Part I
Adult ADHD and Relationships 1
Meet the Couples and their Common Challenges
Gina Pera
The term ADHD looms over society as a confusing misnomer, a relic established decades before modern brain-imaging techniques allowed scientists to plumb the conditionâs true and deeply complex nature. Yesteryearâs experts, by focusing primarily on the most obvious outer sign of physical hyperactivity, concluded that children with ADHD âoutgrewâ the condition, because hyperactivity usually lessened as the children matured. âHyperkinetic reaction of childhoodâ first appeared in the Diagnostic and Statistical Manual (DSM) in 1968, but it represented only a narrow definition of what the 1994 DSM-IV-TR would recognize as a much more complex condition.
Today, we know that most adults who have ADHD manifest no physical hyperactivity, that even many children who have ADHD are not physically hyperactive, and that ADHD persists well into adulthood at a rate of at least 65â70 percent (Barkley, Murphy, & Fischer, 2008; Weiss & Hechtman, 1993). (Note: The term ADHD currently represents all presentations, including Inattentive, as explained later in this chapter.) Today, we also know that ADHD symptoms can wield even more debilitating effects in adulthood than in childhood: After all, adult life requires a great deal more self-managementâincluding earning income, managing finances and households, parenting, driving, maintaining relationships, and taking care of oneâs physical health (Barkley et al., 2008).
This chapter highlights the ADHD traits and behavioral patterns that commonly challenge couples and couple therapists, especially when ADHD has long gone unaddressed. This information lays the foundation for understanding the six couples, later in the chapter, whose stories illustrate familiar clinical scenarios.
The Evidence for ADHD
Researchers say ADHD has likely been with us throughout human history, with references to its familiar manifestations in the medical literature as far back as 1748 (Barkley & Peters, 2012). Today, we understand that ADHD carries a strong genetic component, generally about 76 percent (Faraone et al., 2005). That is, if one identical twin has ADHD, the chance of the co-twin having ADHD is 70â80 percent. With fraternal twins, the rate is half that because they share far less genetic material. With regular siblings, the rate is even lower, though still higher than in the general population. No genes have been discovered, however, that are unique to people with ADHD; rather, it is the combination of various genes that seems to result in this syndrome (Neale et al., 2010).
Since the 1990s, the so-called âDecade of the Brain,â revolutionary brain-imaging methods have exponentially increased our understanding of this most complex human organ and, thus, of conditions such as ADHD. In 1994, Adult ADHD was declared a legitimate diagnosis. And in 1998, the American Medical Associationâs Council on Scientific Affairs called ADHD âone of the best-researched disorders in medicine, and the overall data on its validity are far more compelling than for most mental disorders and even for many medical conditionsâ (Goldman, Genel, Bezman, & Slanetz, 1998). To date, more than 15,000 papers with ADHD or ADD (the older term) as a major focus have been published since 1970, according to PubMed. The literature is clear: ADHD is real, it is more common than most people realize, and its treatments can be highly effective. Equally well documented: ADHD neurobehaviors, when left unaddressed, can limit the options, the self-fulfillment, and even the physical health of the people who have it, and adversely affect everyone in their spheres of influence.
Currently, the prevalence of Adult ADHD is thought to be 4.4 percent (Kessler et al., 2006), a figure largely viewed as extremely conservative, based on problematic diagnostic criteria, and likely to omit millions of people who suffer impairing symptoms. Even if it is a low estimate, 4.4 percent still amounts to more than 10.3 million adults ages 18 and older in the United States alone, according to the 2010 U.S. Census. Given that ADHD can be a highly impairing condition, even the conservative 4.4 percent prevalence rate poses a major public-health concern (Asherson et al., 2012; Hinshaw & Scheffler, 2014). Moreover, only a fraction of that 4.4 percent are diagnosed, perhaps one in ten, with even fewer in treatment, according to Kessler.
The implications of ADHD under-diagnosis loom even larger when we take into account a prevalence rate that some experts consider more realistic: An estimated 16.4 percentânot just 4.4 percentâof U.S. adults suffer sub-threshold impairment from ADHD (Faraone & Biederman, 2005). That translates to about 23â35 million people, not counting their partners and others affected by their difficulties, including siblings, parents, grandparents, friends, children, and co-workers.
By comparison, 150 million Americans wear some type of corrective eyewear to compensate for vision impairments (âVision Problems in the U.S.â, 2008). In centuries past, as with ADHD today, the concept of vision correction (necessitated primarily by the invention of the printing press and the spread of literacy) was mired in stigma until it finally became commonly accepted.
The steady increase in ADHD diagnoses may be more than an artifact of increased awareness of it. Modern life increasingly threatens to over-burden everyoneâs âcognitive capacity.â The world of today places outsized demands on our ability to manage responses to a mind-boggling array of details, temptations, distractions, and electronic stimuli that are tailor-made for hijacking the human attentional system and keeping it in its thrall. Simultaneously, the modern workplace demands a great deal more self-organization than it did in, say, the mid-20th century. For example, the days of secretaries handling paperwork, scheduling, and reminding are mostly long gone. So, too, are structured nine-to-five jobs where duties are clear and straightforward, and work is left at the office. Noisy âopen officesâ drive most of us (with or without ADHD) to distraction. And no-smoking regulations have eliminated one source of âself-medicationâ that previous generations accessed freely: nicotine, with its stimulating effect on the brain. Todayâs employees are normally expected to manage their own schedules, projects, paperwork, and rapidly shifting priorities, with electronic communications keeping many virtually âat workâ nearly 24/7. Two-income couples who have children must also juggle commutes, daycare, and the plethora of after-school activities as well as increased demands around schoolwork.
âWe all have ADHD,â or âWe live in an ADHD world.â So go the common refrains. Yet, as much as people who do not have ADHD feel the pinch of modern pressures, people who do have ADHD are an order of magnitude more vulnerable. Consider them the veritable âcanaries in the coal mineâ of our speeded-up, plugged-in milieu, at once less able to resist distractions and most likely to need the kind of daily structure and environmental supports grown scarce in the 21st century. The temptation is to lament bygone âsimplerâ times while glossing over the dark side, including the risks clearly evident through past centuries for people with ADHD in terms of educational and vocational under-achievement, substance abuse, parenting difficulties, financial mismanagement, relationship conflict, and even incarceration, to name a few deleterious effects. Even today, these same risks ensnare too many people with ADHD. Viewed more positively, modern knowledge offers an opportunityâunparalleled throughout human historyâfor millions of people worldwide to truly understand their âbrain wiringâ and take steps to elevate their lives.
The Primary Brain-Based Challenge: Self-Regulation
âYou can pay attention when you want to.â That phrase painfully reverberates throughout the life trajectory of people with ADHD. In part, this accusation stems from the misnomer Attention-Deficit Hyperactivity Disorder. In fact, ADHD is not a disorder of attention so much as a disorder of self-regulation, according to psychologist Russell Barkley, who first detailed his theory in ADHD and the Nature of Self-Control (1997). For more than 30 years, researchers studying ADHD have identified brain deficits in areas such as inhibition, managing attention, and self-awarenessâoverall, the mental abilities that we humans use to regulate our own behavior. In fact, some experts consider the challenges around self-regulation, or self-control, so central to ADHD that the condition might be more accurately named Self-Regulation Deficit Disorder. As highlighted throughout this guide, ADHD particularly challenges self-regulation of attention, motivation, and emotion.
Neuroimaging research indicates that in people with ADHD, specific brain areas show less reactivity to stimulation than in people without ADHD; these areas include the frontal lobe, the basal ganglia, and the cerebellum (Swanson et al., 2007). To grasp this concept in laypersonâs terms, we must first understand that the human brain is primed for stimulation. It is through stimulation that we engage in life. Our mere interest in somethingâan attractive person, a fun event, a new thought, and even potential danger or riskâtriggers the release of neurotransmitters that arouse and maintain attention until the goal is met: We engage the person, make plans to attend the event, entertain the thought, or react to the danger and risk.
Simply put, people with ADHD find themselves closer-than-average to one end of the human spectrum: the end requiring greater stimulation in order to trigger interest and release those chemicals. These neurochemicals include but are not limited to the neurotransmitter most commonly associated with ADHD: dopamine, the so-called âpleasureâ or ârewardâ molecule. That is why some experts quip that ADHD might best be called Search for Stimulation Syndrome. Imagine fully intending to quickly check the weather report online and get back to work but instead finding yourself three hours later immersed in fascinating YouTube videos about meteorologyâand feeling certain that only 30 minutes has passed. This getting-lost-in-the-stimulation phenomenon can be as frustrating to these adults with ADHD as it is to their partners, leading one to coin this alternative moniker: If Itâs Boring, It Ainât Gonna Happen Unless You Make Me Disorder.
Neither phrase, of course, conveys the complete story of ADHD; each describes only one aspect of this highly variable and complex condition. For example, another key component of ADHD is a vulnerability to distractions; this vulnerability can intensify when the person faces performing tasks that feel overwhelming in size or scope. Nonetheless, phrases such as Stimulation Chasing Syndrome, simplistic as they are, still help to convey to the neophyte a very important concept: ADHD puts individuals at greater risk of getting distracted from what they should be doing at any given timeâworking, sleeping, housekeeping, grocery-shopping, bill-paying, and child-tending, and in general acting in alignment with long-term goalsâand into activities that are more immediately stimulating, rewarding, or gratifying. Or simply any activity that requires less mental effort. Even people without ADHD might well recognize this phenomenon in their own lives, albeit on a smaller scale: When faced with a complex or tedious task, such as filing income taxes, it is tempting to give in to the suddenly compelling need to re-organize the spice rack, a much simpler task.
In a sense, then, there is a kernel of truth to the perception that ADHD adults can do something when they want to do it. As one middle-aged man with late-diagnosis ADHD put it: âI over-do what I want to do and under-do what I need to do.â But a kernel is not the whole truth. Many of these adults also want happier relationships, but they often canât follow through on the myriad details required to make that happen. If âtrying harderâ were a solution, most of these adults would have surmounted their hurdles years ago. On an intellectual level, they typically understand that âmore matureâ behavior is required, that even the most rewarding things in lifeâfulfilling work, satisfying relationships, or good healthâinvolve some tedium and delayed gratification. But on a neurological level, the perceived payoff of performing âboringâ tasks is neither sufficiently immediate nor rewarding enough to kick the brain into gear. Moreover, what might feel simply boring or tedious to the person who does not have ADHD can feel downright unnerving and undo-able to the person who doesâalmost like subjecting oneself to physical and mental âstatic,â or even pain.
This stimulation-chasing characteristic explains a narrow but key aspect of ADHD. It also drops one important clue as to why stimulant medications are largely considered the first-line medication treatment for ADHD (Chapter 5). First, among the public, there is a widespread misconception that stimulants have a âparadoxicalâ effect. That is, it seems counter-intuitive that a stimulant could help people who are already mentally or physically restless. In reality, there is no paradox. Stimulants mitigate ADHD symptoms by increasing the availability of certain brain chemicals, such as dopamine and norepinephrine, which help to transmit signals along neural pathways. As a result, the individual can better inhibit the urge to act without thinking, letting thought rather than impulse guide actions. In a sense, therefore, taking a stimulant medication helps to regulate the âroller coasterâ of erratically lurching from one over-the-top stimulation source to the next, from over-stimulation to under-stimulation and back again.
Medication is not for everyone, however, and it is only one part of the recommended multi-modal treatment for ADHD. As emphasized throughout this book, the strategies deemed most helpful for these individualsâand therefore helpful for the coupleâinclude making the âdaily tasks of livingâ and being in a relationship easier to perform and the perceived rewards for doing so more clear and immediate. These challenges, and their solutions, are explored further in Chapter 2, through the paradigm of Executive Functioning.
The Common Couple Issues: An Overview
Glib generalizations about Adult ADHD or its effect on relationships are, at best, unhelpful. This syndromeâs manifestations are wide-ranging. The individuals affected by it are complex in the ways that all humans are complex. Having ADHD, or being in a relationship with someone who has it, is only one aspect of a personâs complexity.
We can, however, confidently categorize the issues that bring these couples to counseling, because single adults with ADHD face precisely the same issues, including problems with employment, finances, education, driving, sexuality, emotional regulation, communication, health habits, ...