by David Rabiner, Ph.D.
Durham, NC 27708
Until relatively recently, the prevailing view was that ADHD was a disorder of childhood that rarely persisted into the adult years. Studies conducted over the past 10 years, however, have indicated that this is not correct, and that many children with ADHD continue to struggle with the condition beyond adolescence and into their adult years.
As the awareness of ADHD as a long-term condition has increased, so has the need for studies of ADHD in adult populations. Given that social relationships is an area where children with ADHD often struggle, it is especially important to examine interpersonal functioning in adults with ADHD, particularly in regards marital and family relationships, the most important relationships in adults' lives. Because research on adults with ADHD has lagged far behind investigations of children, however, there has been only a single prior study of this topic. Although this study was limited by a small sample size, there was a trend for adults with ADHD to report lower levels of marital satisfaction.
A study published in a recent issue of the Journal of Attention Disorders - www.mhs.com/jad - titled "The Marital and family functioning of adults with ADHD and their spouses" (JAD, 8, 1-10) provides an interesting new examination of this issue. In this study, the authors sought to gain a better understanding of the functioning of clinic-referred adults with ADHD within their family context. The goals of the authors were three-fold.
First, they examined the marital adjustment and family functioning of married adults with ADHD. They hypothesized that adults with ADHD would report lower satisfaction with their marital and family relationships than comparison adults who did not have the disorder.
Second, the authors examined the adjustment of the spouses of adults with ADHD. The authors expected that these adults would report lower levels of satisfaction with their marriage and family life than adults whose spouse did not have ADHD.
Finally, the authors were interested in learning more about the experience of being married to an adult with ADHD. In particular, they wanted to learn how spouses felt that difficulties related to their partner's ADHD affected them and what adjustments they had made because of this.
Participants were 33 adults with ADHD (21 male and 11 female) who had been referred to an adult ADHD specialty clinic located in a university affiliated hospital, 32 of their spouses, 26 comparison adults without ADHD who were recruited from the community, and the spouses of these adults. The adults with ADHD represented all adults participating in a larger study of ADHD in adults who were married; this was 40% of that larger study population. Approximately 80% of couples in both groups had children. Couples in the study had been married for an average of 11 years.
All participants with ADHD had undergone a rigorous diagnostic evaluation to confirm that ADHD was an appropriate diagnosis. (As an interesting sidelight, nearly 40% of adults who presented at this clinic because they believed they had ADHD were not diagnosed with ADHD following the evaluation. This highlights the limitations of "self-diagnosis" in adults and the value of a comprehensive evaluation prior to initiating ADHD specific treatments.) Volunteers from the community were carefully screened to make sure that they did not have the disorder.
Participants completed the Dyadic Adjustment Scale, a 32-item measure that includes subscales intended to assess the degree of satisfaction, affection, cohesion, and distress that adults experience in their marital relationship. To assess perception of family functioning, they completed the 60-item Family Assessment Device. The aspects of family functioning assessed by this measure include problem solving, communcation, emotional responsiveness, emotional involvement, communication, and behavior control.
In addition to these measures, spouses of adults with ADHD were asked several additional questions about the impact their partner's ADHD symptoms had on their lives. The questions asked included the following:
"What are your concerns about your spouse's behavior?"
"How do your partner's ADHD symptoms affect you?"
"Do you have any complaints with regard to your spouse?"
"Do you compensate for your partner's difficulties? If yes, how?"
Unfortunately, these same questions were not asked of spouses married to partners without ADHD, so the ability to compare responses across the groups is not present.
"How do adults with ADHD and their spouse perceive their marital relationship?"
As predicted, adults with ADHD reported significantly poorer marital adjustment than non-ADHD adults across a range of areas. Specifically, they reported lower overall levels of satisfaction, less cohesion, lower levels of affection, and lower levels of consensus. In addition, their total scores on the scale were over 4 times more likely than scores of comparison adults to fall in the "maladjusted range", indicative of significant difficulties in the marital relationship.
Spouses of adults with ADHD reported lower levels of overall marital satisfaction than other spouses, and were more likely to have overall scores on the Dyadic Adjustment Scale that fell in the maladjusted range.
"How do adults with ADHD and their spouse perceive their family relationships?"
In comparison to other adults, adults with ADHD reported less satisfaction with their family relationships. The specific areas of family life that they rated more negatively were emotional involvement, communication, problem solving, and family roles. Their spouses, however, did not report lower satisfaction with family life than spouses of adults without ADHD.
"Do adults with ADHD perceive their marital and family life differently than their partner?"
The researchers also examined how satisfaction with marital and family life compare for adults with ADHD and their spouse. Interestingly, adults with ADHD were less satisfied with their marital relationship than their partner. They were also less satisfied with the quality of their family life than their partner. In contrast, in couples where neither partner had ADHD the level of satisfaction with marital and family life reported by each partner did not significantly differ.
"What complaints and concerns do spouse's of adults with ADHD express and how do they compensate for their partners difficulties?"
Thirty-one of 32 spouses of an adult with ADHD reported that their partner's behavior interfered with their functioning in at least one domain. The most frequently reported complaints and concerns fell within the domains of general household organization/time management (92% of spouses reported problems with their partner in this area), child rearing (55% reported problems in this domain), and communication and/or the marital relationship (54% reporting problems).
Within the general household domain, the complaints frequently reported included not initiating or completing household tasks/chores, excessive procrastination, and losing track of time/having a poor sense of time.
To compensate for their partner's difficulties in these areas, many spouses reported that they had taken on the task of keeping track of appointments for their spouse and providing them with frequent reminders about what they needed to get done. They also reported taking on a greater share of organizational tasks at home including completing almost all of the chores and cleaning up after their partner.
In the child-rearing domain, spouses frequently expressed concerns that their partner was easily frustrated with the children, lost their temper too quickly, and was inconsistent with discipline. In addition, adults with ADHD were described by their partner as often forgetting important child rearing tasks, and as focusing on being the "entertainment parent" rather than helping with discipline. Poor judgment in the form of excessive rough play and impulsive decisions were also noted.
To compensate for what they perceived as their partners' difficulties with child rearing, spouses reported taking care of nearly all child-related tasks and activities. This included car pooling, keeping track of their child's appointments and activities, helping with homework, and communicating with their child's teachers. Many reported having to protect their children from their partner's blow-ups and having to settle the children down after their spouse had "wound them up".
In the communication/marital relationship area, the concerns reported included frequent arguments, misunderstandings, and lack of support. Spouses complained that their partner often failed to follow though on commitments/promises they had made. Problems with intimacy and difficulty with expressing feelings were also noted.
Nearly 40% of spouses of adults with ADHD reported that their partner had work/school difficulties because of their symptoms and also had trouble with financial management. In the work/school domain, the problems described included lack of organization, difficulty getting along with co-workers, and appearing lazy. To help their spouse, partners often took on a secretarial role, by managing customer contacts and organizing their spouse's work. Several noted that they had quit their own job in order to help their partner.
When the ADHD adult was a student, spouses described helping with reading and writing, explaining concepts, organizing homework, and making sure that assignments got turned in. Interestingly, this sounds very similar to what many parents of children/adolescents with ADHD do to help their child.
SUMMARY AND IMPLICATIONS
Results from this study indicate that, on average, adults with ADHD are less satisfied in their marriage than our other adults, less satisfied in their marriage than their partner, and less content with various aspects of their family life.
The experience of spouses with ADHD is somewhat different. Compared to adults whose partner does not have ADHD, they also report lower levels of overall marital satisfaction. They are, however, more satisfied than their partner and are also not less happy about their family life than other adults.
Particularly interesting were the concerns that spouses of adults with ADHD expressed about their partner. Virtually all spouses noted that their partners' symptoms adversely impacted at least one important aspect of marital/family life and that they had developed a number of strategies to compensate for this. The authors note that "...although it was not surprising that more than half the spouses compensated for difficulties with general household organization/time management and child rearing, the fact that many of them also compensated for their partners' difficulties at work or school was unexpected." Spouses frequently took on important roles in organizing their partner's work life and the financial management of their partner's business. Of perhaps greater concern are reports of having to frequently protect the children from partner's emotional outbursts.
Although the results of this study are quite interesting, it is important to note several limitations. First, the sample size is relatively small, and replicating the findings with a larger sample would be a useful next step. In addition, to learn whether the findings reported here are unique to ADHD, it would be important to include couples in which one member has a different psychiatric disorder.
Second, as noted previously, the authors did not interview spouses of partners without ADHD about their concerns in the marriage. Thus, although the qualitative interview results are perhaps the most interesting data reported, these data should be interpreted cautiously because there is no basis for comparing the interview results to what is reported in other couples.
Third, while not a limitation of the study, it is important to emphasize that not all adults with ADHD were dissatisfied in their marriage and family life. In addition, although nearly all spouses reported that their partner's ADHD symptoms created some difficulties in marital/family life, there was wide variability in the difficulties reported. Thus, one should not interpret these results as indicating that all marriages where one partner has ADHD are troubled and that all adults with ADHD are unable to fulfill important obligations as a parent and partner. For example, only 55% of spouses reported specific concerns about their partner's child rearing and with communication in the marital relationship. Thus, many spouses did not report their partner as struggling in these areas.
Overall, this study sheds important new light on how adults with ADHD and their spouses experience their marital and family relationships. The authors suggest that their findings underscore the need for comprehensive evaluations of ADHD adults to include screenings of marital adjustment and family functioning from the perspective of both partners in the marriage, and for interventions to target the areas of concerns that are indicated. This seems like a very sensible recommendation, and future work that builds on this interesting study, and which examines ways to address marital and family difficulties in adults with ADHD, will be a welcome addition to the literature.