By George M. Kapalka, PhD, ABPP
Attention-deficit hyperactivity disorder is the most frequently diagnosed disorder of childhood. In addition, ADHD is a disorder that primarily occurs in boys by as much as a 9-to-1 boy-to-girl ratio. Thus, based on this gender ratio and the latest census data, it can be estimated that 1.8 to 4.5 million boys and male teens in the United States are diagnosed with ADHD.
Not only is ADHD more prevalent in boys and male teens, but male children and adolescents with ADHD are more likely to be brought for mental health treatment. This difference exists because male children and teens typically exhibit more difficulties with self-control and greater severity of disruptive symptoms at home and in school. As a result, parents and teachers need assistance in addressing these problems and seek help from mental health and education professionals.
Forty to 60 percent of individuals with ADHD will continue to exhibit the full range of ADHD symptoms as adults. Based on the US census data, it can be estimated that 1.2 to three million of children and teens with ADHD will be affected by the disorder into adulthood, and males constitute up to 90 percent of that population. Thus, it is clearly evident that most adults with ADHD are males.
ADHD Symptoms in Males
The symptoms of ADHD are characterized along two dimensions, hyperactivity/impulsivity distractibility/disorganization.
In addition, since impulsivity is a common dimension that underlies many of the symptoms, males with ADHD often exhibit difficulties with self-control and are known to be defiant and aggressive. Parents, teachers, spouses and coworkers find these behaviors very frustrating, and males with ADHD frequently experience conflicts with close family members (especially, parents, siblings and spouses), teachers and coworkers (especially, supervisors).
Some males with ADHD are not impulsive, defiant or aggressive, and instead present with limited attention span, disorganization, difficulties completing tasks and forgetfulness. As children, these males usually do not exhibit problems with acting out, but they often have academic difficulties and fall behind their peers in common academic skills (for example, writing, reading and mathematics). Disorganization can be a particularly troubling symptom, and males who exhibit this problem usually have difficulties keeping track of their assignments, books, notebooks, and other materials. As a result, they frustrate their parents, teachers, supervisors and spouses and are frequently reprimanded for being so absent-minded.
It is common for boys and male teens with ADHD to have difficulties with social adjustment. Because their self control and impulse control tends to be poor, male children with ADHD are frustrating to their peers during social interactions. For example, when joining a peer group, boys with ADHD often attempt to take over leadership and want to impose on others their preference for what activity the group should perform. In addition, boys with ADHD frequently exhibit problems sharing and are often explosive when they do not get their way. Consequently, many boys with ADHD have difficulties making friends and maintaining good peer relationships.
Adult males with ADHD continue to exhibit most of the above problems. They usually have difficulties meeting the demands of employment and change jobs frequently. They have problems keeping up with routine household maintenance (for example, remembering to pay bills), and they are often seen by others as being irresponsible. If the impulsivity persists into adulthood, they exhibit problems making decisions and sometimes exercise bad judgment. They are described as difficult spouses and partners, and they typically have poor parenting skills.
Because boys, teens and adult males with ADHD exhibit problems in so many areas of day-to-day functioning, they are commonly exposed to the experience of failure. Parents, teachers, and other caretakers of boys and male teens with ADHD usually find themselves reprimanding and correcting, and because so many boys with ADHD exhibit behavioral difficulties, they regularly get yelled at and punished by adults. Adult males with ADHD tend to have conflicts with their spouses and find parenting their own children to be difficult. As a result, it is common for males with ADHD to exhibit low self-esteem, limited academic motivation, anger and hypersensitivity. These secondary difficulties further exacerbate the primary symptoms of ADHD, thus making it even more difficult for males with ADHD to relate well with their parents, teachers, spouses, coworkers and peers.
Males with ADHD are at risk for developing other problems as well. About one-half of males with ADHD show signs of another mental disorder, commonly including depression, anxiety and conduct disorders. These rates are even higher for adult males with ADHD, and three quarters of them are diagnosed with another mental disorder. Adolescent and adult males with ADHD are at risk to engage in criminal behaviors and to abuse drugs. Furthermore, they are likely to have significant educational problems: about one-third of boys with ADHD are retained in school at least once, about one-third receive special education, nearly half receive at least one suspension, ten to 33 percent either drop out or are expelled from school, and only ten percent complete college.
Relationships with Men with ADHD
Men with ADHD frequently have conflicts with their spouses, girlfriends, and partners, and sharing an intimate relationship with a male with ADHD can be a frustrating experience. Whether the men exhibit symptoms of significant impulsivity or inattentiveness/disorganization, their abilities to be effective partners and fathers are adversely affected.
Impulsive men have problems with delay of gratification and frequently perform behaviors that get them in trouble. They may have difficulties suppressing the impulse to engage in activities that are ‘fun,’ and may make poor choices, neglecting work duties and spending inappropriate amounts of time being involved in hobbies or leisure. This may have an adverse impact on their abilities to hold a job or advance within the workplace. Because work may not seem as important to them, they may not exert the amount of effort necessary to secure and cultivate a stable and profitable career. When at work, they may have limited abilities to tolerate frustration, and may overreact to being told what to do by their bosses and supervisors. Indeed, men with ADHD are much more likely to have problems maintaining a job (Barkley, 2006). This is likely to strain the relationship between a male with ADHD and his spouse or partner.
Because many of these men crave stimulation and often pursue high-risk hobbies, like racing or extreme sports. Their spouses may find those activities nerve-racking. Issues of masculinity complicate this tendency. Many men feel that they prove their masculinity by behaving like a ‘real man’ – for instance, facing danger and refusing to show fear. This attitude drives them toward occupations and professions where they face danger and need to demonstrate abilities to handle the risk. While socialization factors are likely to play a major role in the development of such expectations, biological factors also play a contributing role. Males with ADHD, whose frontal lobes tend to be underactive, tend to crave stimulation, perhaps in an effort to increase activity in their brain to help them feel more ‘normal.’ When such a male was also socialized to express his masculinity by staring down danger, he will be especially likely to be drawn toward high-risk activities. Spouses of men with ADHD must become aware of this dynamic to help them better understand why their partners do some of the things they do.
Men with ADHD often have difficulties handling frustration. This may reveal itself at home by lack of attention to house chores and home-maintenance duties. Because they are drawn toward stimulation, rather than the mundane tasks of day-to-day life, they may neglect their responsibilities, which is likely to further aggravate their spouses. As the partner begins to feel more and more dissatisfied, a power struggle may unfold within the home, where the spouse attempts to get the man to do what is needed at home, and the men resists those efforts and feels that the spouse is attempting to control him and tell him what to do. This contest of wills further strains the relationship and adds to tension and conflicts.
Men who have difficulties dealing with frustration tend to make explosive fathers. When they issue a command and do not get immediate compliance (or, even worse, encounter resistance from the child), fathers with ADHD have difficulties containing their urge to react and tend to yell and punish their children too severely. In fact, fathers with ADHD are especially likely to utilize physical means of parenting, like spanking (Barkley, 2006). This may be because men with ADHD may have experienced this form of punishment as children, and are now repeating this pattern.
Mothers who witness their children being severely punished (or yelled at) by the fathers tend to act protectively toward their children and confront the father about the inappropriateness of their behaviors. Often, these conflicts occur in front of the children. When this takes place, many fathers feel that their authority and masculinity is being challenged, and conflict between the parents ensues. This is counterproductive and tends to damage the relationship between the parents, and strain the bond between the father and the child. Even if such conflict takes place away from the children, the father usually thinks that the mother is dictating to him how to parent, and feels controlled by his spouse.
Impulsive men tend to react explosively not only with their children, but also with their spouses. When being told something they do not like to hear, they tend to overreact. Sometimes, this may take the form of a short, snippy response. Sometimes, it may be more intense. Either way, spouses often feel that they need to ‘walk on eggshells’ to prevent conflicts. Again, this tends to strain the relationship, and negatively affects intimacy and closeness.
Men with ADHD who are not impulsive also present with difficulties in relationships with their spouses. Because they find it hard to keep track of their things, they often misplace tools, clothing, and other items they need. This may result in additional expenses, when items (like tools) need to be replaced because of carelessness. In addition, men with ADHD easily get distracted or side-tracked, and they need reminders to complete the tasks they are responsible for, like home maintenance, paying bills, renewing car registration or driver’s license, etc. These can result in adverse consequences for the men and additional costs for the family.
Disorganized men also tend to have problems at work. They may forget about meetings or tasks that were assigned to them, and may misplace items they need to perform their job duties. Once again, these difficulties result in problems maintaining employment and advancing within their career. Spouses find these problems very difficult and often feel that the men do not sufficiently carry their load and contribute an insufficient income. This, in turn, makes men feel that their masculinity is being challenged, and conflicts in the relationships are likely to intensify.
Treating Males with ADHD
When boys and teens with ADHD are brought for mental health treatment, they commonly view it as punishment for the difficulties that they have been exhibiting and the frustration their symptoms have been causing their parents and teachers. It is rare for parents to bring boys into treatment when symptoms first appear. Almost always, by the time the boy or teen is brought for treatment, conflicts have long existed within the home and arguments over issues such as poor school performance, lack of follow-through with home tasks, and defiance were commonplace for quite some time, usually at least a few years. Along the way, the boy likely internalized a defensive attitude, and he recognizes that he is being blamed for these problems, even though he may not recognize how it is that he contributes to them. This may interfere with the establishment of a therapeutic alliance, since the boy will likely try to prove that there is nothing wrong with him and he is not to blame for the conflicts.
It is important for parents to recognize that they should not blame their son for all conflicts, and should not communicate to him that they are bringing him for treatment because he is exhibiting too many problems. Such an approach will exacerbate the defensiveness and significantly interfere with treatment. Instead, it may be more effective to frame the treatment as an attempt to seek assistance from a professional who helps people get along with each other. Even if the boy feels he is not to blame, he is likely to recognize that significant conflicts have been taking place. The treatment should be portrayed as involving various members of the family (which, is likely to be accurate, since parenting work is usually necessary) where everyone will work on things they can change to better communicate and get along with each other.
When men with ADHD enter treatment, they commonly view it as a last resort effort to address the difficulties that they have been exhibiting. Because their existence is filled with conflicts and failures, they often feel that they have hit the lowest point in their life. Coming to treatment means to them that they have to accept that they can not deal with their difficulties on their own. Men are socialized to be problem-solvers, and often gauge their masculinity by the degree to which they are able to successfully address whatever problems they encounter. Accepting help may be viewed as a sign of weakness.
The socialization of males in our society includes powerful codes that define appropriate and inappropriate behaviors. Since early in life, boys are socialized against expressing vulnerable emotions. This is done through modeling (for example, boys do not commonly see their fathers express tender or vulnerable feelings, especially not to them directly), as well as reinforcement (boys are usually rewarded for suppressing the expression of pain, sadness, or similar feelings). Consequently, many boys do not develop the language that is needed to express a wide range of emotions, and are likely to be uncomfortable in a setting that focuses on expressing those emotions (for example, in a therapist’s office).
With this in mind, therapy with boys and male teens often involves some play activities. This makes it easier for males to interact with the therapist and fosters rapport building. Many therapists utilize a variety of tasks, such as playing with toy cars or building blocks. Some games may also be useful, like checkers, or some card games. Usually, only those games are utilized that do not require much verbal exchange for the purpose of playing the game (for example, playing ‘war’ is better than ‘go fish’). When the play activity does not require verbal exchange, it allows the therapist and the client to begin chatting about pertinent issues while the game goes on. Initiating such a verbal exchange while playing reduces the extent to which the boy feels ‘on the spot’ and may make the sessions more ‘fun,’ thus lessening the extent to which he may feel uncomfortable or defensive.
Because males often are limited in their abilities to express emotional content, various techniques may be utilized to help them develop the appropriate language. For example, the therapist can name several feelings and ask the boy which comes closest to reflecting how he felt in a given situations. Therapists can also use hand-outs that assist in this task. Many forms of ‘feeling faces’ are widely available, where a number of faces with different feelings are drawn on a page, with the name of the feeling underneath, and they boy may be asked to circle those faces that reflect how he feels about a given situations. Most boys and teens have fun with this activity, because some of the faces are comical. Teens who prefer a more stoic approach may be helped through the use of a hand-out with a large number of feeling words grouped into several categories. These techniques can help the boy or teen improve their abilities to express their feelings verbally.
When treating males with ADHD, it is important to help them feel that their own perceptions of the difficulties and/or conflicts that are taking place (at home, in school, and/or in the workplace) are important and valid. At the start of treatment, therapists usually try to get the client to agree to work on at least one problem, such as figuring out ways to reduce arguments between the client and his spouse, or reducing problems related to the workplace. If the client is able to identify at least one problem that he wants to work on, his motivation to attend treatment is likely to be more significant, and the treatment will be viewed as one that may lead to more tangible improvements. Therapy can then proceed to try to accomplish this tangible goal, helping the male to learn the necessary skills he needs to accomplish this goal. Keeping a pragmatic focus will increase the likelihood that the boy, teen or man with ADHD will want to remain in treatment.
Because males with ADHD present difficulties in so many of their personal relationships, it is usually necessary to treat not only the client but also his parents and/or his spouse/partner. Parents need to develop ways to deal with the problem behaviors they encounter with their son. As Russell Barkley once put it, parents need to develop a “prosthetic environment” within the home to help the boy/teen develop the skills he needs to get his symptoms under control. Similarly, spouses need help developing techniques they will need to address the frictions that occur within the home. Parents and spouses/partners must accept that they have to play an important role in helping the male with ADHD gain control of his symptoms. For this reason, mental health professionals usually invite the parents and spouses/partners into treatment in order to comprehensively intervene in various aspects of the client’s life that are affected by symptoms of ADHD.
George M. Kapalka, PhD, ABPP, is the head of the Department of Psychological
Counseling at Monmouth University, West Long Branch, NJ, 07764. Dr. Kapalka email address is firstname.lastname@example.org