THE ADHD RELATIONSHIP SEX SURVEY I CREATED—and somehow got 3,000 people to take—had a section that asked about the types of treatments that respondents had tried, how much effort they had put into it, and how effective they felt the treatment has been. There has certainly been a lot of research already looking at this, although mostly about medication, so we know what works, but there hadn’t been any research connecting this to couples’ relationships and sexual satisfaction. It was important to include it, because untreated or ineffectively managed ADHD will have a different effect on the relationship than when it is well managed. I would even go so far as to say that the couples with completely untreated (and probably undiagnosed) ADHD will have an entirely different experience from the ones who understand ADHD well, put in the necessary effort to work with it, and have found a treatment regimen that works well for them. This is why diagnosis and treatment are so important—and why it can be so gratifying to work with these individuals and couples. Life often gets quite a bit better once you know what you’re dealing with.

In addition to seeing how ADHD status and gender impacted respondents’ impressions of their own and their partner’s efforts and treatment effectiveness, I thought it would be interesting to do some deeper analysis. I compared those who put in the most effort with those who put in the least effort, and those who felt treatment was the most effective with those who found it the least effective. In other words, let’s see what the best are doing and how it’s working out for them. There should be some worthy lessons in there.

How Hard Are You Working At It?

In the survey, I asked people to rate how much effort they were putting into managing their own or their partner’s ADHD. This could involve taking medication, working with a therapist, coach, or organizer, educating oneself about ADHD, using a reminder system, finding apps, and all that other good stuff that is recommended. The non-ADHD men rated themselves as working pretty hard, but lower than the rest of the folks rated their own effort. Those with ADHD are working hard, but so are the non-ADHD women. This fits what I tend to see in my office. There are certainly exceptions, but I get way more calls from women inquiring about services for their male partners with ADHD than I get from men for their female partners (like, almost none) and way more women join their boyfriend’s or husband’s sessions than vice versa.

My interpretation of the gender difference is that women are socialized to be caretakers of their partners and the relationship in general, so if their boyfriend or husband has ADHD that is negatively affecting the relationship, then non-ADHD women are going to swing into action to fix it, including sometimes working harder at it than he is. If the woman is the one with ADHD, she is going to work on it, too. This isn’t to say that men don’t care about the relationship, but that guys are less likely to seek help or get involved when their girlfriend or wife has ADHD. They will get involved in other matters, but not as much on this one.

Since we all seek fairness and balance (at least when we feel like we’re getting the short end of the stick), this difference in perceived self-effort between the two partners can obviously be a set up for arguments and resentment. But wait, it gets worse!

I’m Working Harder Than You Are

I also asked survey respondents to rate how much effort they felt that their partners were putting into managing their or their partner’s ADHD. Perhaps not surprisingly, most respondents rated themselves as working much harder than they rated their partners as working, which doesn’t actually add up if you think about it. The only exception here is that the non-ADHD men rated their ADHD women partners as working just as hard as they themselves were.

One possible interpretation of this is that non-ADHD men are more magnanimous in their ratings of their partner’s efforts and that they don’t give themselves more credit than they deserve. While this would be great if it was true, their partners rated these guys as putting in quite a bit less work than everyone else rated their partners. Meanwhile, non-ADHD men rated their partners as putting in more effort than anyone else rated their partners. So basically ADHD women are working much more than their non-ADHD men which can be a set-up for arguments about fairness. By contrast, ADHD men and non-ADHD women rated their partners as putting in about the same effort and there was less of a difference between self-effort and partner’s effort, possibly making for less to feel resentful over.

This rating of one’s own effort as higher than someone else’s is hardly unique to couples with ADHD or getting treatment. We all tend to give ourselves more credit than we give other people, whether they are our romantic partners, coworkers, or neighbors. Part of this is just about information imbalance—we know everything we do but not everything our partner does, since tasks that go unseen may not be counted in the mental tally of who’s done what. So when we think back on what we have each done, we remember more of our tasks and fewer of the other person’s.

The fact that it is a universal process probably comes as small consolation when you and your partner are in the heat of arguing about workload and you’re both totally convinced that you’re right. On the plus side, you agree that you each have a romantic partner who is delusional. Also, despite the fact that self-effort was always rated higher than partner effort, the two were correlated— those who worked the hardest tended to think that their partners also worked hard. So there is some justice. If you are aware of this perceptual bias, you can counterbalance it and give some benefit of the doubt or at least round up your partner’s effort a bit so you feel less resentful, which is probably more beneficial to you than it is to your partner.

Another wrinkle on this is that the respondents who felt that ADHD had the most negative effect on sex rated themselves as putting in much more effort and their partners as putting in much less effort. This large imbalance creates the obvious problem that when one partner is (presumably) putting in much less effort at managing ADHD, it’s less likely that the ADHD will be managed well and will therefore cause more problems for the relationship. However, the perception of such imbalanced effort is also itself a cause of strife, especially when there is a belief that that lack of effort is making things worse. That’s a double whammy you’re going to want to avoid.

Treatment Effort Matters More Than You Think

Sex is motivating.

Okay, probably nobody will debate me on that statement, but I have the data to back it up, at least when it comes to putting in good effort on managing ADHD. Those respondents who put in more effort on managing ADHD felt somewhat more strongly that ADHD added barriers to a more satisfying sex life, compared to those who put in less effort on managing ADHD. Does that negative effect on their sex life create additional motivation to work on their or their partner’s ADHD? Seems like it does.

Creating a better sex life is unlikely to be the only reason for someone to put in more work on their or their partner’s ADHD, but as a therapist, I look for every motivation I can find to help individuals and couples do better. And since we know that sexual satisfaction tends to correlate with broader relationship satisfaction, there can be ripple effects from every bit of progress.

So, what would be most motivating to get you to put in more effort on managing your or your partner’s ADHD? What would be most motivating for your partner?

I also asked respondents to rate how much effort their partners put in on managing ADHD. I then looked to see how that perceived effort correlated with the answers to other questions. Some of the interesting, and not at all surprising, results show that those who feel that their partner puts in more effort on managing ADHD:

• Are more comfortable making sexual requests of their partner
• Are more comfortable fulfilling their partner’s sexual requests
• Are more comfortable sharing sexual fantasies and turn-ons with their partner
• Feel their partner makes their sexual pleasure more of a priority
• Are somewhat more willing to make their partner’s sexual pleasure a priority (most people already rate themselves pretty high on this one so there is less of a difference)
• Are more sexually generous when not in the mood
• Feel their partner is more sexually generous when not in the mood
• Feel that their partner reads them better sexually
• Feel more positive or less negative about partner’s porn use

First of all, those all seem worth aspiring to and would certainly contribute to a better sex life and relationship overall. Perhaps they are returning the favor of good effort elsewhere? Generosity tends to beget generosity. It seems like good effort in and out of bed is rewarded in and out of bed. If so, then we can say that putting in effort on managing ADHD is an aphrodisiac, something that may be worth reminding your partner of if they are slacking.

First, be a good partner and work hard, in and out of bed. Second, be sure that your partner knows about the work that you’re doing and the effort that you’re putting in, because we tend to underestimate what our partners do.

The lessons here then are clear. First, be a good partner and work hard, in and out of bed. Second, be sure that your partner knows about the work that you’re doing and the effort that you’re putting in, because we tend to underestimate what our partners do. On the flipside, give your partner a little benefit of the doubt, knowing that they may be doing more than you realize. On the other hand, if you really have doubts about their efforts and it is affecting your sexual feelings towards them (and more), then explain that to them, especially if this is something that is important to them and thereby motivating.

Maximizing Treatment Effectiveness

While generally respondents found that treatment was helpful, those with ADHD rated treatment as more effective than their non-ADHD partners did. I can think of two reasons for this. First, it may be that the person with ADHD is more attuned to what treatment is doing and sees more of the benefits, since they’re primarily the one on the receiving end (except for couples therapy). By contrast, the non-ADHD partner needs to infer what the treatment is doing based on what can be observed—e.g., you seem less distracted because you leave fewer half-empty glasses lying around.

The other possibility is that the two partners have different priorities for treatment and in general. For example, I had a couple where it was really important to the non-ADHD wife that all the beds be made every morning because it gave her a sense of order in the world. Unfortunately, there is no amount of medication, therapy, or coaching that will give her husband the same feeling of primal bliss from tightly tucked duvets. Treatment did allow him to help more with breakfast and making the kids’ lunches though and maybe sometimes pitch in on the beds, even if only to please his wife. So treatment helped in some ways and perhaps enabled them to better negotiate their difference of opinion about the merits of made beds—just as every couple needs to negotiate their differences.

Which Treatments Work Best?

Because the effect that ADHD has on someone’s life and relationship depends on how effectively it’s managed, I did a bunch of analysis looking at what treatments respondents tried and how well they worked. Let’s start by looking at how much various treatments were used. I asked respondents to indicate all of the treatments for ADHD they or their partner used within the last year.

Educating themselves about ADHD and medication were by far the most commonly used treatments, with about two thirds of respondents using each of them. About one third had used lifestyle management and psychological therapy. The other treatments were quite a bit less frequently used.

I then asked respondents to rate to what extent they felt that treatment overall has been effective in managing their or their partner’s ADHD symptoms. Most people had used more than one treatment (more on that shortly) and I didn’t ask them to rate each treatment individually. This would be good data to have, but the survey was already too long. Fortunately, my stats consultant was able to do some crazy number crunching and extract out the effect that each treatment had. Here are those results in rank order, from most to least effective:

1. Medication
2. Lifestyle management
3. Coaching
4. ADHD education
5. Psychological therapy (no effect)
6. Professional organizer (no effect)
7. Other (negative effect)

Most of these results are not surprising and the ones that are do actually make sense when you think about it. In the survey, I asked a very specific question—how effective treatment has been at managing ADHD symptoms. I didn’t ask the broader question about how effective it has been at improving the relationship or overall happiness. ADHD symptoms can affect both of those, but so do lots and lots of other things that have nothing to do with ADHD. So while relationship satisfaction and overall happiness are probably what people care most about, the narrower question of symptoms gives a cleaner result.

Let’s run through each of the treatments individually. It is well established that medications do a great job of managing ADHD symptoms and for that reason I tend to be a fan of them, for the folks who need them. It also helps that stimulants are pretty easy to get right for most patients, so primary care docs who aren’t ADHD experts can do a good job with them, meaning that many Americans have access to a competent local prescriber to manage their meds. However, there is a well-known saying that pills don’t teach skills which is absolutely true. All of life’s problems aren’t solved at the pill bottle, but it is a great place to start because it makes all the other efforts, strategies, and treatments for ADHD work better. Therefore, if you or your partner have not yet tried ADHD medication and have been frustrated with the lack of progress, then it may be worth considering how this piece of the treatment puzzle could benefit the rest. Remember that trying medication is not like getting a tattoo where you are forever changed and you therefore need to make the absolutely best decision. If the medication isn’t helping, then you just don’t take it again tomorrow. Done.

It was gratifying to see that lifestyle management was second on the list, since I spend so much time bugging clients about it. This involves all that New Year’s resolution stuff that we should all do better on: exercise, sleep, diet, stress management, etc. Of course, the knowing is easier than the doing, especially for those with insufficiently managed ADHD (or with meds that haven’t yet kicked in in the morning or have worn off at night). Fortunately, you don’t need to train for an Ironman, get eight hours of sleep, eat vegan, or meditate ten times a day in order to see the benefits of working on your lifestyle. Even partial progress is helpful. For example, if instead of getting six hours of sleep each night, you get seven (or even six and a half) you will probably find that you feel and function better the next day. Don’t let perfectionism, and the inevitable falling short, stop you from doing what you can. And if you fall off the wagon, then just get back on. Tomorrow is a new day.

All my ADHD coach friends will be glad to see that they were #3 on the list. Unlike most therapists, ADHD coaches tend to focus more on helping clients meet daily demands and be more effective by dealing more directly with ADHD symptoms and other barriers. If you’re considering hiring a coach, be sure that they know ADHD well (which also applies to prescribers, therapists, and organizers) and ask about their training, because it can be quite variable.

I strongly believe that knowledge is power when it comes to ADHD and I now have the data to prove it in case you would like to be more powerful. Educating oneself about ADHD may not top the list, but given that it tends to be inexpensive and easy, it’s a worthy investment. After all, there’s no sense in re-inventing the wheel if other smart people have figured some things out before you. So soak in those books, webinars, podcasts, websites, support group meetings, conferences, etc.

As a psychologist, I was surprised (and disappointed) to see that psychological therapy was not rated as having any effect—until I remembered that I asked about ADHD symptoms. Unlike coaching which gets more into the practical matters of daily life, I wouldn’t expect therapy to directly address those symptoms. Other research tells us that what it does benefit is how the individual and couple deal with those symptoms and get along. It would also be helpful with the anxiety, depression, substance use, and other conditions that are more likely to come along with ADHD, as well as with the relationship dynamics that can develop. This is a good example of how the specific wording of a question can have a large effect on the answers you get. It probably also doesn’t help that there aren’t enough therapists with sufficient expertise in adult ADHD, whether for individual or couples therapy, so respondents may not have gotten all the benefit they could have. Therefore, if you are going to see a therapist, make sure they have the knowledge you need them to have.

I was also surprised to see that professional organizers were not found to be helpful with ADHD symptoms. It could be that there were too few respondents to pick up the effect or that there are not enough organizers who really know ADHD well, which limits their effectiveness. However, I think that the real reason for this lack of effectiveness has more to do with who tends to seek the services of an organizer, which I will talk about next.

Finally, I asked respondents about their use of other treatments. Granted, this could be a rather mixed bag, including chiropractic interventions, specific dietary changes (not just eating healthy), natural remedies, brain training programs, supplements, mindfulness, etc., so when we look at their effectiveness, it’s possible that the benefits of one are being canceled out by the ineffectiveness of the others. However, other research has not found much benefit for any of these alternative treatments, except mindfulness (and besides, is there anyone that you couldn’t recommend mindfulness for?). Interestingly, unlike professional organizing which was found to have no effect, these alternative treatments were actually found to have a statistically significant negative effect. I will talk more about this shortly, but it doesn’t change my basic opinion about alternative treatments for ADHD: I am willing to be convinced that they are effective, but until we have the research to prove it, I can’t recommend any of them so your time and money are probably better spent elsewhere. This is especially true for proposed interventions that are time consuming, expensive, or just a plain hassle (elimination diet, anyone?) because the significant investment overshadows the unlikely return.

Because finding knowledgeable treatment providers is so important, check out the provider directories list in Appendix B for where to find the professionals who know what you need them to know.

Are More Treatments Better?

The typical advice for managing ADHD is to use a multimodal treatment program that involves using several interventions, and this is what most people tend to do. The average number of treatments used was 2.4. Overall, the biggest improvement came from the first treatment that respondents tried. Adding a second and then third made things even better, whereas a fourth treatment added less and a fifth treatment even less. So far so good, but this is where things get weird—using five treatment methods was more helpful than using four, but using six was actually less effective than using four and using seven was less effective than using two. Huh?

This is one of those places where group averages can be deceptive. The reason why the response to treatment seems to get worse after five is that people who have the most severe ADHD and/or co-occurring conditions and/or don’t respond well to initial treatments are obviously more likely continue to try more treatments, with the hope that they find something that works. Therefore, what we are seeing here is more about initial severity or poor treatment response than it is about treatment making things worse. Those with simpler situations and/or great responses to the first one or two treatments tend to stop there. Mission accomplished.

Since only 3% of respondents used a professional organizer, it could be that they were mostly those who weren’t getting a good response to other treatments and therefore the benefits of working with an organizer weren’t captured here because of their overall worse treatment response. Something similar may be going on with the alternative treatments, that they were mostly used by people who had not gotten enough benefit elsewhere. It seems unlikely to me that these alternative treatments truly had a negative effect, since mostly it would just be no positive effect, but unlike the professional organizers, they may not have had some positive effect to offset the overall worse treatment response from the folks who used them.

The lesson from this data is that generally more treatments tend to work better than fewer treatments, although with some diminishing returns. Therefore, the recommendation would be to start with the treatments that we know are most likely to be effective (medication and lifestyle management, followed by ADHD coaching). I would also put ADHD education towards the top of the list—given that it tends to be pretty cheap and easy, and it has a good return on investment, even if it doesn’t itself make the most dramatic difference. I would also recommend psychological therapy and working with a professional organizer if it seems relevant to your situation. Although I can recommend mindfulness, I can’t currently recommend any alternative treatments until we have good data to show their benefit.

Group averages aside, which treatments you ultimately choose will depend on your situation as well as your personal preferences. However, I would encourage you to be kind of greedy about treatment benefits and to not settle for some partial benefit. There is a lot on the line here, so push a bit to maximize what you get from treatment. And probably the non-ADHD partner should also have some input, not only on treatment effectiveness but also on treatment targets.

Ari Tuckman, PsyD, CST, is a certified sex therapist and psychologist specializing in the diagnosis and treatment of ADHD in children and adults. A prolific writer and international presenter, he is the author of four books on ADHD. He also hosts the popular podcast, More Attention, Less Deficit, for adults with ADHD.
This article was adapted with permission from his new book, ADHD After Dark: Better Sex Life, Better Relationship (Routledge, 2019).