Attention Deficit Hyperactivity Disorder (ADHD) in Couple and Family Therapy
KeywordsAttention Deficit Hyperactivity Disorder Executive Function Attention Deficit Hyperactivity Disorder Attention Deficit Hyperactivity Disorder Symptom Couple Therapy
Attention deficit hyperactivity disorder (ADHD) is a genetically based, neurobiological disorder that begins in childhood but persists into adulthood at a rate of at least 65–70% (Barkley 2014). It is estimated that only one in ten adults with ADHD in the USA is diagnosed. Many of these adults are currently misdiagnosed with depression, anxiety, or other conditions. Couples wherein one or both partners have ADHD often experience excessive conflict and negative interactions that threaten or even end their relationships. The ADHD partner often listens poorly, fails to finish tasks or fulfill commitments, manifests inappropriate emotional outbursts, and generally acts in the relationship more like a child than an adult.
Compounding the potential for disruption to the couple and the family unit: Adult ADHD itself is associated with sequelae including higher than average rates of undereducation, underemployment, bankruptcy, traffic accidents, and interpersonal violence (Barkley 2014). When ADHD goes long unrecognized or misunderstood – as it has for most adults – domestic problems tend to intensify over time. The partners of these adults misattribute ADHD-related problem behaviors to malicious motives, lack of love, immaturity, or their own deficiencies. The adults with ADHD themselves feel misunderstood and frustrated. Both partners’ negative reactions to the “invisible elephant in the room” of ADHD gradually create a downward spiral in the relationship and for each individual.
Therapists trained primarily in couple or family interventions sometimes feel ill prepared to address significant individual psychopathology contributing to or interacting with relationship concerns—in part because traditional systemic formulations have often marginalized or ignored the etiological role of individual pathology in family system functioning.
Adult ADHD-Focused Couple Therapy (Pera and Robin 2016) is specifically designed to address relationship dysfunction and the full range of issues around domestic cooperation for couples where one or both partners have ADHD.
Theoretical Context for Concept
Until recently, ADHD was considered primarily a disorder of attention, impulse control, and hyperactivity. Now researchers know that ADHD is fundamentally a disorder of self-regulation of executive functions and that the 18 DSM-5 ADHD symptoms can be considered akin to executive functions (Barkley 2014). Executive functions are higher-order processes of the brain that guide an individual’s behavior over time, analogous to the chief executive officer of a company or the conductor of an orchestra. To use the latter metaphor, the conductor selects the musicians and music, rehearses the orchestra, and leads the musicians during the concert. If the conductor does a good job, the music sounds fine. If not, it sounds mediocre – or even cacophonous. In adult ADHD, the brain is inconsistently “conducting” the person’s daily functioning; core executive functions are not efficiently operating in a purposeful, task-oriented direction.
Neuroimaging research has identified deficits in areas of the brain associated with the executive functions of inhibition, attention, distractibility, organization, time, self-awareness, emotional self-control, and motivation in people with ADHD, compared to those without ADHD (Pera and Robin 2016). These areas include the frontal lobe, the basal ganglia, and the cerebellum. Intrinsically interesting tasks such as the Internet and video games produce higher reactivity in these areas of the brain and more task completion for everyone, regardless of the presence of ADHD. Intrinsically less interesting tasks – such as doing chores, listening to another person speak, and paying bills – require more brain stimulation for the person to complete. The neurogenetic brain deficits found in adults with ADHD interfere with such tasks. As a result, many aspects of ADHD-challenged relationships suffer.
Alter views of the relationship: Couples are provided with psycho-education regarding ADHD, its causes, how it impacts relationships, and how changing their view of the nature of their relationship’s challenges reduces blame and sets the stage for positive change.
Modify dysfunctional interactions: Targeted interventions address dangerous and destructive behaviors that ADHD partners may exhibit (e.g., violence, anger outbursts, abusive remarks, denial).
Decrease emotional avoidance: Clinicians employ techniques such as consciousness raising and motivational interviewing to cut through denial and low self-awareness of ADHD as well as the associated tactics around blame and avoidance that some individuals with ADHD have developed as poor coping responses.
Improve communication: Direct communication training and the modified Imago Dialogue help couples improve their interpersonal exchanges.
Promote relationship strengths: The therapist continually emphasizes the importance of partners praising each other’s efforts, increasing positive activities, using rewarding incentives for habit and behavior change, and rekindling romance.
Interventions designed to teach the ADHD partner how to get the most out of medication
Cognitive restructuring designed to replace the distorted thinking developed over the years when ADHD had not been identified with more reasonable thinking
Behavioral interventions that improve time management, organization, planning, and follow-through
Educate the Couple about ADHD. The therapist provides the couple with a scientifically based explanation of ADHD as an executive function disorder, summarizes the evidence for its genetic/neurobiological etiology, describes how it impairs individuals and couples, summarizes how a diagnosis is made, and outlines the various treatment strategies available to the couple. Each partner is encouraged to ask questions and to fully process their reactions to the diagnosis in joint or individual sessions.
Clarify the Partners’ Cognitions. Prior to learning about ADHD, couples often harbor misattributions or distorted cognitions about each other’s behaviors, responses, and counter-responses. The non-ADHD partner often attributes the ADHD partner’s actions to malicious motives or not caring about the relationship, leading to depressed and angry affect and poor coping behavior. The ADHD partner often views the non-ADHD partner’s actions as over controlling and hypercritical. It is important to remember that sometimes both partners have ADHD, manifesting in perhaps very different ways; these dual-ADHD couples experience patterns similar to the ADHD and “non-ADHD” partner.
The therapist uses adult ADHD-focused cognitive restructuring to help the couple identify their dysfunctional coping responses and reframe their challenges through the lens of ADHD as a neurobiological disorder. This new perspective promotes less toxic and more neutral cognitions, establishing a stable foundation for more positive affect and teamwork in learning coping behaviors and improving their ability to problem-solve long after therapy ends.
Optimize Medication. Many physicians conduct only brief medication monitoring visits. They do not provide couples with the knowledge or tools to access, much less optimize, the benefits of medication. While respecting professional boundaries, the knowledgeable therapist can provide critically needed help in informing about medication; guiding the couple to select meaningful, medication-sensitive targets for change (e.g., attentive listening, efficient follow-through, and enhanced emotional self- control); employing a simple system for monitoring medication effects; and helping the couple work as a team in giving feedback to the physician.
Acquire New Habits and Improve Coping Behavior. The therapist teaches the couples “nuts and bolts” strategies for behavior change. These include reliably adopting physical supports (e.g., calendar planners, prioritized “to-do” lists, and reminder systems) and cognitive strategies around “getting things done” (e.g., managing time, breaking down complex tasks into small steps, overcoming procrastination and distractibility, and utilizing positive incentive systems). The couple learns how to work as a team in applying these techniques to their important household and family projects. In experiencing successful task completion around these projects – typically for the first time – couples gain new optimism in improving other aspects of their life together.
Communicate Attentively and Empathically. The couple learns to identify and replace negative communication habits with positive, solution-oriented habits. The result: They can listen to each other without interruption, express their thoughts and feelings with dignity and respect, and mutually problem-solve disagreements. The highly structured Imago Therapy technique called The Dialogue serves as the centerpiece of communication training, chosen because it reduces impulsivity, increases sustained attention, and fosters empathy.
Co-parent Effectively. Adults with ADHD typically experience extreme difficulty in consistently implementing the rules, routines, structure, incentives, and punishments needed to parent effectively. This is true whether or not their children also have ADHD. (Given the high heritability of ADHD, however, chances are good that biological children will also have ADHD, which only increases demands around creating consistent routines and structure, not to mention regulating tempers.) As a result, their partners perform more than their fair share of the parenting, especially when it comes to discipline. Moreover, they come to consider the ADHD partner to be “like another child to be parented.” The therapist helps the couple “get on the same page” with regard to evidence-based parenting strategies. They also apply to parenting the lessons learned from step 4, Behavior and Habit Change.
Address Other Challenges. ADHD-challenged couples grapple with various specific issues around sexual intimacy, money management, cyber addiction, and denial of ADHD. Distinct modules in Adult ADHD-Focused Couple Therapy address each of these challenges.
The therapist typically goes through these steps in the order described above, but the therapy is flexibly tailored to the needs of each couple. Both partners attend most sessions, but the therapist may at times choose to meet individually with each partner. This can be especially helpful when the adult with ADHD needs to be “brought up to speed” on many basic personal habit-change and cognitive-restructuring techniques before they can be expected to implement cooperative strategies.
Application of Concept and Clinical Example
Michael and Rose have been arguing for most of their 26-year marriage, with conflicts centering on spending, chore sharing, and co-parenting. Michael has worked off and on as a carpenter for a home-building company. Rose works as the longtime billing manager in a busy psychiatric clinic. The couple allowed the more intimate aspects of relationship to fall by the wayside years ago, due to the historical futility at improving these areas. Rose earns the more reliable salary, acted as primary caregiver for the children, and, having finally given up on inspiring Michael’s cooperation, performs most household chores. After her many tearful breakdowns, Michael would always once again agree to help more with laundry, dinner preparation, or with the kids’ homework. But he never followed through for long, and he cannot explain why. Rose said the reason is clear: He doesn’t care; he does only what he wants to do. Over the years, Rose coped by dreaming of “Plan B” – that is, the time when their children were living on their own, and she could finally make decisions based on her happiness. That “empty nest” time has come. Their youngest just moved out.
One day at work, Rose confided to a staff psychologist that she was filing for divorce. The more the psychologist listened, however, the more she perceived “red flags” for ADHD. Rose responded with incredulity. On the drive home, however, she had time to think. The description fit. Michael has his good qualities; they were just so overwhelmed by the problematic behaviors. If it is possible that their long-running conflicts are due to a treatable condition, she decides she owes it to him and their marriage to pursue the possibility.
In preparation to deploying “Plan B,” Rose had in recent months turned her attention to sprucing up and then selling their 1960s home. Michael, currently out of work, possesses the “sprucing up” skills but not the follow-through. He has always started renovation projects with great enthusiasm. He eventually loses steam, however, and returns to other more interesting, passive activities, such as watching YouTube videos on random topics. When it came to issues such as the months-long unfinished bathroom tile, Michael minimized with quips such as “Grout is over-rated” and promised “I’ll get to it.” Just last week, Rose declared, “I’m done with your lame excuses.” She accused him of being a “do-nothing who does not care about your marriage, just like your father.” He retorted that she is “a controlling bitch, just like your mother.” That’s when Rose gave up on renovating the house. The next day, she confided in the clinic psychologist her plans for divorce.
Now, Rose wants to give their marriage one last try. She presented the possibility of ADHD to Michael and asked him to pursue an evaluation. Initially, he balked. Clearly sensing, however, that a refusal would mean the end of his marriage – and being vaguely aware that ADHD might explain his lifelong struggles – he made the appointment. Once evaluated and diagnosed, he half-heartedly agreed to couple therapy. Rose knew that the therapist would need to provide reason for optimism quite quickly, to keep Michael “in the game.” Their one attempt at couple therapy, years ago, failed because the therapist kept delving into Michael’s dysfunctional family of origin without offering any strategies for addressing the couple’s domestic problems, leaving him feeling hopeless and defeated before he got started.
ADHD Education. The therapist thoroughly explains what ADHD is, the variable ways in which it can manifest, and how the diagnosis is made. “This explains a lot about my dad,” said Michael, after learning of ADHD’s high heritability. “It explains a lot about Michael’s approach to work, too,” said Rose. One the one hand, Michael could easily sell customers on his plans for remodeling, and they would be impressed with his enthusiastic “blaze of glory” start. But as time went on, they grew frustrated that he would “hyper-focus” on small details and loses focus toward more monotonous tasks, such as measuring and hanging doors. Too many times, he simply stopped showing up, thus forfeiting payment for work completed. Michael was relieved to learn that his lifelong pattern of avoidance was common for late-diagnosis adults with ADHD – and that there was hope for change.
Also like many other adults with ADHD, Michael’s attention darts to the new and exciting. Left in the dust: the “daily tasks of living” and nurturing a relationship. To put simply one aspect of ADHD, the associated neurobiology can lead a person to crave the stimulation of exciting or novel tasks but shut down when the task becomes mundane. Michael learns to view his ADHD as a challenge to be coped with, not an excuse. Rose comes to understand that the underlying issues are biomedical in nature, not intentional. Both partners learn that in order to have a more satisfying relationship and smoother-running domestic life, they need to cooperate in implementing ADHD-targeted strategies and altering their mindsets.
Clarify Cognitions. Using the figure detailing the Adult ADHD-Focused Dysfunctional Interaction Cycle (Pera and Robin 2016, p. 66), the therapist explains to Rose and Michael that they aren’t alone. Other couples dealing with unrecognized ADHD predictably develop tightly held and toxic misperceptions about each other’s behaviors, reactions, and counter-reactions. For example, the therapist reframes Michael’s poor follow-through on various promises as a natural consequence of his ADHD brain turning off repetitive or tedious tasks, not laziness or lack of regard. Likewise, Rose’s critical statements become better understood as the natural frustration of a partner who has for years had no viable explanation for her spouse’s repeated failure to finish what he agrees to do and who forgets important agreements – and always finds a way to avoid important discussions.
Optimize Medication. Michael expressed a lot of anxiety about “Big Pharma” and the possible negative effects of medication – a bit odd for a person who smokes two packs of cigarettes per day. Nonetheless, the therapist provided him with clearly explained scientific information about stimulant medication and urged him to attend an adult ADHD support group meeting on this topic. After talking there with other adults, including men Michael’s age, who benefitted greatly from medication, Michael reluctantly agreed to try it.
The couple chose two medication targets for change: (1) Michael conversing attentively with Rose during dinner and (2) Michael following through on three simple, mutually agreed-upon household tasks each day. After the prescribing physician gradually increased Michael’s dosage of stimulant medication over 3 weeks, the couple concurred in seeing great improvement in both target behaviors. Again, it is emphasized, a team approach helps both partners stay on track and optimistic about making further improvements. As part of the treatment team, the physician agreed that Rose should accompany Michael to his medication follow-up visits.
Acquire New Habits and Improve Coping Behavior. Michael acknowledges that he wants to be more actively engaged in his marriage and their “team effort.” He expresses a desire to complete the household renovation, one that promises to give their marriage a beautiful “fresh start.” Simultaneously, though, he feels hamstrung by doubts, reinforced by past failures. The list seems overwhelming. He dreads Rose having to endlessly nag him to finish. The therapist explained the importance of acknowledging and problem-solving around those fears, especially around making and completing plans.
First, he prompted the couple to list on paper all the steps of the renovation, sequence the steps, break them down into small steps, note them on a calendar spanning several months, and detail how they would carry out the first step. During the next few weeks, the therapist directed the couple to sit down each evening for 10 min, reviewing the day’s work and remaining tasks. They used their smartphones to structure daily and weekly to-do lists, set reminders, and reward their progress. They selected motivating rewards such as dinner out or movies for completing each phase. To their surprise, they steadily accomplished a great deal without deteriorating into “screaming meanies.”
Communicate Attentively and Empathically. Michael and Rose called it a “freeing experience.” That is, their gradually learning to reframe their challenges through the neurobiological lens of ADHD rather than Michael being “lazy and never listening” and Rose being “hypercritical and controlling.” This breakthrough led to improved positive regard, further solidified by ongoing progress on shared goals at home. Between these events and Michael’s ongoing medication treatment, he showed more active engagement with Rose – listening, remembering more, and being more thoughtful. For her part, Rose had dropped the incessant inflammatory criticism.
With this more positive foundation established, the therapist worked to strengthen the pair’s communication beyond the chore list. Using the structure of the Imago Couple Dialogue, Michael and Rose learned how to have more respectful conversations about intimate issues and practical problem-solving. They practiced sharing appreciations for each other and dealing with grievances. Under their therapist’s direction, the couple had been “checking in” with each other for 10 minutes daily, primarily to note renovation progress and coordinate the next day’s goals. Now, the therapist assigned them the task of using part of that time to practice new elements of The Dialogue learned in session.
Co-parenting. Because their children were now grown and on their own, this component of the intervention was no longer needed. Yet, given the pileup of years spent arguing about co-parenting, the therapist found it important to review how ADHD, left unrecognized, can present co-parenting challenges. Rose now better understood why Michael was always the “fun” parent, leaving her to be the “heavy.” As the children grew, the constantly changing rules and guidelines were too much for Michael to keep track of. He also did not trust himself with meting out discipline, fearful of repeating his own father’s violent punishments.
Address Other Challenges. Michael and Rose had not been sexually intimate for 3 years at the time that they entered therapy. They had grown so angry and distant from each other. Yet, the therapist took no direct steps to help them restart sexual intimacy. After they started attributing their entrenched problems to ADHD as the “elephant in the room,” and found new success in working cooperatively, they naturally rekindled their desire and again enjoyed sexual intimacy. This couple fortunately had no comorbid addictive behaviors that also needed intervention.
Other couples of course will need targeted help in improving patterns around managing income and outgo, curbing electronic overuse, tackling ADHD challenges related to sleep, and nurturing physical and emotional intimacy. Throughout, practical strategies typically lay the foundation for success. After all, even physical intimacy typically relies on cooperation in the rest of life, including both partners being in bed at the same time instead of one staying up until the wee hours checking social media.
Each couple challenged by adult ADHD is different. ADHD itself is a syndrome, meaning that symptoms are variable individual to individual. Moreover, most adults with ADHD will have a second coexisting condition. The poor coping responses to unrecognized ADHD take myriad shapes as well, influenced by socioeconomic backgrounds, culture and ethnicity, educational levels, and other aspects of personality. The partners of these adults might also have ADHD – or any other human foible. Family-of-origin issues always form a part of the picture. Yet, when ADHD is challenging the relationship, predictable patterns can ensnare even the most mutually loving partners and lead to a mistakenly dire prognosis for the more troubled couples. ADHD-informed strategies can provide the all-important foundation for healing ADHD-challenged relationships (Pera and Robin 2016).
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