: 21). 

Unhelpful patterns seen in ADHD affected couples

Given there are many facets affected in relationships identifying the patterns that occur and helping couples see them can be a way to begin addressing the issues. I have outlined some below.

The parent child dynamic:

Partners move into parenting behaviours in order to manage the ADHD – this often involves giving up important aspects of their own life to maintain stability.  This dynamic reinforces a further cycle of shame and secrecy from the ADHD partner and resentment and anger from spouse.  The pattern also leads to hopelessness on both sides, often one person experiences the partners disdain due to failure to complete tasks, this is followed by a loss of self confidence and withdrawal. The non ADHD partner often sees the ADHD partner’s actions as deliberate and thus feels justified in the anger.

Painful misinterpretations, distance /conflict and blame

Orlov (2010) describes painful misinterpretations where couples interpret a person’s unavailability and distraction as not loving them anymore. (“How can he not see that I need him to greet me when he gets home – he seems oblivious to me”).  This occurs due to the ADHD sufferer becoming accustomed to people being annoyed at them and finding ways to weather these frustrations and disappointments eg by ignoring them or seeing them in equal ways to other day to day frustrations.  

Symptom-Response-Response pattern

This involves being drawn into a “dance” that amplifies the problem into a greater couple relationship problem.  For example the symptom of distraction or impulsivity is not necessarily pathological (and may have actually been an appealing feature in the courtship phase- fun/ life of the party, interesting) thus the ADHD partner may not see the “symptom” as a problem – however the response from the partner will understandably be anger/frustration – leading the ADHD partner to respond with withdrawal, hopelessness, avoidance.  This amplifies the issue into a larger martial problem as a negative spiral of responses occurs (Orlov 2010).

Oscillation between hyperfocus and distraction/forgetfulness – leading to depression and feelings of failure.

When partners are unable to listen carefully or follow through on plans and agreements stress increases.  Alternatively, when a person is hyperfocused and heavily engrossed in an activity partners can feel unimportant and irrelevant.   Distraction leading to forgetfulness such as forgetting to pick up the children, forgetting to bring important items, forgetting to pay a bill  etc.  When happening regularly can be damaging to a relationship because they prevent a person from being able to rely on their partner.  Plus the person with ADHD feels like a failure and the pattern is reinforced by the non-ADHD partners anger.

Addressing ADHD in Couples Therapy 

Manage ambivalence and avoidance around diagnosis and treatment.

Often ADHD sufferers are reluctant to seek diagnosis and treatment because of stigma and shame.   By the time couples have presented for counselling where one partner has ADHD there is often a long history of hurt, misunderstanding and resentment.  For the ADHD sufferer they often present with a sense of guilt and anxiety as they are aware of the pattern of letting their partner down.  The non-ADHD partner is often on the cusp of leaving, they report being exhausted and have little empathy for the partner after many years of holding up the system. Educating them about obtaining a thorough psychiatric assessment and likelihood of medication is the priority if not already covered.  Providing resources with scientific evidence will be crucial if a partner is ambivalent about treatment.

Therapy at this stage involves acknowledgement of both partners pain and grief.  An exploration and validation of both positions and creating a safe space for expression of emotion.  The trap for the therapist here is to take sides and this must be avoided.  

Boszormeni-Nagy (1978) also emphasises in “contextual therapy” that both partners must fully understand the nature of a disorder that affects the functioning of a relationship.  In this case, understanding not only the impact on the self and the relationship but also the meaning each attaches to the others behaviour.  He also emphasises the concept of relational ethics where both partners are entitled to have their welfare and interests considered (Kilcarr, P 2002).

Slow down interactions and explore the impact of ADHD on self and the relationship 

Couples with ADHD benefit from techniques that assist them to slow down their interactions – to enhance focus and attention on what their partner is saying, providing structure for conversations, reducing reactivity and identifying the patterns mentioned above.    Improving communication through building skills in empathising, reflecting, validating and deepening couples understanding of each others world are all valuable techniques.  Gottman Method Couples Therapy provides a structure for deepening conversations with couples and improving empathy and validation skills.  Additionally, Imago Relationship Therapy (IRT) developed by Harville Hendrix and Helen Hunt (1988)  also promotes listening skills, self control and problem solving.    

Many people with ADHD describe feeling like they are “driving in the rain with a bad windshield wipers at 90 miles per hour.  Every once in a while things are clear but most of the time you’re not sure what’s coming at you”. (Hallowell 2005).  Approaches that promote empathy and acceptance and a secondary focus on change can be useful, See – Integrative Behavioural Couples Therapy (Christensen, Doss and Jacobsen, 2020).

Address Unhelpful Patterns and Set Boundaries 

Parent-child dynamic:  Treating this often involves the non-ADHD partner letting go of some behaviors that are less impactful to the relationship for them along with helping the ADHD partner to increase their functioning. Organising regular meetings to manage the division of labour and scheduling regular time and/or therapy for more productive conversations to occur can be a starting point.

Painful misinterpretations:  Education about ADHD and the patterns that occur will assist in the couple to become less reactive.  Helping both partners to ask questions and remain neutral, along with having regular conversations about motives and differences will help this occur.  

Symptom – Response, Response cycle:  If the non-ADHD partner is able to recognize feeling lonely when the partner is distracted and communicate this – the partner will be more likely to respond to new practical ideas such as making a time to re-connect.   Impulsivity leads to a sense of chaos for partners, thus naming this and developing set routines may be required to ease anxiety for the non-ADHD partner. Helping partners to consider both responses and not allowing the ADHD partner to see an angry response as the cause of the problem will help de-escalate.  Also, coaching the non-ADHD partner to learn responses that produce positive outcomes is crucial.  However it is important to note that the ADHD partner is still responsible for managing the ADHD symptoms as this is the start of the Symptom- Response-Response cycle thus medical treatment is most likely to be required. 

Hyperfocus and distraction:  Encouraging partners to set an alarm clock can help people keep track along with not bringing technology to important times of connection such as meal times or when spending one on one time together.  Furthermore setting aside a regular time for a conversation that is free from stimuli such as noise, televisions etc is important.  Gottman Method Couples Therapy suggests setting aside 20 minutes a day for listening and validating partner concerns and talking about problems or positives that have happened outside of the relationship.  Allocating time in a structured way for empathising and validating with a focus away from problem solving enhances closeness and reduces loneliness in the relationship.

There is much to be written on this topic, however as the awareness and diagnosis of ADHD in adults is on the rise, it is inevitable that health professionals seeing individuals with ADHD will be faced with the challenge of supporting partners effected by the condition.  It is my hope that this article has provided some ideas for understanding the full impact on relationships and some tools to guide clinicians working with this population.

References

www.adhdmarraige.com

www.ADHDFocusedCoupleTherapy.com

Barkley, R et.al. (2008). ADHD in Adults What the Science Says.   The Guilford Press.

Christensen, A Doss, B and Jacobsen, N  (2020). Integrative Behavioural Couples Therapy. Norton and Norton NY. 

Epstein J and Loren R (2013) “Changes in the Definition of ADHD in DSM-5: Subtle but Important”.  In Neuropsychiatry (London) 2013 Oct 1:3(5): 455-458

Gottman J and Sliver N (2015).  The Seven Principles for Making Marriage Work.  Random House, New York.

Hallowell, E and Ratey, J and (2005).   Delivered from Distraction – Getting The Most Out Of Life With Attention Deficit Disorder. Ballantine Books, NY. 

Kilcarr, P (2002) Making Marriages Work for Individuals with ADHD. in Clinician’s Guide to Adult 

ADHD Assessment and Intervention. 

Orlov, M and Kohlenberge, N (2014).  The Couples Guide to Thriving with ADHD.  Speciality Press USA.

Orlov, M (2010).  The ADHD Effect on Marriage.  Speciality Press Inc Florida USA. 

Pera G and Robin A (2016) eds.  ADHD-Focused Couple Therapy Clinical Interventions.  Taylor and Francis, UK. 

Ramtekkar, U et.al (2020) Sex and Age Differences in Attention-Deficit/Hyperactivity Disorder symptoms and diagnoses: Implications for DSM-V and ICD-11.  In J AM Child  Child Adolescent Psychiatry2010 MArch 49(3): 217-28.    

WebMD Your ADHD Relationship Survival Guide Sept 2022.

Weir, K (2012) Pay Attention to me: Undiagnosed ADHD affects millions of adults and their romantic relationships. America Psychological Association March 2012, vol 43:No3 

Wymbs, B et.al (2021) Adult ADHD and romantic relationships:  What we know and when we can do to help.  In Journal of Marital and Family Therapy.  Volume 47 Issue 3 pp664-681. 

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