6. ADHD/ADD- Focus - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Off, Odd, Different… Special? Learning Disabilities, ADHD, Aspergers Syndrome, and Giftedness in Couples and Couple Therapy
Chapter 6: ATTENTION DEFICIT HYPERACTIVITY DISORDER  (and ADD) - Focus


Debra complains, "…and Marc gets involved with his guitar…"  Marc watches her intently, looking concerned and a bit sad.  He gives a soft sigh as she reiterates another of his acts of dismissal.  It is clear that he feels badly about disappointing and hurting her.  Debra continues talking… and eventually, Marc's gaze wanders to the window where a branch sways in the wind.  He watches it move gently back and forth as if hypnotized.  "And, it's just hard," Debra says tearfully, head bowed, and hands clasped.  Marc continues to watch the branch.  "And, he just doesn't care!" Debra glances at Marc, sees his blank stare off to the side and snaps, "There he goes again!"  She adds a withering death stare.  "Huh?  What?" Marc replies.  Marc is busted.

But Marc does care.  With his Attention Deficit Hyperactivity Disorder, Marc's attention wanes.  Just as it did in school he loses track, despite his best intentions during Debra's expansive discourse.  ADHD and Attention Deficit Disorder (ADD) share the common issue of high distractibility.  ADHD and ADD can be considered learning disabilities as well, but are often given specific attention because of their prevalence and impact on learning and socialization.  The therapist had observed the dynamic between Debra and Marc.  Marc had been trying to pay attention, but it was obviously a struggle.  He had to fight against being distracted… and he often lost the battle.  With wandering attention, Marc missed subtleties of cues that subsequently he could not respond to- for example, Debra's tears, bowed head, clasping hands, and especially, the quavering voice.  The golden rule of couplehood was violated- "If you really love me, you would be completely attentive and responsive to my every need, no matter how subtle!"  The golden rule of relationships (therapist-client, teacher-student, friend-friend) regarding respect is virtually the same.  However, there are not addendums for the golden rules regarding ADHD or ADD, stating "However, love or respect will not automatically overcome any issues making attention or response difficult!"  The therapist surprised the couple with an apparent shift in topic.  Rather than working on communications or other couple's dynamics for instance, he asked Marc if he had problems with paying attention in school as a kid.  Marc confirmed he had gotten into a lot of trouble for not paying attention in school.  The therapist further explored and eventually confirmed that Marc probably had ADHD or ADD.  Or, if he did not make some clinical threshold for such diagnoses, he had inherent distractibility issues.

This therapeutic exploration helped Debra realize that the golden rule was not immune to ADHD influences (and a myriad of other emotional, psychological, cultural, and processing issues as well).  Therapy helped Debra understand that Marc's ADHD made paying attention difficult despite him loving her.  And, Marc really wanting to and trying hard to pay attention.  She subsequently accepted that he needed help keeping focused.  She accepted that she could help Marc deal with being distractible, focus, and stay attentive.  Marc took responsibility that attention was a critical challenge to success in his relationship and elsewhere.  With the therapist's assistance, he improved recognition of her deeper messages conveyed by her non-verbal cues.  Previously, when Debra thought Marc was being dismissive, she snapped at and badly treated him.  Individuals hurt by inattention may feel entitled to be hurtful back, activating vengeful retribution by ostracizing, teasing, and aggression.  Unaware of their transgressions, ADHD or ADD individuals get negativity that seems to come out of nowhere.  Mistreatment seems completely unjustified.  This may prompt retaliatory behaviors by ADHD or ADD individuals, which prompts more retaliation if the cycle is not broken.  Marc would snap back or become passive-aggressive when Debra became harsh.  If not overtly reactive, someone such as Marc may withdraw and feel helpless and doomed, or become increasingly resentful.  The therapist used knowledge of ADHD and ADD characteristics to identify their dynamics and successfully interrupted the negative communication cycle between Marc and Debra.  Individuals like Marc with ADHD tend to have low self-esteem, mood lability, low frustration tolerance, and temper outbursts.  They also tend to be academic and vocational underachievers.  They would have and continue to suffer these issues before coming into the couple's relationship.  Unidentified or identified such problems will influence partner interactions.

ADHD issues create challenges for individuals in daily functioning, but also can specifically seriously compromise attempts to establish intimacy.  Hyperactivity, distractibility, and preoccupation can harm emotional intimacy between the ADHD person and a partner.  "By the time couples finally realize that adult AD/HD is the common thread running through their long-term woes, they're often hanging onto their last, frayed nerve- and maybe their last dollar, too.  It often takes a decisive event- discovery of secret debts, a job loss, an affair, an eye-opening article about AD/HD- to focus attention after years of missed red flags" (Pera, 2011, page 15).  In Marc and Debra's case, it was Marc getting so involved with cover band practice that he forgot to pick up their son from school.  He was left alone in the school yard for an hour before anyone noticed.  It had been scary for their son, but it terrified Debra what could have happened.  The pattern of distraction and forgetfulness that she had dealt with and tolerated for years became unacceptable when their son's well-being was threatened.  Their relationship had deteriorated over the years already, and their problems extended intimacy instability to several areas.  Someone like Marc can get so involved in "his or her own thoughts that he or she is usually unable to establish the closeness and communication that can lead to sexual intimacy (Nadeau, 1993)" (Betchen, 2003, page 104).  For Marc, Debra's anger and rejection were the worse consequence of his issues.  Relationship unhappiness and negativity were piled on top of previous negative experiences he had accrued since childhood.

DSM DIAGNOSIS
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), (APA, 1994. p.83-84) gives the clinical diagnostic criteria that mental health professions use for the ADHD diagnosis.  Of the core issues, inattention is considered significant enough for the diagnosis.  Attention Deficit Disorder (ADD) may be a more accurate diagnosis if attention and distractibility are the problems without the other two core issues.  For diagnosis of ADHD, the DSM-IV required six or more of the following problematic and developmentally inappropriate symptoms of inattention for at least six months

INATTENTION:

1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

2. Often has difficulty sustaining attention in tasks or play activities

3. Often does not seem to listen when spoken to directly

4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

5. Often has difficulty organizing tasks and activities

6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as school work or homework)

7. Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)

8. Is often easily distracted by extraneous stimuli

9. Is often forgetful in daily activities

Generally, adults become concerned about children with ADHD because of hyperactivity and impulsiveness that causes behavioral disruptions.  The same issues in adults however may be assumed to be a purposeful or perhaps, a moral failing.  The DSM-IV required six or more of the following problematic and developmentally inappropriate symptoms of hyperactivity or impulsiveness for at least six months.

HYPERACTIVITY:

1. Often fidgets with hands or feet or squirms in seat

2. Often leaves seat in classroom or in other situations in which remaining seated is expected

3. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

4. Often has difficulty playing or engaging in leisure activities quietly

5. Is often "on the go" or often acts as if "driven by a motor"

6. Often talks excessively

IMPULSIVITY:

1. Often blurts out answers before questions have been completed

2. Often has difficulty awaiting turn

3. Often interrupts or intrudes on others (e.g. butts into conversations or games)

4. Some hyperactive, impulsive or inattentive symptoms that caused impairment were present before 7 years of age

Some significant impairment in social, academic, or occupational functioning from the symptoms must occur in at least two settings (e.g., at school or work and at home).  Also, other explanations, such as other disorders, physiological, or environmental need to be eliminated.  The difficulty with diagnosis is that disruptions in a multitude of social and relational situations can also precipitate similar behaviors.  Other disorders may either co-occur with ADHD or ADD or be the cause the problematic behaviors.  The updated DSM V has emphasized that the diagnosis extends into adulthood.  "The ADHD diagnosis in previous editions of DSM was written to help clinicians identify the disorder in children.  Almost two decades of research conclusively show that a significant number of individuals diagnosed with ADHD as children continue to experience the disorder as adults.  Evidence of this came from studies in which individuals were tracked for years or even decades after their initial childhood diagnosis.  The results showed that ADHD does not fade at a specific age.  Studies also showed that the DSM-IV criteria worked as well for adults as they did for children but that a lower threshold of symptoms (five instead of six) was sufficient for a reliable diagnosis" (APA. 2013).  Adults with ADHD or ADD who have managed to be successful or developed effective compensations may have found situations, jobs, and careers that accentuate their strengths successfully.  On the other hand, they may enter relationships or therapy with ineffective to effective compensations for core issues.  "Undiagnosed adults often lug around a lifetime of poor coping strategies and cognitive distortions; over time the same becomes true for their mates.  With both people reacting blindly to the effects of AD/HD, which counseling frequently doesn't identify, their life together can feel like a wild roller-coaster ride" (Pera, 2011, page 15).  ADHD individuals may be relatively proficient in hiding their issues, or have habitually avoided circumstances that expose their challenges as deficits.  In the emotionally and physically intimate circumstances of a partnered couple, the consequences cannot stay hidden or be avoided for long.  Debra could make some case that she did not know what she was really getting into with Marc.

NEGATIVE EXPERIENCES SET RELATIONSHIPS QUICKLY
Individuals don't need a lot of negative experiences to begin disliking others.  Moving on to the next moment may be characteristic of young children, or giving someone the benefit of a doubt or letting it pass may be social etiquette acquired with maturity.  However "Many have noted that it takes few social exchanges over a period of only 20-30 minutes between children with ADHD and nondisabled children for the latter children to find the former disruptive, unpredictable, and aggressive, and hence to react to them with aversion, criticism, rejection, and sometimes even counter-aggression…" (Barkley, 2006, p.199-200).  Blachman in her survey of research found that "Children with ADHD have been repeatedly found to experience extremely high rates of peer rejection--presumably as a result of their intrusive and disruptive behaviors, limited understanding of the impact of their behavior on others, and strong likelihood of comorbid oppositionality or aggression… Such peer rejection occurs almost immediately upon social contact… and even those children with ADHD who are not aggressive tend to be rejected because of their overzealous and insensitive behaviors… Children with ADHD often serve as 'negative social catalysts,' fueling conflictual social interactions among their peers... Thus, the seemingly intractable peer problems of children with ADHD remain an area of concern for researchers and clinicians, particularly in light of the stability of peer rejection…and the abundance of evidence demonstrating the role that childhood peer difficulties play in both concurrent and future maladjustment in such areas as mental health problems, delinquency, and school failure…" (2002).  

From childhood through adolescence and into adulthood, individuals with ADHD often get rejected for their behavior.  Eventually, they may cluster with others with like energy and behaviors.  They may be drawn into increasingly problematic lifestyles including risk-taking, alcohol and illicit drug use, and marginal social behavior.  They become problematic prospects for intimate mutually supportive relationships because of their behavior.  Ironically, they may become the "bad boys" and "bad girls" that a certain subset of people is attracted to.  Debra admitted that she was attracted to Marc because he was a "bad boy."  He was a free spirit, played guitar with a heavy metal cover band, loved snowboarding, and had so much… energy.  The therapist asked what it was that both attracted her and then bothered her with Marc.  Debra was not stumped by the question at all, but went through the list of her initial attractions while adding their negative aspects that unfolded over time.  Marc was really great in the beginning.  And he had such great… energy.  He virtually attacked the world with his intensity.  He was more than game to try new things and have adventures.  "When novelty and stimulation are higher- at the beginning of a relationship or a job, for instance- many people with AD/HD function at a high level.  Frequently, their mates fail to recognize certain behaviors as red flags for long-term AD/HD.  These are reasons AD/HD can fly under the radar.  With previously high functioning AD/HD adults, its' sometimes the gradual addition of new responsibilities that can ultimately overwhelm their brains' capacities, diminishing competencies over time and exposing counterproductive coping strategies" (Pera, 2011, page 15-16).

It turned out eventually that Marc had so much energy that he had trouble keeping jobs and staying focused on any career path.  His spirit cause him trouble staying focused on her when she needed him to.  Sometimes, the band and snowboarding seemed more important than her.  Marc often got caught up in band practice and forgot the time, coming home quite late.  Challenged that she was aware of his light and dark sides well before ever getting married, Debra spoke of the positive qualities and how she felt that he would change if she was patient and supported him. She felt she could "fix" him by being loving and understanding.  Marc clearly loved her and committed to changing, but their love and commitment was not enough.  She torn between caring for Marc and feeling betrayed.  At times, she got self-righteous about her anger and other times, she felt badly about how negative she had become.  "Late-diagnosis adults tend to describe themselves with terms like failure, defective, socially undesirable, and incompetent.  Similarly, their mates have acquired self-blaming misattributions, like bad-tempered, nagging, and fault finding" (page 16).  The therapist asked Marc if he appreciated being Debra's "project."  Or, her "failed project."  Marc immediately knew what the therapist was referring to.  He felt badly that he disappointed her, but also resented Debra judging him.  Validating his resentment while simultaneously acknowledging Debra's frustration gained the therapist credibility with both partners.

"This couple needs a walloping dose of optimism.  They need to start feeling that they can turn their relationship around, with the right help.  Their therapist might feel like the little Dutch boy at the dike, but not knowing which holes to plug first: the emotional, the medical, or the practical" (page 15).  The therapist awareness and knowledge about ADHD can give the partners confidence in their relationship.  Therapy needed to process all these dynamics with awareness that someone such as Marc carries years and decades of self-esteem assaults, negative judgments, failures, and resentments.  His difficulties, low self-esteem, frustration, and misconnection with Debra are not off or odd, but entirely logical and predictable given his poorly addressed ADHD issues.  What has been occurring recently is not unprecedented.  Debra's disappointment and judgment, as well as her trying to "fix" him are altogether too familiar to Marc.  Others including parents and teachers did all that before.  The therapist's awareness and honoring of Marc's life challenged or colored by his ADHD issues facilitates rapport between them.  It helps articulate to Debra reasons for Marc's behavior other than him not caring for her.

The therapist may need to be very assertive about examining ADHD issues and identifying them as a critical if not foundational cause of their relationship problems.  This may challenge the therapist's style.  "Experienced clinicians treating AD/HD use approaches that traditionally have been viewed as overstepping therapeutic boundaries or being too 'active'" (page 16).  Strong directives, clear boundaries, and specific rules used with ADHD children may be developmentally adjusted for the adult client.  The therapist may take a pseudo-parental role and in both therapy sessions and for homework, teach and require interactions that work best for ADHD individuals.  This may include physically active interaction, the use of touch, visual cues, storytelling, alarms on the computer or cellphone to cue contact, and scripted routines and structured communication.  Helping Marc become self-aware of his own process, aids him in making better behavior choices.  As Debra understands Marc's process, she can compartmentalize his behavior as his burden rather than be devastated that it means he does not care.  Getting Marc to empower Debra to be an invested caring monitor helps join them together not just to help him, but also to help the relationship.  Debra's observations, feedback, and cueing can morph from hectoring negativity to positive alliance.  Debra takes on a participant-coaching role with Marc's permission.  Any growth or change by Marc becomes the couple's success.

As is the case with other issues that draw therapeutic attention, the therapist may find that ADHD is but one of many factors affecting an individual and the couple.  ADHD's impact should not be over-stated as the single causal factor.  However, the therapist should remember that ADHD and other factors often reciprocally influence each other.  By the time, the therapist sees an individual or a couple the various factors may have qualitatively altered and merged in some unique fashion.  These factors may have combined like the various ingredients- each with distinctive qualities and in different portions thrown into a cooking pot.  The "heat" of life transforms the ingredients and produces a "stew" of that may or may not be particularly palatable to the partners.  None of the ingredient/factors or the cooking/process of history and interactions can be removed.  Thus, the therapist is challenged to accept what is present (the stew… the relationship mess!) and interject new communication and relational elements and adapt interactions  such that the relationship becomes palatable… or in clinical terms, functional.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
phone: (510) 614-5641
fax: (510) 889-6553
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