The Distracted Couple

The Impact of ADHD on Adult Relationships

Larry Maucieri PhD, Jon Carlson PsyD, Larry Maucieri PhD, Jon Carlson PsyD, Larry Maucieri, Jon Carlson

• Publisher: Crown House Publishing
• Year: 2014
• Print ISBN: 9781845908775
• eBook ISBN: 9781845908805
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

In total, this volume addresses many of the issues that couples face when either one or both partners has ADHD and the many ways that clinicians can help them in dealing with these issues.Although historically the diagnosis and treatment of ADHD have focused on children, more recently clinicians and researchers have explored the impact of ADHD on adults. Few, however, have focused on the effects of adult ADHD on relationships and marriages, which makes this a must-read for all of those interested in and working with adults with ADHD.

Part I

Effects of ADHD on Couples

Chapter One

ADD, ADHD, & Adults: Sorting It All Out

Larry Maucieri, PhD

ADD, ADHD and Adults: Sorting it All Out

The evolving science and practice exploring attention deficit hyperactivity disorder (ADHD) have yielded a number of interesting and exciting findings that directly impact our understanding and knowledge of the disorder. In recent decades, the notion of ADHD as strictly a disorder of childhood has been challenged, such that it is now also reliably identified and treated in adults (Safren, Perlman, Sprich, & Otto, 2005). The focus of this book is on the impact of adult lifespan ADHD on interpersonal relationships, specifically marriages and romantic partnerships. Before addressing the patterns, challenges, and range of interventions for couples impacted by adult ADHD, however, it is helpful to summarize the most recent literature involving adult ADHD. This summary of the current science and practice is intended to provide readers with a brief but solid foundation on which to understand the phenomenon of adult ADHD. It should provide the reader with a helpful context within which the interventions that follow may be practiced and understood. As we in mental health care transition from using the DSM-IV-TR to DSM-5, part of this chapter will focus on the evolution of ADHD as a diagnostic entity in these diagnostic manuals.

To provide readers with a solid background, recent work involving a number of aspects of ADHD is presented here. This includes the evolving diagnosis and conceptualization of ADHD; the DSM‑IV-TR and expected DSM-5 criteria for the disorder (American Psychiatric Association, 2000; 2013); the prevalence of adult ADHD; the biological bases of the disorder; issues and concerns that frequently occur with adult ADHD; and contemporary treatment approaches for the disorder. We mention some of the earliest theories involving what has come to be known as ADHD, before focusing for the remainder of the chapter on the most recent work and concepts related to the disorder.

The Evolving Diagnosis of ADHD

While not always recognized by its current name, the syndrome that is attention deficit hyperactivity disorder (ADHD) has been written about, debated, and discussed for at least 100 years. Consistent with the science of the times, in the early 1900s it was characterized as resulting from “a lack of moral control and the failure of the individual to conform to the environmental expectations for behavior” (Wadsworth & Harper, 2007, p. 101). The disorder was later conceptualized as other diagnostic entities such as hyperkinesis disorder of childhood and minimal brain dysfunction before it gradually evolved into the syndrome recognized today as ADHD (Wadsworth & Harper, 2007).

Similar to the medical and biological bases empirically discovered for other psychiatric disorders (e.g., schizophrenia, bipolar disorder), in recent decades, ADHD has also been conceptualized as having a significant neurobiological component. Some of the most recent work in this area is detailed below. As Waite and Brooks (2013) note in this text, however, ADHD is not a purely biological disorder and socio-cultural factors are quite germane in the development and symptom manifestation of ADHD in children, adolescents, and adults. We begin with a cutting-edge theory from eminent ADHD expert Russell Barkley who posits a concept relating to and possibly explaining some of the characteristics of ADHD.

Sluggish Cognitive Tempo

Independent of the DSM-related criteria developed for ADHD which are explored below (APA, 2000), a number of other recent theories and concepts related to the disorder have emerged in the last few years, and it may be beneficial for clinicians and providers to have some knowledge of them. Barkley (2012), for instance, recently described a correlate of ADHD called sluggish cognitive tempo (SCT). Individuals with SCT are described as exhibiting reduced activity, a tendency to daydream, confusion, and lethargy. These symptoms might occur not only in the context of ADHD, but in other well-established disorders (e.g., depression). Barkley (2012) argues, though, that among those who meet criteria for ADHD, a subset of them distinctly exhibit SCT. It should be noted that within his model SCT may also occur in individuals who do not meet the diagnostic criteria of ADHD, such that SCT and ADHD may be related, but they are separable entities. Barkley (2012) suggests that the concept of SCT is distinct from ADHD as supported by factor analyses of parent and teacher ratings of children, and that SCT is associated with executive impairments and psychosocial deficits in adult participants beyond what could be explained by ADHD alone.

While this investigation might imply some overlap between SCT and (in DSM-IV-TR conceptualization consistent with the time of his publication) the predominantly inattentive type of ADHD, the combined type of ADHD, and to a lesser extent the hyperactive-impulsive type of ADHD, Barkley (2012) does not suggest that SCT is redundant with and fully captured by the inattentive aspects of ADHD. Rather, he argues that there is a high degree of overlap between SCT and ADHD. In this regard, some diagnoses that have been made as ADHD predominately inattentive type might actually reflect a case of high SCT along with other elements of ADHD present, rather than an actual case of ADHD itself. Finally, Barkley (2012) stated that SCT might be considered a distinct diagnosis in the forthcoming DSM-5, although this was not the case in the final formulation of the DSM-5 (APA, 2013). Still, the introduction of SCT within the conceptualization of ADHD may indicate a transition toward a more spectrum-oriented conceptualization of ADHD.

Revisiting Criteria for ADHD: Recent Developments

Before considering the evolving DSM criteria for ADHD below, it is interesting to note some of the recent work on what ADHD entails, and how well this has or has not been captured within the DSM criteria that are so often used to define ADHD. Barkley (2012), for instance, reports that some authors wonder if the DSM-IV-TR types of ADHD (defined below) might represent not so much distinct subtypes of the disorder as variable levels of severity on an ADHD spectrum.

A fair number of critics note that the DSM-IV and DSM-IV-TR criteria for ADHD are heavily skewed toward the experiences and behaviors of children (Weisler & Goodman, 2008). This might naturally reflect that the disorder was long considered an exclusive syndrome of childhood and adolescence. However, there is increased awareness that for many individuals, at least some of the symptoms of ADHD endure into adulthood. Some of these symptoms may even evolve in presentation. For example, one study suggested that a validated computerized measure of sustained attention often used to help diagnose ADHD may be optimally administered for this purpose with children in morning hours, but would be valid during both morning and afternoon times for young adults (Hunt, Bienstock, & Qiang, 2012). An important area of interest for clinicians is the mounting evidence in support of ADHD symptoms persisting into adulthood and the need to better understand its presentation so that it may be effectively remediated.

Executive Impairments and ADHD

As the name suggests, attentional deficits are a core feature of ADHD. However, recent empirical work has also strongly implicated executive impairments as well. For instance, a recent study by Boonstra, Kooij, Oosterlaan, Sergeant, and Buitelaar (2010) comparing adults with ADHD matched with controls on age and gender found that the executive functions of inhibition and set shifting were particular areas of deficit for adults with ADHD. As of yet, these difficulties have not been well codified in the DSM criteria or conceptualization of ADHD, but it had been hoped that the criteria in the DSM-5 may do so. In reality, the DSM-5 did not drastically alter the criteria from the DSM-IV-TR, such that an executive impairment became a core diagnostic feature of the disorder (APA 2000, 2013). This change would have been helpful and important as clinicians working with ADHD need to be fully aware of all related issues and problems that reliably occur as part of the disorder. A detailed exploration of executive impairments in adult ADHD is nonetheless provided within this text by Tuckman (2013).

Executive impairment as a central feature of ADHD is supported by other recent work. Fedele, Hartung, Canu, and Wilkowski (2010) concluded in their work that two core factors of ADHD involve cognitive flexibility and disinhibition. While these features are well-established in the clinical and research literature on ADHD, they were not clearly reflected in the core criteria of the DSM-IV-TR for ADHD.

Tuckman (2013) argues that executive impairments are a hallmark of ADHD that persist from childhood into adulthood. In support of this idea, Miller, Ho, and Hinshaw (2012) found that executive dysfunction continued into young adulthood among females who had been diagnosed with ADHD in childhood, even in those individuals whose other ADHD symptoms remitted. Clearly, then, a greater awareness of executive impairment as part of adult ADHD is needed.

As we have already seen, while the DSM criteria are not perfect in their characterization of the ADHD experience, they are used pervasively and are quite influential in the clinical understanding of this disorder. A review of the established DSM-IV-TR criteria for ADHD is helpful in this regard, with a particular emphasis on how these criteria have evolved in the DSM-5, and how closely aligned these documents are to some of the more current developments in ADHD research and clinical work.

ADHD: DSM Conceptualizations

An exploration of the ADHD symptom criteria in recent decades and the recent changes in the criteria are highly useful. These standards in mental health care are presented and deconstructed for a deeper understanding of their strengths and limitations. We focus here on the DSM criteria as these are the most widely used in the USA. While these criteria apply to all individuals who might meet a diagnosis of ADHD, the literature demonstrates that these criteria are not an equally good fit for all ethnic and gender groups (Waite & Brooks, 2013). From a broader sociocultural perspective, ADHD conceptualization, diagnosis, and treatment plans may be specifically suited for Caucasian males, resulting in suboptimal recognition and treatment of the disorder in women and individuals from diverse backgrounds (Waite & Ivey, 2009).

An Assessment of ADHD in the DSM-IV-TR

Although the DSM criteria changed slightly in May of 2013, it is worthwhile to briefly review the DSM-IV-TR criteria for ADHD that had been used since 2000. Doing so will allow a better understanding of how the disorder has been understood and conceptualized in recent years, and how it might differ from the extant contemporary literature involving ADHD. Furthermore, this knowledge provides a solid foundation for understanding and critiquing the new DSM-5 criteria for this disorder released in May 2013.

The DSM-IV-TR configuration of ADHD involved two broad dimensions of the syndrome: inattention and hyperactivity-impulsivity (APA, 2000). Note that in the latter grouping both hyperactivity and impulsivity were represented in one set of symptoms, rather than as separate areas of concern. To formally meet this diagnosis per DSM-IV-TR specifications, one would have needed to manifest a minimum of six of the criterion symptoms in one or both of these broad categories. This would have then yielded three possible types of ADHD by DSM-IV-TR criteria: 1) the p...

Table of contents

• Cover
• Praise
• Title Page
• Dedication
• Contents
• Contributors
• Foreword
• Acknowledgements
• Introduction
• Part I: Effects of ADHD on Couples
• Part II: ADHD in Diverse and Less Recognized Groups
• Part III: Working with Couples with ADHD
• Conclusion: What Follows Next?
• Name Index
• Subject Index
• Copyright