The Couple's Guide to Thriving with ADHD
By Melissa Orlov, Nancie Kohlenberger, Steve Robb
Specialty Press, Inc. Copyright © 2014 Melissa Orlov and Nancie Kohlenberger, LMFT
All rights reserved.
Diagnosis, Treatment and the Two of You
"Lacking self-control robs you of free will. This is one of the most tragic consequences of ADHD. You might think that you're doing what you desire. Yet if you can't inhibit your behavior, you miss out on the delay between an event and your response. That delay is essential: It gives you the chance to think. Even more critically, that delay empowers you to choose freely."
— Russell Barkley
Treatment is one of the first things couples think about when they discover one or both of them has ADHD. But managing ADHD is complex, as there is no one-size-fits-all treatment. Because of this complexity, our information about treatment can be found in two different places. This chapter provides a concise overview of what we think you need to know about optimizing treatment of ADHD. With this knowledge you can move on to the good stuff — creating a happy relationship.
Our second resource is the Overview of Treatments for Adult ADHD on Melissa's website (www.adhdmarriage.com). This site provides more in-depth information about specific treatment options and issues. Moreover, it is updated regularly and includes numerous links to important online information.
Because we are not medical doctors, Dr. Edward Hallowell and Dr. John Ratey graciously agreed to review and approve this chapter. They are practicing psychiatrists and co-authors of Driven to Distraction and many other books on ADHD. Hallowell and Ratey are two of the world's leading medical experts on ADHD.
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Confusion about Diagnosis and Treatment
With no proven physiological tests for ADHD at this time, getting the right diagnosis is something of an art form. Clinicians must assess:
Whether or not the cluster of symptoms and behaviors clearly indicate ADHD
Whether these symptoms might be something else (such as bipolar disorder) that looks similar to ADHD
If ADHD (if it exists) is complicated by coexisting conditions, such as anxiety, depression or sleep disorders
Diagnosis is just the very beginning of what is typically a longer-than- expected journey on the way to creating a thriving relationship. As this journey unfolds, it is typical that non-ADHD partners suffer from anxieties and pose questions related to the repetitive nature of entrenched ADHD symptoms. For example, while observing their partner's slow progress at managing ADHD symptoms, they might wonder, Is my partner really dedicated to this? If so, why isn't he working harder to address his ADHD? As understandable as these feelings and uncertainties are, they miss the larger point. People with ADHD have trouble getting organized and following through. That's part of having ADHD. Since, by definition, those with ADHD have trouble getting organized, it is a cart-before-the-horse challenge for them to be organized enough to get a diagnosis and then put effective treatment in place. The process can be frustrating for both partners — particularly early on.
But let's start at the beginning — with the diagnosis. If you wish to skip to treatment information, go to page 18.
ADHD partner: I've just found out that I probably have ADHD. Figuring out what to do next just seems completely overwhelming. Can you give me some ideas of where to start?
ADHD partner: Are there physical tests I can take instead of having a psychological evaluation? I'm 55 and may have trouble recalling childhood memories. I may also have a hard time coming up with specific examples that help me answer the questions.
A psychiatrist, psychologist or primary care physician familiar with ADHD is your best resource for an ADHD diagnosis. In some areas you'll find the local expert is a pediatric psychiatrist, whom you may wish to contact. Expertise with ADHD is what you should seek, as ADHD can be tricky to diagnose accurately because it often is accompanied by other conditions such as anxiety or depression that can obscure it. In addition, other conditions such as sleep apnea, bipolar disorder, undiagnosed celiac disease, or a very hectic and overscheduled life can superficially mimic ADHD. Ask your doctor how often she diagnoses and treats ADHD to make sure she will be good at teasing apart the various diagnostic options.
If your current physicians don't have the expertise to diagnose ADHD, there are some other resources available to find help. These include:
CHADD (Children and Adults with Attention Deficit Disorder), a national organization that keeps a small online database of professionals in the field of ADHD. In addition, and often a better bet, local CHADD chapters may keep a list of local resources. Contact the chapter nearest you to see if it has such a list.
The short but growing referrals list at www.adhdmarriage.com.
The PsychologyToday.com online database. This site is large and allows you to search by zip code and insurance plan. Make sure to call and ask if the person you find genuinely has expertise in ADHD. Many in this database have checked the "treats ADHD" box along with a long list of other options, suggesting they are not specialists in ADHD.
Your local school district or learning disabilities group, which often knows of professionals in your area.
A Google search of "ADHD diagnosis in (your state or city)" or "ADHD doctors in (your state or city)." The search may help you find resources worth exploring. For the sake of evaluation, avoid any resources you find that tout "alternative approaches" or that aren't licensed. You can assess these alternative resources for treatment later, once you know whether or not you have ADHD.
The online database at GoodTherapy.org. Although the "expert search" is somewhat hidden, this site does provide useful information. At the time of this printing, you must go to www.goodtherapy.org then choose "find a therapist," then the "advanced search" tab. Finally, click on "concerns" and choose "Inattention, Impulsivity & Hyperactivity: (ADHD)." To refine your search, choose a state before clicking "search."
ADHD-specific clinics. Some major medical centers, such as Massachusetts General Hospital in Boston and Mt. Sinai Medical Center in New York City, have these. Check your local hospital.
Clinics that specialize in Cognitive Behavioral Therapy. These clinics may also know of local diagnosticians.
A good diagnosis will include a look at your personal and family history, your medical issues and, possibly, your marital concerns. You will be asked questions to understand whether or not you qualify for a diagnosis as established in the diagnostic manual (known as the DSM-5).
Your doctor may also use a computer program to test the speed of your responses and your ability to stay focused on a task. Separately, in 2013, the FDA approved the use of an EEG to aid in ADHD diagnoses when used in conjunction with a full diagnostic interview and testing. This ruling is considered controversial by many, as it is based on a single study of 275 children done by the manufacturer of the EEG machine.
Some doctors (particularly those who don't specialize in ADHD) may give you a quick diagnosis after a brief review of your concerns and a discussion of your history. If you've done your research and you're pretty convinced that you have garden-variety ADHD, this may suffice, though it's not ideal because of all the possible coexisting conditions. However, diagnosis should never be based solely on whether or not you respond to stimulant medication. This is an inappropriate and dangerous form of diagnosis, as you will likely gain more focus using a stimulant whether or not you have ADHD. A hasty diagnosis could lead to an incorrect conclusion or a diagnosis that overlooks other important conditions (such as depression, anxiety, or sleep deprivation) that often go hand in hand with ADHD.
If you can, ask for handouts about ADHD and any treatments you discuss with your doctor. It's hard to remember all of the information he or she will give you.
Is It ADHD or ADD, and Is It Mild or Severe?
Non-ADHD partner: Is there a difference between ADHD and ADD? When I think of ADHD I think of the classic person who can't sit still. Yet my ADD partner seems to have no energy and is often in la la land.
ADHD partner: Is it possible to have "mild" ADD, and how might this affect my relationship?
First, "attention deficit hyperactivity disorder" is misnamed. ADHD isn't about a deficit of attention — it's about attention dysregulation. A person with ADHD can be very distractible much of the time but also have periods of intense focus, sometimes called hyperfocus. The "deficit" is really a deficit of control, or regulation, over one's attention. Just because a person with ADHD wants to pay attention to something doesn't mean he or she will be able to do so at that moment. ADHD treatment is all about putting strategies in place to help the person with ADHD have more control over his or her attention, emotional regulation, memory and behaviors.
ADHD can vary greatly in intensity. Those with milder ADHD might find they are somewhat distractible and not at all impulsive, while others are so distractible they can barely function and are also wildly impulsive, highly emotionally reactive, terrible organizers of projects and time, and have very poor short-term memory. It's not surprising that there is a correlation between the severity of ADHD symptoms and a person's ability/inability to succeed in a wide variety of life functions such as work, dating, schooling and driving.
In addition to different levels of intensity, there are also different types of ADHD. Distraction is the primary symptom of the condition that used to be called ADD (but is now just included in ADHD) whereas hyperactivity (alone or in combination with distraction) is a symptom of other subtypes of ADHD. So ADHD looks very different in different people.
What Else Might it Be?
ADHD partner: In the diagnostic process, what are the disorders most likely to be confused with ADHD?
ADHD partner: My doctor has diagnosed me with both ADHD and anxiety. Is there any rule about what should be treated first?
In a review of the research about ADHD in adults, researchers and ADHD experts Russell Barkley, Ph.D., Kevin Murphy, Ph.D., and Mariellen Fischer, Ph.D., found that more than 80% of adults with ADHD will experience at least one other condition in their lifetime, more than 50% will experience two or more, and more than one-third will experience three or more conditions (Barkley, Murphy & Fischer, 2008, p. 241).
The most common conditions that coexist with ADHD are listed below. The incidence percentages are in ranges (from multiple research studies) that give you an idea of the likelihood of co-occurrence:
Depression: 16-31% may be currently depressed, with a lifetime likelihood of 53%.
Anxiety: 24-43% of those with ADHD may also suffer from anxiety, depending upon a number of factors.
Oppositional Defiant Disorder: 24-35% of those with ADHD may also be diagnosed with ODD, a disorder characterized by being overly stubborn or rebellious, and refusing to obey rules.
Conduct Disorder: 17-25% of adults with ADHD may also have this. Those with CD often lie, cheat, steal, fight or bully others.
Dyslexia and Dyscalculia: Considered a reading disability, dyslexia shows up in at least 20% of individuals with ADHD, according to Dr. Ned Hallowell. (Hallowell & Ratey, n.d.). Dyscalculia (a learning disability related to calculations) and dysgraphia (visual processing) also occur with greater frequency in those who have ADHD than the general population.
Alcohol Dependence or Substance Abuse: People with ADHD can have addictive tendencies, perhaps due to low impulse control or chemical issues in the brain. The likelihood that someone with ADHD will have an alcohol abuse issue in his or her lifetime is 21-53%. Those with ADHD are also more likely to use other substances, particularly marijuana and psychedelics. Interestingly, some research done with young adults found that the correlation between ADHD and substance abuse may be directly tied to the combination of having both ADHD and co-occurring conduct disorder.
Tobacco Use: Repeated studies indicate that there is a direct correlation between the number and severity of ADHD symptoms and the use of tobacco. This may be because nicotine has a stimulant-like effect similar to the ADHD medication methylphenidate — in other words, nicotine is a form of self-medication for ADHD. About 40% of adults with ADHD smoke ("Smoking and ADHD: What," n.d.).
Other co-existing conditions: Tourette syndrome (very rare, but with some overlap with ADHD); learning disabilities (very common); bipolar disorder (research varies about whether there is an increased incidence of bipolar in those who also have ADHD); sleep apnea. Fifteen percent of those with ADHD have celiac disease (Niederhofer, n.d.).
What to Treat First
Knowing what else you may have along with ADHD will help your doctor provide the best treatment. If you have a history of depression, for example, your doctor might choose to start treating both the ADHD and your depression with an anti-depressant rather than a stimulant medication. If you don't have a long-term history of depression, on the other hand, it might be valuable to treat the ADHD symptoms first, as depression or anxiety might be tied to the untreated ADHD. Once the ADHD is discovered and treated, the other conditions might disappear.
According to Dr. John Ratey, co-occurring anxiety is often treated successfully with ADHD medication, so the two issues can be handled simultaneously. As he says, "The evolutionary reason for this [i.e., the link between anxiety and ADHD] is that we need to be anxious when we are not focused. As we become more focused we get less anxious. Though this seems paradoxical to many, it is nevertheless true." (J. Ratey, personal communication, December 2, 2013.)
Some disorders look a lot like ADHD but aren't. These include sleep deprivation, sleep apnea, an eye tracking disorder, and something that Hallowell calls "pseudo ADD." The latter may occur when your life is overfilled with commitments and your brain becomes overwhelmed. To rule out the possibility of pseudo ADD, eliminate some of your commitments. If your distraction and feelings of being overwhelmed go away, you don't have ADHD.
Bipolar disorder is often confused with ADHD (and sometimes coexists with it). Bipolar disorder is a mood disorder, and those who have it suffer from extended rages, long periods of sleep deprivation, manic behavior, racing thoughts and more.
Multi-Modal Treatment for ADHD — A Stool with Three Legs
You most likely have ADHD either because you inherited it or because of a brain trauma. As there are many genes involved in the expression of ADHD, it is not completely understood yet. Most of these genes are associated with the neuro-transmitters dopamine and norepinephrine, chemicals that are important to the attention and reward systems of the brain. So this means that ADHD is about the chemistry of your brain. But that's not all. It is also about the developmental rate, size and functionality of specific areas of the brain.
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Though not all of the details are well understood, the net result is difficulty in the attention and reward systems of the brain, as well as in what are called "executive functions."
What's most important is to understand how to optimize treatment so that ADHD symptoms are managed well enough to get out of the way of a thriving relationship. To help our clients optimize treatment, we describe it as having three legs, like a stool. And, like that stool, the best treatment only "stands" if all three legs are employed. You should be consciously selecting options from all three legs. If you are not doing so, you are not optimizing your ability to manage your ADHD. We will describe each leg in more detail later in this chapter.
What Are Executive Functions (EF)?
Executive functions help you exhibit control over your actions so you can reach a goal you wish to achieve. According to Ari Tuckman (2012), those with ADHD exhibit weaknesses in some or all of these areas:
The ability to hold information in the very short term to use to process two or more things, or until deciding to move the thought to long-term memory. Weak working memory leads to easy distraction, difficulty staying on task, impulsive decision making, forgetfulness, and lack of interest in reading.
Sense of time:
The ability to estimate and monitor the passage of time.
The ability to put on the brakes and think before we act. It is also important in delaying gratification.
The ability to carry an intention or thought forward in time so you may act on it.
The ability to create perspective that help us keep difficult emotions in check.
Being able to motivate yourself to do something, even if it's boring or hard.
Hindsight and forethought:
Using lessons from the past to inform current behavior and decisions; the ability to visualize the future to plan a sequence of events.
In order to understand how you are doing, it is important to take a baseline before you start treatment if you can. Use a symptom tracking worksheet like the one we will describe in a moment, and add these items:
Weight and regularity of meals
Sleep patterns: when you typically sleep, and for how long
Agitation, anger, irritability and emotionality. Are your moods stable? Are there times of the day when you are more likely to be upset or moody (for example, at the end of the day)? Do you explode suddenly in anger and frustration?
Your ADHD symptoms
Include your partner when making your observations, and write it all down. (Continues...)
Excerpted from The Couple's Guide to Thriving with ADHD by Melissa Orlov, Nancie Kohlenberger, Steve Robb. Copyright © 2014 Melissa Orlov and Nancie Kohlenberger, LMFT. Excerpted by permission of Specialty Press, Inc..
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