The Three Legged Stool of ADHD Treatment

Optimal treatment for an adult with ADHD in a committed relationship has three specific parts, the first two of which are true for treating ADHD all of the time, and the third of which is specific to being in a successful relationship.  Because good treatment “stands” on three legs I like to think of it as a three-legged stool.  You need all three legs to optimally treat ADHD:

Leg 1:  Making physical changes to your body.  ADHD is the result of specific physical features in your body, including lower than normal levels of dopamine.  These can be effectively addressed at the root cause (physical) level.  Examples of leg 1 treatments include:  medication, aerobic exercise, fish oil, better sleep and nutrition.
Leg 2:  Making behavioral (habit) changes.  Physical differences manifest themselves as symptoms and behaviors.  Coping strategies such as retreat and denial that have been developed over the years without the benefit of physical changes are sub-optimal and often self-defeating within a committed relationship.  So moving away from destructive coping strategies to creating “external structures” to support the ADHD partner is essential to improving your relationship.  Examples of simple habit changes that can make a big difference include:  lists and systems; alarms and reminders; anger management; separating bank accounts; hiring help; learning to not interrupt, etc.  Cognitive behavioral therapy, so much in the news lately as a good treatment for ADHD, falls into leg 2 treatments.
Leg 3:  Developing strategies to use when interacting with your spouse.  These include communication strategies and creating a hierarchy of issues to attack.  You can’t do it all at once, so picking the most meaningful symptoms and habits to address is an important step.  A couple might decide to: designate a time to work together to plan household tasks for the week; develop verbal cues to stop escalation of disagreements; or schedule time to be together to overcome distraction.
To my knowledge, no one has studied the specifics of leg three, but numerous research studies have shown that combining physical and behavioral changes is better than either alone.  Medication alone, for example, often helps, but is sub-optimal.  Physically changing the way your brain works is a great start, but it’s what you do with that changed brain – i.e. your behaviors – that you and your spouse will notice most.
It’s a common misperception that a person with ADHD can make the behavioral changes without the physical changes by “just trying harder.”  But that assumes that the person with the ADHD hasn’t been trying all these years.  Not so!  In general, people with ADHD try really, really hard, but something in their wiring (lack of focus, inability to create a hierarchy, impulsivity, etc.) has gotten in their way.  To succeed, they need to get the ADHD symptom out of the way so that they can then make the behavioral change.
Moving ahead with treatment seems obviously beneficial to a non-ADHD spouse but often is complicated for the ADHD partner by years of repeated failures.  One ADHD woman spoke of it this way:
“I have something of an aversion to medications, which is one issue for me.  But the bigger issue is that I just have this feeling that I ought to be able to do this on my own, without the help of medication.  Also, I have to admit that when I take the medications (intermittently) it is a painful reminder of how incompetent I am without the crutch.  Too painful, really.”
The logic here, actually, is internally consistent and has to do with a poor self image developed over many years of failure.  I suggested that she think of this chemical imbalance just as she would a hormonal chemical imbalance.  If a doctor told her she wasn’t creating enough estrogen, for example, she would feel fine about taking medication to correct the issue and would never consider telling herself she ought to be able to create more on her own.  ADHD is, among other things, a chemical imbalance.  It, too, benefits from “righting” that imbalance.
If you or someone you love has ADHD, try thinking about treatment as a three-legged stool.  It will help you both understand where opportunity exists to further improve treatment.
This post was adapted from The ADHD Effect on Marriage.  For more details, see the book.