Compounding effects of adult ADHD and comorbidities on intimate relationships

Although research about adult Attention Deficit Hyperactivity Disorder (adult ADHD) has become more prevalent since the condition’s recognition in the 1990s, information remains scarce about if and how its psychiatric comorbidities may compound impact on functionality in relationships. Studies abound on the independent effects on relationships of two of adult ADHD’s most common comorbidities - mood and substance use disorders. However, adults with ADHD sans comorbidities often experience interpersonal relationship difficulties due to the disorder’s signature symptoms alone - hyperactivity, impulsivity, and inattentiveness - as well as due to adult ADHD’s oft-observed dimension of emotional lability. The primary purpose of this study is to review the literature regarding the impact on intimate relationships of adult ADHD, as well as look at the potential compounding effects of comorbid mood or substance use disorder. The secondary purpose of this paper is to examine the literature on integrative therapy to treat couples wherein at least one partner struggles with adult ADHD, with or without comorbidities. Future research and practice implications are also discussed, including the hope for focus on the positive aspects of ADHD for individuals and relationships.

Introduction

Adult attention deficit hyperactivity disorder (Adult ADHD)

Although Attention Deficit Hyperactivity Disorder (ADHD) was regarded until the end of the 20^th century to be only a childhood disorder, a growing body of research has found adult manifestations. Evidence suggests a higher likelihood of childhood-onset; however, differences in symptom expression – e.g., by gender and age – complicate timely diagnosis [1,2]. While in childhood the condition tends to present only with varying levels of its signature symptoms of inattention, impulsivity, and hyperactivity, adulthood hyperactivity usually resembles restlessness; also, adult ADHD tends to present with comorbidities – e.g., obesity, insomnia, mood disorders, and addictive behaviors – each with functional impairments [1,2]. Meta-analyses of international researchers have found adult ADHD to extend to 57 % of adults from childhood [3], and only 9.1% of young adults diagnosed with w/ADHD as children showed sustained remission of symptoms 16 years after childhood diagnosis [4], making it one of the most common mental health disorders in adulthood [2,3,5].

Adult ADHD is associated with costs across domains including education, employment, and health; for example, health problems (such as obesity), substance use disorders, and mood disorders resulted in higher medical insurance claims for adults with ADHD versus those without [6]. ADHD during adulthood can wreak havoc on personal relationships, particularly intimate ones.

The coronavirus-19 (COVID-19) pandemic has brought on many problems for individuals and personal relationships, including intimate ones. The restrictions on the lockdown during the pandemic caused significant levels of emotional distress for all individuals and some researchers have argued that adults with ADHD would have greater levels of stress during the pandemic [7,8], as their perceived level of stress is often higher than adults with ADHD [8,9] found that higher levels of COVID-19-related anxiety were related to increased cigarette smoking and alcohol consumption in young adult males with ADHD.

As many adjust to stay-at-home-related realities such as working and schooling from home, many couples are now under significant amounts of stress. In addition to external stressors, such as possible job loss and health issues, there are also internal stressors, such as depression and anxiety, affecting individuals and their intimate relationships [10] For adults with ADHD and their partners, the stress of the pandemic may exacerbate problems, including maladaptive behaviors and poor communication.

The purpose of this study is to examine the literature on interpersonal relationship difficulties that face adults with ADHD, with and without comorbidities. Additionally, the paper explores empirical literature on integrative therapy to treat couples wherein at least one partner presents with ADHD symptoms.

Independent effects of adult ADHD on peers, family and intimate relationships

Peer and family relationships: ADHD during adulthood can wreak havoc on relationships. It has been associated with relationship difficulties at work and in friendships [11-13] ADHD symptoms hindered work relationships due to impulsive talking [12] and problems with authority, including rule-breaking [12,13]. Other ADHD-related behaviors that negatively affected adult peer relationships included: impulsivity; mood lability and lack of control over irritability, anger, or hostility; arguments and fights; forgetfulness; and inattention [11-13].

Several studies [14,15] have suggested that emotional lability is a potential dimension of adult ADHD, independent of psychiatric comorbidity symptoms. Moreover, emotional impulsiveness showed a negative effect on social relationships for adults with ADHD [14], and emotional lability was the main predictor of social functional impairment [15]. Adults with ADHD even reported avoiding certain social situations for fear of exhibiting mood instability [13].

Adult ADHD can also compromise family relationships. Michielsen, et al. [16] observed that older adults with ADHD were more likely than their non-ADHD counterparts to report feeling lonely and having few family members in their support network. Several studies found adults with ADHD more likely to suffer strained relationships with their parents than were adults without ADHD [12,13,16]. Johnston, et al. [17] posit that, as parents, adults with ADHD, due to deficits in their behavioral and emotional control, may introduce a chaotic environment, ineffective problem-solving, insubstantial child monitoring, and erratic or over-reactive discipline. In a parental training program, adults with ADHD were more likely than those without ADHD to go off-task or break rules while interacting with their children [18]. Parents with the impulsive/hyperactive type (versus the inattentive type) of ADHD tended to overestimate their competence in parenting – compared to their observed competence - which, researchers noted, aligns with previous studies finding positive illusory bias in self-assessment by children with ADHD [19]. Pharmacotherapy for adults with ADHD gradually resulted in less negative talk, fewer commands, and increased praise toward their children, yielding their children’s corresponding reduced negative behavior [20].

Intimate relationships

The presence of ADHD in at least one partner can contribute to intimate relationship problems. Adults with ADHD reported less satisfaction in, and more trouble navigating, romantic relationships, and were more likely to be divorced than adults without ADHD [1,16,21,22]. In a longitudinal study, adults diagnosed during childhood with ADHD were three times likelier to be divorced than adults in a comparison group [21], much as was the case in a study wherein the likelihood of lifetime singlehood or history of divorce among older adults with ADHD was three times higher than among those without the disorder [16].

Exploration into the effects of adult ADHD on intimate relationships has revealed associations between ADHD symptoms and certain relationship elements. Spouses of partners with ADHD reported lower intimacy and less satisfaction in their marriages than spouses of non-ADHD partners [23]. The severity of ADHD symptoms among college students was positively correlated with fear of intimacy, particularly in the context of reflection about past intimacy problems, and also positively correlated with cynicism about the possibility of ever being close with a partner; however, fear of intimacy was not associated with lowered self-assessment of relationship competence (e.g., communication skills, romantic appeal) – the latter result, researchers noted, corresponded with research showing positive illusory bias in self-assessment among children with ADHD [24]. Also, increased ADHD symptomology, though linked with fear of intimacy, was nonetheless associated with risky sexual behavior [24].

ADHD’s effect on empathy revealed deficits that would presume to hinder intimate relationships. A literature review cited a body of research demonstrating deficits in facial and vocal emotion recognition as well as in cognitive empathy among adults with ADHD [25]. Roy, et al. [26] found that, in a sample of adults with ADHD, 15% were found to be on the autism spectrum (associated with deficits in emotional and cognitive empathy), versus 0.06% in the general population.

Symptomalogical dimensions of adult ADHD have revealed assorted intimate relationship outcomes. Adults with primary hyperactivity symptoms of ADHD were more likely than those with primarily impulsivity or inattention symptoms to report divorce or dissatisfaction in their intimate relationships [27,28]. Canu, et al. [29] found that symptoms of impulsivity and hyperactivity combined with inattention (that is, the symptoms of the combined type of adult ADHD) were more likely to be associated with low conflict resolution and less relationship satisfaction than symptoms of the inattentive type or than the absence of ADHD symptoms. College students with self-reported symptoms of the combined type of ADHD reported lower romantic relationship quality than did students without ADHD symptoms [30]. Interestingly, among young adults, hyperactive/impulsive symptoms predicted past the fear of intimacy, while inattentive symptoms predicted current pessimism about intimacy [24]. Both genders with combined-type ADHD tended to report lower relationship quality than did subjects with no ADHD symptoms; only for females, each type of ADHD symptom independently predicted lower reported relationship quality, mediated in each case by emotional dysregulation and hostile conflict [30].

Symptoms of ADHD have been associated with intimate partner violence (IPV), anger, hostile conflict, and low conflict resolution. Adult ADHD symptoms were risk factors for IPV among a sample of adults without other IPV risk factors (e.g., childhood maltreatment or substance use) [31]. Romero-Martinez, et al. [32] identified adult ADHD’s impulsiveness and inattentiveness to be related to the risk of IPV, especially regarding difficulties decoding facial expression and exercising cognitive flexibility, but a study examining links between adult ADHD and community violence found an association between IPV and hyperactivity [33]. Emotional lability was present among ADHD-affected adults without comorbidities, and anger was the emotion most related to antisocial behavior [15]. Likewise, Bruner, et al. [30] found that emotion dysregulation and hostile conflict mediated reports of low relationship quality among women with ADHD; and Canu, et al. [29] found low conflict resolution associated with reported dissatisfaction in relationship quality among couples where one partner had ADHD.

Of note is that researchers observed positive illusory bias in self-assessment of relationship skills by adults with ADHD, who rated themselves as more competent than was observed by their partners, friends, or family members; moreover, increased discrepancy between self-assessment and observed assessment of symptom severity predicted increased positive illusory bias [34]. Similarly, Marsh, et al. [24] found that increased symptom severity was not associated with decreased self-assessment of relationship skills.

Two common comorbidities of adult ADHD: Mood and substance use disorders

A significant difference from childhood ADHD is that the adult form is more likely to present with comorbidities.

Katzman, et al. [1] report on research showing that as many as 80% of adults with ADHD have at least one co-existing psychiatric disorder; the highest risks are mood disorders and anxiety disorders. Libutzski, et al. [6] found that the costliest comorbidities were obesity, SUDs, mood, and anxiety disorders. The comorbid psychiatric disorders, much like comorbid somatic conditions, share neurobiological similarities to adult ADHD, which can complicate diagnosis and treatment [1].

The effects of comorbid mood and substance use disorders deserve in-depth attention, given their prevalence. Katzman, et al. [1] noted that, while only 11% of adults with ADHD receive treatment, the diagnosis triples the likelihood of Major Depressive Disorder (MDD) and quadruples the likelihood of any mood disorder, with reported rates among adults with ADHD of depression as high as 53.3% and bipolar disorder (BP) as high as 47.1%; meanwhile, SUDs are approximately twice as likely among adults with ADHD as among adults in the general population. The effects of adult ADHD on comorbid SUDs or mood disorders have been observed to be bidirectional in terms of prevalence [35], severity, and negative outcomes [36].

Given that there is limited research on the impact on intimate relationships when ADHD is concomitant with at least one comorbidity, the independent effects on intimate relationships of mood and substance use disorders will briefly be explored before considering the potential compounding effect of ADHD.

Independent effects of comorbidities on intimate relationships

Mood disorders: Depression: Depression alone has been found to exert a variety of negative effects on intimate relationships. For example, young women with depression reported difficulty developing or maintaining intimate relationships; however, they also reported high rates of sexual activity, including unsafe sex, for temporary mitigation of depressive symptoms and because of increased impulsivity, apathy, and alcohol use [37].

Like adult ADHD symptoms, depressive symptoms were found to reduce affective and cognitive functioning necessary for empathy [38] and were antecedent and consequent to conflict in romantic relationships [39,40] and to decreased marital satisfaction [39,41].

Bipolar disorder: Bipolar disorder (BP), too, has been found to negatively impact intimate relationship functioning and satisfaction. A 2017 literature review by Grover, et al. [42] cited multiple findings of poorer marital adjustment in couples affected by BP compared to controls. A majority of spouses of partners with BP expressed marital distress concerning family finances, career decisions, and completion of household tasks [43]. Parker, et al. [44] found that subjects with BP were more likely to lose their partners than were those with unipolar depressive disorder.

Factors of BP underlying marital dissatisfaction were studied. As with ADHD, deficiencies in components of empathy such as emotion recognition and perspective taking were observed in partners with BP [45]. Granek, et al. [46] found that BP patients were unaware of their partners’ feelings of resentment and self-sacrifice, while their spouses were unaware of the patients’ feelings of loneliness and social distress, despair about impaired social and professional development, and burdensomeness of self-care; spouses and patients alike reported that BP impacted their relationships with elevated volatility, anger, lack of trust, and reduced number of children.

Substance use disorders: Research abounds citing negative outcomes of SUD on intimate relationships. Bekircan, et al. [47] found SUD associated with an increased divorce rate and low marital adjustment. Cranford [48] observed significantly higher rates of lifetime marital dissolution among subjects with lifetime alcohol use disorder than among those without it. Pachado, et al. [49] saw a positive association between increased frequency of crack cocaine use and severity of intimate relationship problems. A 2012 Brazilian study found a decreased quality of life for probands with SUD than for controls across almost every domain and in the overall score – with worse scores observed only among probands’ live-in family members [50].

Compounding effects of comorbidities on intimate relationships affected by adult ADHD

Research is extremely limited on outcomes for couples affected by ADHD and comorbidity, but given the negative effects on relationships of adult ADHD alone and of mood disorders and SUDs alone, the presupposition would be compounding negative effects. Research results incidental to other primary investigations seem to support the notion. For instance, Pachado, et al. [49], while studying the quality of life among subjects with SUD, found that coexisting adult ADHD exacerbated the severity of problems in interpersonal relationships. Gonzalez, et al. [33], looking at associations between adult ADHD and violent behavior in the community, found that severe and repetitive acts of violence, including against intimate partners, were linked with severe ADHD symptoms, which in turn tended to be accompanied by coexisting psychopathologies such as SUD and mood dysregulation. Wunderli, et al. [51] observed an additive negative effect on social and emotional empathy among adults with ADHD who were also using cocaine.

Integrative interventions for couples distressed by compounded effects of adult ADHD and comorbidities

Practitioners working with troubled couples should be knowledgeable about the possibility of, presentation of, appropriate screening procedures for, and potential outcomes of adult ADHD [52] -especially if symptoms are unrecognized by the partners - and be able to discern whether symptoms of mood disorder or SUD are comorbid; practitioners also should note that, since research points to emotional lability as a potential core aspect of ADHD, distinguishing between core and comorbid mood symptoms may prove challenging.

Research is lacking in couples therapy where ADHD is comorbid with a mood or substance use disorder. Similarly, integrative treatment – that is, combination interventions that mix couples therapy approaches with interventions for ADHD and other presenting issues – is limited, but has demonstrated some success [22] Integrative couples therapy for ADHD can introduce evidence-based psychosocial interventions (with or without pharmacotherapy) found effective for ADHD symptoms, such as cognitive behavior therapy (CBT) [1,53], mindfulness [54] and behavioral skills training [1,55].

One such integrated approach for couples affected by ADHD implemented six weeks of 1.5-hour weekly group sessions that combined evidence-based couples therapy with CBT for ADHD [56]. The pilot study focused on promoting ADHD self-management and improving interpersonal communication and problem-solving skills. Each week, core components of CBT for adult ADHD were integrated with an evidence-based relationship distress prevention program [57]. CBT for ADHD included psychoeducation, relationship-building skills practice, learning to distinguish, accept, and tolerate unchangeable ADHD-related behaviors, and reframing of differences as potential relationship strengths. Wymbs & Molina [56] argue that it is important to include the partner in therapy to help encourage the self-regulation, such as attentiveness and behavioral self-control, of the partner with ADHD. Each session also included a discussion of (a) accepting differences in partner behavior as strengths of the relationship, and (b) tolerance of minor, inappropriate behaviors that partners cannot change After the program, couples reported reduced relationship negativity and fewer conflict-inducing behaviors; regarding reduced relationship negativity, the effect size was larger for male respondents. Also, while participants with ADHD self-reported no effect of treatment on their conflict-inducing behaviors (e.g. doesn’t respond when spoken to, pay bills late, doesn’t remember being told things, takes out frustrations on me), their partners did find a small effect, underscoring the importance of including significant others in ADHD treatment to help corroborate assessments of ADHD symptom improvement.

A study of integrative treatment for couples wherein ADHD and IPV were both present, as well as, in some cases, comorbid mood or substance use disorders, implemented pharmacotherapy, psychoeducation, and ADHD coaching, along with treatment as usual for IPV [58]. As noted earlier, individuals with ADHD are at increased risk for IPV perpetration [32,33]. In this year-long longitudinal study with IPV offenders with ADHD in a forensic outpatient setting, a treatment that was focused on safety planning, enhanced communication skills, and solution-focused or emotion-focused couples’ therapy was provided if needed and if possible. Both ADHD symptoms and IPV symptoms significantly decreased over time, and researchers concluded that the decrease in IPV frequency was directly related to the decrease in ADHD symptoms, suggesting that ADHD symptom reduction was essential to IPV treatment whether or not a comorbid mood or substance disorder was present [58].

Marin, et al. [59] described a study of multimodal group therapy with ten sessions for adults with ADHD. The integrative model incorporates problem-solving, mindfulness, CBT, and systematic family therapy. While their study did not exclude individuals with comorbid conditions, such as depression, anxiety, and bipolar disorder, those with severe concomitant substance abuse and/or severe personality disorders were excluded. The family systems sessions focused primarily on individuals’ families of origin to uncover behavioral patterns with a direct negative impact on intimate relationships.

Future direction: Practice and research implications

Practitioners must be mindful not only of the complicated and varied symptomalogical dimensions of adult ADHD – including emotional lability, which has not been officially acknowledged as a core symptom of adult ADHD, despite a body of research linking it with the condition - but also of adult ADHD’s potential effects on couples, despite limited scholarly research on the latter. Many couples may be unaware of ADHD symptoms, so the condition may lurk undiagnosed in one or both partners. Clinicians must model sensitivity regarding potential deep-seated and longstanding shame concerning symptoms and attendant functional impairments in the partner with ADHD, address emotional distress, born of the effects of ADHD on the relationship, for which the partner without ADHD may require treatment, and assist couples to identify strengths that ADHD may bring to the individuals and their relationship. Simultaneously, mental health providers must be on the lookout for psychiatric comorbidities of ADHD-parsing overlapping symptoms that could confuse diagnoses-that may demand interventions alongside the ADHD itself. An integrated treatment approach that brings together couples counseling techniques, as well as interventions for ADHD and its comorbidities, could prove difficult-suggesting the need for consultation with other mental health professionals well-versed in ADHD issues-but also gratifying and successful for all involved.

The limited amount of research on the effects of ADHD on couples, and into whether and how comorbidities may compound effects, urges exploration in these areas [22]. Further empirical research into interventions for couples affected by adult ADHD, whether with or without specific comorbidities, may shed light on approaches that could help spare individuals, couples, and their families unnecessary conflict and dissolution, and allow focus on positive aspects of living with ADHD.

Conclusion

Adult ADHD and its common comorbidities of mood and substance use disorders each independently may negatively affect intimate relationships, with potentially compounding effects. Further research is needed to confirm the compounding effects, as is awareness by couples therapy practitioners of the likely possibility that presenting problems could be partly or largely driven by core, and possibly comorbidity-complicated, adult ADHD in one or both partners in a distressed relationship. Although it may be difficult to parse psychopathological factors at play in relationship discord due to overlapping and bidirectionally exacerbated symptoms of adult ADHD and its comorbidities (Mcgough, 2016), integrative interventions that address ADHD as well as each of its possibly present comorbidities may provide structure, relief, and hope for adult ADHD-impacted unions, as well as permit recognition of strengths ADHD, brings to individuals and their relationships. Finally, as seen by the COVID-19 pandemic, contextual factors play a role when working with couples and underscore the importance of employing integrative interventions that address multifaceted issues, while utilizing the strengths of the couple and the individuals within them.

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