MSc in Clinical Psychology

Romantic relationships, emotional regulation and quality of

life among adults with ADHD in comparison with adults with

no ADHD

June, 2017
Name: Hjördís Unnur Másdóttir
ID number: 230974-5869
Supervisor/s: Linda Bára Lýðsdóttir and Jón Friðrik Sigurðsson
Running head: QUALITY OF LIFE AMONG ADULTS WITH ADHD 1

This article is part of a research project for a master’s degree in clinical psychology from

Reykjavík University. The project was conducted in collaboration with a fellow student,

Ragnhildur Bjarkadóttir. The collaboration included concept development, application to the

Bioethics Committee, data collection from participants and computerizing of the data.

The supervisors were Linda Bára Lýðsdóttir, psychologist at VIRK Rehabilitation

Fund and Jón Friðrik Sigurðsson, Professor at Reykjavik University and the University of

Iceland (Faculty of Medicine) and psychologist at Landspítali.

When this paper will be submitted to a scientific journal the co-authors will be

Ragnhildur Bjarkadóttir, Linda Bára Lýðsdóttir and Jón Friðrik Sigurðsson.

The study aims were to investigate whether individuals diagnosed with ADHD show

more emotional dysregulation than individuals not diagnosed with ADHD and if they value

their romantic relationships and quality of life less, as previous research indicates

In the first of the three semesters of the project, a literature review was carried out and

submitted to the supervisors with a research proposal. In the second semester all study

procedures, including arrangements and implementation, were completed according to ethical

guidelines and with approval from the Icelandic Bioethics Committee. The questionnaires

were selected and a socio-demographic questionnaire was designed. Cooperation was sought

from the ADHD Association of Iceland to find ADHD participants for the study.

Advertisements were designed to introduce the study. The comparison group was found

through social media, acquaintances and advertisements posted at Reykjavík University. The

data collection began and the questionnaires were provided to participants. The method

chapter was written and submitted.

In the last semester, data collection and computerizing the data was completed, data

was analyses and a research article was written.

QUALITY OF LIFE 2

I would like to thank my supervisors for all their support and motivation. I want to

thank my wonderful family, Kári, Tindur and Nói, and all my friends, for their support and

understanding. I especially want to thank my dear friend, Freyja Hlíðkvist, for the invaluable

time she spent with me to reach my goal. I also want to thank the ADHD Association of

Iceland and all the teachers and staff at Reykjavík University, as well as my fellow student,

Ragnhildur Bjarkadóttir, for all the wonderful and informative conversations we had

throughout this process. Last, but not least, I extend my sincere gratitude to all the

participants in the study. This would not have been possible without you.

I wonder what happens next.

Are things the way they were before?

Hjördís Unnur Másdóttir 2017

QUALITY OF LIFE 3

Abstract

Aim This study aims to investigate whether individuals diagnosed with ADHD show more

emotional dysregulation than individuals not diagnosed with ADHD and if they value their

romantic relationships and quality of life less, as previous research indicates. The research

therefore aims to assess whether the relationship between emotional dysregulation, romantic

relationships and quality of life is different between ADHD adults and non-ADHD adults

Method Participants (N = 42) with confirmed diagnosis of ADHD, mean age 36 (SD =7.1),

their spouses, mean age 36 (SD = 7.5) and a comparison group of 31 couples (N = 31), mean

age 41.6 (SD = 9.5) answered the following questionnaires: Barkley ADHD Current

Symptoms Scale (BCS), Difficulty in Emotion Regulations Scale (DERS), Dyadic

Adjustment Scale (DAS) and Quality of Life Scale (QLS), along with a questionnaire about

socio-demographic information.

Results The ADHD individuals valued their quality of life and romantic relationships less

than the comparison group. The DAS and the DERS explained 58.4% variance in quality of

life as measured with the QLS in ADHD group, 35.0% in the spouses' group and 41.7% in

the comparison group.

Conclusions This study confirms that emotional dysregulation has a major impact on quality

of life within the ADHD group and that the emotional dysregulation subscales predict some

variation of quality of life within ADHD spouses’ and comparison groups. Furthermore, it

reveals that emotional dysregulation is a greater predictor of quality of life than romantic

relationship.
QUALITY OF LIFE 4

ADHD (Attention Deficit and Hyperactivity Disorder) is a behavioural disorder with

neurological roots that was previously believed to be a disorder that only affected children

were affected by. However, extensive research conducted by various scholars during the

recent years has revealed that these individuals are indeed, as adults, affected by ADHD in as

many as 60-70% of the cases (Barkley, Murphy, & Fischer, 2011; Hechtman, 1999;

Mannuzza & Klein, 2000). Over the past 40 years, American research has revealed that 5-8%

of the non-adult population has ADHD symptoms and following those children to adulthood

has shown that more than 66% continue to have ADHD as adults, or between 3-5% of the

entire adult US population. Comparative studies in Europe have shown prevalence rates of

ADHD in adults of 5.3% (Kessler, Adler, Barkley, Biederman, & al, 2006).

Longitudinal studies have shown that ADHD can persist into adulthood, either as a

full-scale chronic disorder or as a partial disorder. Furthermore, studies have revealed that

attention deficits appear to remain more stable throughout life, while it appears that

symptoms of hyperactivity decline and signs of restlessness increase Additional symptoms

have been found within cognitive performance related to specific brain functions in the

executive function (EF). People with ADHD have poorer executive functioning, leading to

deficiencies in organizing and achieving future goals, which perpetuates issues with problem

solving and self- regulation (Fuster, 2009; Welsh & Pennington, 1988).

Although ADHD is considered to be a disorder of deficient self-regulation, research

has primarily focused on cognitive and behavioural factors, leaving emotional aspects

neglected. Previous theories included emotional impulsivity (EI), emotional inhibition and

self- regulation (DESR) in ADHD, describing it as a deficiency in the effortful and executive

control of emotions leading to low frustration tolerance and anger. Even though ADHD

symptoms, such as outbursts or anger, are usually short-lived, they generally affect an
QUALITY OF LIFE 5

individual’s social interactions and functions (Haavik, Halmøy, Lundervold, & Fasmer, 2010;

Retz, Stieglitz, Corbisiero, Retz-Junginger, & Rösler, 2012).

Barkley (1997) suggested that emotional dysregulation should be considered a core

symptom in ADHD rather than as an associated symptom (Shaw, Stringaris, Nigg, &

Leibenluft, 2014). This view is consistent with conceptualizations of ADHD as a disorder of

self-regulation, motivation and arousal (Nigg, 2005). In DSM III the emotional part was

excluded, although recent neuroimaging studies imply correlation between ADHD and

emotional dysregulation. These implications are based on results demonstrating that both are

related to the same area of the brain; the lateral prefrontal cortex and the anterior cingulate

cortex (Bush, Valera, & Seidman, 2005; Herrmann, Biehl, Jacob, & Deckert, 2010; Matte,

Rohde, & Grevet, 2012; Ochsner, Silvers, & Buhle, 2012).

Barkley and his colleagues (2011) found, during their clinical studies, that 60% of

ADHD individuals showed symptoms of quick-temper, low frustration tolerance, emotional

overreacting and being easily distracted by nearby activities. Concurrently, these behaviours

showed to be evident in less than 15% of individuals within the control group. These findings

have been supported by other studies and further establish that individuals with these

symptoms respond well to treatment (Reimherr et al., 2005, 2007; Rösler, Casas, Konofal, &

Buitelaar, 2010; Surman et al., 2011, 2013). Barkley (2010) argues that emotions are not

more intense among ADHD individuals, but rather that emotions are more easily exposed,

most likely as a result of complications with EI (emotional inhibition). The individual’s effort

in emotional self-regulation proves to be insufficient in supporting their personal goals and

welfare and in meeting social norms of emotional expression. Moreover, research has shown

that when people cannot control their emotional responses to everyday events they

experience longer periods of distress, which can easily evolve into added anxiety and

depression (Aldao, Nolen-Hoeksema, & Schweizer, 2010).

QUALITY OF LIFE 6

In a review by Levenson et al. (2014) on emotional regulation’s prediction of marital

satisfaction, it is assumed that poor emotional regulation directly contributes to negative

behavior in marriage and happiness in populations. It has been asserted that the majority of

ADHD symptoms, such as poor social skills and lack of impulse control, directly affect

ADHD adults’ dating, engagements or marriages (Bruner, Kuryluk, & Whitton, 2015; Eakin

et al., 2004; Minde et al., 2003; Murphy & Barkley, 1996; Nigg, 2005). Furthermore, clinical

research indicates that these individuals report more marital difficulties and less marital

satisfaction than others (Dixon, 1995). Despite the fact that many studies imply that adults

with ADHD experience difficulties in relationships with friends and family, surprisingly few

studies have directly addressed this issue (Barkley, 2015).

There are indications that spouses of ADHD individuals take more responsibility at

home, in organizing and planning everyday life, leading them to experience a lack of

emotional support from their ADHD spouses and to become overwhelmed by these

imbalances in their relationships (Robin & Payson, 2002). In Eakin and colleagues’ research

(2004), spouses of ADHD individuals showed less marital satisfaction than individuals

within the control group, reporting that their partner’s difficulties interfered with their daily

life domains. The ADHD partners showed a more negative view of their marital satisfaction

than their spouses. Scholars have speculated whether this can be explained by the adverse

impacts an ADHD individual has on their own perception of their marital satisfaction.

Additionally, the spouses’ higher value of marital satisfaction could be explained by a feeling

of positive influence on the family life they experience by compensating for their partners.

Various studies have demonstrated a significant relationship between marital

satisfaction and quality of life (Gameiro, Nazaré, Fonseca, Moura-Ramos, & Canavarro,

2011; Pereira, Daibs, Tobias-Machado, & Pompeo, 2011). The literary record on quality of

life is diverse and not all scholars agree, because although the core aspects are the same
QUALITY OF LIFE 7

between studies, the definitions are vast and inconsistent (Farquhar, 1995). According to

Felce and Perry’s model on quality of life (1995), there is a broad range of life domains and

individual values that define quality of life, such as development and activity, and physical,

material, social, and emotional wellbeing. Many different aspects of quality of life have been

studied over the years, but all come to the same conclusion: an individual reaches satisfaction

with their lifestyle when they reach satisfaction with their needs and goals (Felce & Perry,

1995). In other words, to consider one’s quality of life as satisfactory, the majority of these

important aspects have to be in balance, although individual values can differ between

people.

Individuals with ADHD tend to have a lower valuation of their quality of life than

others. Research indicates that this is due to their inability to set and complete personal goals,

which can have an impact on personal perception and experience of physical, mental and

social wellbeing. For instance, this can lead to difficulties in completing education and more

frequent changes in employment than other populations. Likewise, they are two times more

likely to divorce or separate (Danckaerts et al., 2010; Harpin, 2005). In a review on the

relationship between emotional impairment and quality of life in ADHD children and adults,

Wehmeier, Schacht and Barkley (2010) report that studies imply that some of the emotional

dysregulation in these individuals arises from difficulties in executive functioning.

Furthermore, they report that ADHD symptoms have a greater impact on quality of life than

other psychiatric disorders. These conclusions are in accordance with Barkley and Murphy’s

results (2010), that emotional dysregulation contributes to impairment in major life activities,

thereby lowering the quality of life value for ADHD individuals, although more research is

required to further evaluate the extent of these impacts (Surman et al., 2013).

Taken together, emotional dysregulation impacts ADHD individuals’ lives in

different domains (Barkley & Murphy, 2010), resulting in lower values in their romantic
QUALITY OF LIFE 8

relationships than others (Bruner et al., 2015; Eakin et al., 2004; Minde et al., 2003; Murphy

& Barkley, 1996; Nigg, 2005), and adverse effects on their overall quality of life (Danckaerts

et al., 2010; Harpin, 2005).

This study aims to investigate whether individuals diagnosed with ADHD show more

emotional dysregulation than individuals not diagnosed with ADHD and if they value their

romantic relationships and quality of life less, as previous research indicates. The research

therefore aims to assess whether the relationship between emotional dysregulation, romantic

relationships and quality of life is different between ADHD adults and non-ADHD adults.

It is hypothesized that 1) ADHD individuals value their quality of life less than individuals

not diagnosed with ADHD, 2) ADHD individuals value their romantic relationships less than

individuals not diagnosed with ADHD, 3) ADHD individuals report more emotional

dysregulation than individuals not diagnosed with ADHD, 4) evaluations of emotional

dysregulation predict quality of life in individuals with ADHD, 5) evaluations of romantic

relationships predict quality of life in those not diagnosed with ADHD.

Method

Participants

Three groups of participants were recruited for this study: a) 42 individuals diagnosed

with ADHD (ADHD group) b) 42 spouses of ADHD individuals, not diagnosed with ADHD

(spouses) and c) 62 individuals (31 couples) not diagnosed with ADHD (comparison group).

All participants were required to be between 20 and 67 years of age and currently being in a

long-term relationship (one year or longer). The average age for all the participants was 38.4

years (SD = 8.7, range 21 - 67). The average age in the ADHD group was 36 years (SD = 7.1,

range 23 - 57); the average age for the spouses’ group was 36 years (SD = 7.5, range 21 - 61);

and the comparison group’s average age was 41.6 years (SD = 9.5, range 25 - 67)
QUALITY OF LIFE 9

Individuals in the ADHD group had to be clinically diagnosed with ADHD by a

physician (psychologist or psychiatrist), with current symptoms of inattention, hyperactivity

and impulsivity. Their spouses had to give their consent to participate in the study as well.

Couples were excluded from the study if the non-ADHD spouse was screened with ADHD.

Respondents in the comparison group had to match the age and relationship criteria,

including the spousal consent for participation, and were excluded if they were screened with

symptoms of ADHD.

Measures

The research was conducted with the use of the following questionnaires: The

Barkley ADHD Current Symptoms Scale (BCS), Difficulty in Emotion Regulations Scale

(DERS), Dyadic Adjustment Scale (DAS) and Quality of Life Scale (QLS), along with a

questionnaire about socio-demographic information. In addition, participants simultaneously

completed other questionnaires (Depression & Anxiety and Stress Scale, Brief Cope and

Rosenberg Self-Esteem Scale) intended and collected for related studies.

Socio-demographic data: All participants answered a socio-demographic

questionnaire, which included age, relationship or marital status, number of long-term

relationships, number of children and level of education.

The Barkley ADHD Current Symptoms Scale (BCSS) (Barkley, 2011) is a self-rated

questionnaire that consists of two subscales, one for Inattention and the other for

Hyperactivity/Impulsivity, both with nine questions. The questions are scored on a 4-point

Likert scale. The total score on the list ranges from 0 to 57 and the scores for each subscale

range from 0 to 27. This rating scale corresponds to the DSM-IV diagnostic criteria of

ADHD and the symptoms must have been present for at least the previous six months. The

scale asks participants to report the age of onset for ADHD symptoms and describe how often

their symptoms interfere with social activities, such as relationships, work, school and home
QUALITY OF LIFE 10

life. The scale shows high internal consistency (Cronbach´s α = .914 in the original version)

and good psychometric properties. The Icelandic version of the questionnaire has proven to

be adequate (Magnússon et al., 2006).

The Quality of Life Scale (QLS; Burckhardt & Anderson, 2003) is a 16-item

questionnaire measuring six conceptual domains of quality of life, such as personal

relationships (marital status, family, friends), physical and mental health, social and

community activity and self-reliance skills. The answer options are provided on a 7-point

Likert scale where scores can range from 16 to 112 with the average total score for healthy

populations set around 90. Previous research shows the reliability to be satisfactory

(Cronbach´s α = .82 to .92) (Burckhardt & Anderson, 2003). The Icelandic version of QLS

indicates equally adequate psychometric characteristics (Cronbach´s α = 72-.86) (Jónsdóttir

& Sigurðardóttir, 2016).

The Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) is a

self-report inventory that consists of 36 items designed to assess emotional awareness,

acceptance and perceived ability to regulate emotions. The list is comprised of six subscales:

1) Non-acceptance of emotions (Nonacceptance), 2) difficulties engaging in goal-directed

behaviour (Goals), 3) impulse control difficulties (Impulse), 4) lack of emotional awareness

(Awareness), 5) limited access to emotion regulation strategies (Strategies) and 6) lack of

emotional clarity (Clarity). Participants rate how often each item applies on a 5-point Likert

scale. Research has demonstrated good internal consistency (Cronbach´s α = .93) (Gratz &

Roemer, 2004). The Icelandic translation has also demonstrated good psychometric

properties (Ocares & Magnúsdóttir, 2009).

Dyadic Adjustment Scale (DAS; Spanier, 1976, 1988) is a 32-item measure developed

for married couples or similar dyads to rate their marital satisfaction for the previous 12

months, with low scores indicating higher marital satisfaction. The Scale has adequate
QUALITY OF LIFE 11

reliability and validity (Cronbach´s α= .84-.96) (Spanier, 1988). The Icelandic version of the

scale has good psychometric properties (Cronbach´s α= .9) (Sæmundsdóttir & Jónsdóttir,

2011).

Procedure

Recruiting participants in the study was in collaboration with the ADHD Association

of Iceland (via email) and through acquaintances (snowball sampling). Advertisements were

posted via email to members of the ADHD Association of Iceland to introduce the study.

Those who were interested in participating contacted researchers by email or phone and were

given a more detailed description of the study.

The comparison group (non-ADHD adults) was recruited through social media,

acquaintances (snowball effect) and through advertisements at the Reykjavik University.

Participants could either fill out the questionnaires at Reykjavík University or at home,

where the researcher would bring the material. All the couples chose to fill out the

questionnaires at home. The researcher obtained informed consent from both parties.

Subsequently, detailed instructions for filling out the questionnaires were given to each party

separately and without discussing the questions or possible answers. The researcher collected

the material after a given two to four-day timeframe.

To maintain anonymity, all questionnaires were only marked with a number

indicating which group they belonged to. The questionnaires were deleted after entry into an

excel document with marked numbers.

All study procedures, including arrangements and implementation, were attained

within ethical guidelines and with approval from the Icelandic Bioethics Committee (ref.no.

16-111).

Statistical analysis

Data was entered into the SPSS, version 21 (IBM SPSS Statistics 24, 2013), Alpha
QUALITY OF LIFE 12

reliability coefficients were calculated for scales and subscales, followed by an examination

of the demographic characteristics in the sample. Descriptive statistics were calculated for all

the variables with frequencies, crosstabs and chi square tests. ANOVA was calculated to

compare the groups on the questionnaires and then a Bonferoni test was executed to evaluate

where the differences appeared. In order to understand the relations between variables,

correlations were carried out by using Pearson’s r. Lastly, hierarchical linear regression

analysis was conducted to examine whether the DERS and the DAS predicted the participants’

quality of life (the QLS) and to determine if there were differences between those diagnosed

with ADHD, their spouses and the comparison group.

Results

Demographic characteristic.

Table 1 describes the demographic characteristics of the participants in the three

groups. As the table shows, there are no significant differences between the three groups

regarding number of children (p > .005), but the comparison group reported longer

relationships (p < .020) than the two other groups. The length of relationships was on average

four years longer in the comparison group than in the ADHD group.
 QUALITY OF LIFE 13

Table 1. Demographic characteristics for each group, mean (M), standard deviation (SD),
statistics and percentage (%).

Demographic variables ADHD Spouse Comparison

M (SD) M (SD) M (SD) F
Children 2.1 (1.5) 1.9 (1.3) 1.6 (1.0) 1.86
Length of relationship 9.7 (6.4) 9.8 (6.4) 13.5 (7.5) 5.37**

ADHD Spouse Comparison

N (%) N (%) N (%) Chi-square
Marital status 3.7
Marriage 19 (45.2) 19 (45.2) 38 (61.3)
Living together 23 (54.8) 23 (54.8) 24 (38.7)

Education 0.3
Elementary or less 5 (12.2) 10 (23.8) 10 (16.1)
College 13 (31.7) 10 (26.2) 10 (19.4)
University 17 (41.5) 15 (35.7) 10 (38.7)
Other 5 (12.2) 6 (14.3) 16 (25.8)
Note: **p <.05.

No significant difference was found between groups regarding marital status. The ADHD

group had the highest level of education (University) although no significant difference

emerged between groups (all three were well educated).

Table 2 describes the results from ANOVA, that was carried out to analyse the

differences between groups’ means on the four scales administrated, the QLS, the DERS (six

subscales), the DAS and the ADHD symptoms (ADHD-INT and ADHD-HYP) and a

Bonferoni test was calculated to see where the differences emerge. All the scales had

satisfactory Cronbach´s alpha.

 QUALITY OF LIFE 14

Table 2. Mean scores, standard deviation (SD) for ADHD, spouses and control, the difference
between ADHD, spouse and control for the scale and subscales
ADHD Spouses Comparison
Psychological
M (SD) (N) M (SD) (N) M (SD) (N) F α
instruments
QLS 80.0 (13.1) (42) 85.0 (10.4) (42) 87.1 (10.9) (62) 4.9* .86

DAS 86.1 (9.7) (42) 84.5 (9.2) (42) 81.5 (9.3) (62) 3.2* .30
Non-
17.3 (6.7) (42) 11.7 (5.5) (42) 11.3 (4.7) (62) 16.4** .79
acceptance
Goals 18.7 (5.0) (42) 13.7 (5.3) (42) 13.0 (4.1) (62) 19.9** .83

Impulse 16.3 (6.7) (42) 11.5 (5.2) (42) 9.7 (3.4) (62) 22.2** .79

Awareness 16.6 (4.6) (42) 15.4 (4.5) (42) 15.5 (4.3) (62) 0.85 .89

Strategies 20.7 (8.3) (42) 15.0 (3.1) (42) 14.0 (4.9) (62) 15.9** .77

Clarity 11.8 (3.7) (42) 8.8 (3.1) (42) 8.4 (2.9) (62) 16.4** .82

ADHD-INT 17.2 (5.5) (41) 5.7 (4.8) (41) 4.6 (4.1) (61) 98.5** .95

ADHD-HYP 15.0 (6.1) (40) 3.6 (3.1) (42) 3.2 (3.8) (61) 101.2** .94
Note: *p < 0.05, **p < 0.01

As shown in Table 2 there is an apparent difference of mean scores between the three

groups. The ADHD group indicated less marital satisfaction and quality of life than the other

two groups. They also scored higher on all the DERS subscales, indicating that they have

more difficulties in emotional regulation, and on both the ADHD-INT and ADHD-HYP

scales, as expected.

A considerable similarity was seen in the mean scores between the spouses’ and

comparison groups, except on the DERS Impulse scale, in which the spouses’ group scored

higher.

The Bonferoni test shows significant differences on DAS and QLS between the

ADHD (p < .046) and the comparison group (p < .007), with the ADHD group reporting less
QUALITY OF LIFE 15

marital satisfaction and quality of life. The ADHD group (p < .001) , was different from both

the other groups on all emotional regulation subscales, apart from Awareness scale, where the

results were similar for all three groups. The differences between the spouses’ group and the

comparison group were not significant on any of the emotional regulation subscales. The

difference on the ADHD-INT and the ADHD-HYP are significant between the ADHD group

(p < .01), and both other groups, but not significant between the spouses’ and the comparison

groups.

Pearson's r correlations were carried out to evaluate the relationship between the QLS,

the DAS and the DERS subscales for all the three groups. In all the groups, there was a

negative correlation between the DAS and the QLS, r(143) = -.288, (p < .001) and between

the majority of the DERS subscales and the QLS; Non-acceptance r(143) = -.540, (p < .001),

Goals r(143) = -.308, (p < .001), Impulse r(143) = -.365, (p < .001), Awareness r(143) = -

.460, (p < .001), Strategies r(143) = -.444, (p < .001), Clarity r(143) = -.564, (p < .001).

In the ADHD group there was a negative correlation between the QLS and all the

DERS subscales, Non-acceptance r(143) = -.531, (p < .001), Awareness r(143) = -.566, (p <

.001), Strategies r(143) = -.481, (p < .001), Clarity r(143) = -.717, (p < .001), except with

Goals and Impulse. In the spouses’ group there was a negative correlation between QLS and

Non-acceptance r(143) = -.472, (p < .001) and Awareness r(143) = -.380, (p < .05). While in

the comparison group negative correlations emerged between the QLS and all the DERS

scales, Non-acceptance r(59) = -.476, (p < .001), Impulse r(59) = -.433, (p < .001),

Awareness r(59) = -.408, (p < .001), Strategies r(59) = -.381, (p < .001), Clarity r(59) = -

.578, (p < .001), except Goals.

Regression

In order to investigate if emotional regulation or romantic relationships differently

predicted quality of life for the three groups, three separate hierarchical linear regressions
QUALITY OF LIFE 16

were carried out for each of the groups. First the DAS was entered in block 1, and then the

DERS subscales were entered into block 2, with the QLS as an outcome variable. This was

conducted separately for each group.

In order to in investigate if the relationship between the predicted variables and the

outcome variables were linear, the Durbin-Watson statistic was calculated. The conclusions

indicate that there is independence of residuals for all groups, 2.410 for the ADHD group,

1.770 for the spouses and 1.885 for the comparison group.

First, a hierarchical linear regression was conducted for the data from the ADHD

group. As can be seen in Table 3, the DAS scale was first entered into the analysis in model

1. Results showed that it accounted for 8.3% of the variation in quality of life, adjusted R2 =

6% which is a small effect according to Cohen (2013). Then the DAS and the DERS

subscales were entered in model 2. These variables accounted for 65.5% of the variation in

quality of life, with adjusted R2 = 58.4%, which is a medium size effect according to Cohen

(2013). As the table shows, the DAS and the DERS Impulse and Awareness subscales

predicted quality of life F(7, 34) = 9.2 p < .001.

For the spouses’ group, the DAS accounted for 1.5% of the variation in quality of life,

with adjusted R2 = 1.0%, a small size effect according to Cohen (2013). Model 2, which

consisted of the DAS and the DERS subscales, accounted for 46.1% of the variation in

quality of life, with adjusted R2 = 35.0%, a medium size effect according to Cohen (2013). As

the table shows, the DAS and three of the DERS subscales, Nonacceptance (p <.05), Goals (p

<.05) and Awareness (p < .001) (model 2), significantly contributed to the quality of life

among the spouses F(7, 34) = 4.2 p < .005.

QUALITY OF LIFE

Table 3. Summary of multiple regression analysis for the DAS and emotional dysregulation
subscales predicting quality of life for all groups
Predictor
Groups β t-value R2 F-value
variables
ADHD
DAS -288 -1.900
Model 1 .060 F(1,40) = 3.6

DAS -224 -2.006

Nonacceptance -.114 -.577
Goals -.080 -.584
Impulse .365 2.323*
Awareness -.393 -2.510*
Strategies -.454 -1.578
Clarity -.231 -1.145
Model 2 .584 F(7,35) = 9.2**
Spouses
DAS -222 -.779
Model 1 .010 F(1,40) = .608
DAS .087 .629
Nonacceptance -.374 -2.524*
Goals -.448 -2.349*
Impulse .050 .260
Awareness -.661 -3.625**
Strategies .053 .246
Clarity .258 1.459
Model 2 .350 F(7,34) = 4.2**
Comparison
DAS -.307 -2.438*
Model 1 .079 F(1,57) = .5.9*
DAS -.204 -1.911
Nonacceptance -.410 -2.196*
Goals .095 .698
Impulse -.281 -1.776
Awareness -.036 -.253
Strategies .373 1.887
Clarity -.446 -2.841**
Model 2 .417 F(7,51) = 6.9**
Note: Dependent variable: quality of life, * p < 0.05, ** p < 0.01
QUALITY OF LIFE 18

Both of the models were statistically different for the comparison group. The DAS

accounted for 9.4% of the variation in quality of life, with adjusted R2 = 7.9%, a small size

effect according to Cohen (2013) F(1, 57) = 5.9, p < .05.

The DAS and the DERS subscales accounted for 48.7% of the variation in quality of

life in the comparison group, with adjusted R2 = 41.7%, a medium size effect according to

Cohen (2013) and it predicted quality of life significantly, F(7, 51) = 6.9, p <.001. One of the

DERS subscales contributed significantly to the prediction of quality of life in the

comparison group (p <.05), in model 2.

Conclusion

The aim with this study was to investigate if individuals, diagnosed with ADHD, show more

emotional dysregulation than individuals not diagnosed with ADHD, and if they perceive

their romantic relationships and quality of life more negatively. Furthermore, the study aimed

at evaluating if the relationship between emotional dysregulation, romantic relationships and

quality of life was different between those diagnosed with ADHD and those not diagnosed.

As expected, there were significant differences between the ADHD group and both

their spouses and the comparison group in terms of ADHD symptoms, e.g. the ADHD

symptoms were present in the ADHD group.

The ADHD group valued their quality of life and their romantic relationships

significantly worse than the comparison group, but the difference between the ADHD group

and their spouses was not significant. These findings are consistent with previous research

that has demonstrated that ADHD individuals valuate their quality of life worse than the

other groups (Danckaerts et al., 2010; Harpin, 2005). Furthermore, previous studies indicate

that spouses of ADHD individuals may be, to some extent, less satisfied than others in their

romantic relationship, due to the imbalance between each party concerning responsibility and

decision-making (Robin & Payson, 2002). Surprisingly though, the difference between the
QUALITY OF LIFE 19

ADHD individuals and their spouses was not significant and neither was the difference

between spouses and the comparison group on the DAS or the QLS. It implies that the

spouses differ from both groups, to a certain degree, in how they value their quality of life

and their romantic relationships (Gameiro et al., 2011; Pereira et al., 2011).

The results of this study are comparable with the findings of previous studies; that

ADHD individuals and their spouses are less satisfied in their romantic relationships than

couples in the comparison group (Dixon, 1995; Robin & Payson, 2002). This study concludes

that ADHD individuals are the least satisfied of all the participants on both the quality of life

and romantic relationships.

When analysing what predicts how individuals evaluated their quality of life, it

became clear that emotional dysregulation of ADHD individuals had greater impact on their

quality of life than their romantic relationships. This result is corroborated by previous

studies; emotional dysregulation is a major factor in an ADHD individual’s life (Barkley &

Murphy, 2010).

The ADHD individuals scored differently on the DERS scales than the other two

groups, which indicates, like previous studies, that they have in general poor emotional

regulation that impacts their daily life. The spouses’ group scored slightly higher on the

DERS subscales in comparison with the comparison group, but the differences were not

significant. It was hypothesized that the spouses and the comparison group would respond

similarly on the DERS subscales due to the absence of ADHD symptoms. It is possible that

the spouses of the ADHD individuals experience some difficulties in controlling their

emotions due to their close relationship with their ADHD spouses. The only DERS subscale

in the ADHD group that was not significantly different from the other two groups was

Awareness, which indicates that all the participants in the study have some problem with

knowledge, acceptance and validation of one’s emotions.

QUALITY OF LIFE 20

Emotional dysregulation was a greater predictor of quality of life in all the groups

than romantic relationship. However, romantic relationships still predicted some variation

within the comparison group, as is seen in previous studies, demonstrating that marital

satisfaction has a significant relation to quality of life (Gameiro et al., 2011; Pereira et al.,

2011).

It is not surprising that the DERS scales predicted some degree of variation in the

quality of life within the ADHD group, due to the large impact emotional dysregulation has

on ADHD individuals in their daily life (Surman et al., 2013). The subscales that made

significant predictions in the model were Impulse and Awareness. The DERS subscales that

contributed to the prediction of quality of life in the spouses’ group were Non-acceptance,

Goals and Awareness. The Awareness subscale was the only subscale that contributed to the

prediction of the quality of life in both the spouses’ and the ADHD groups. These findings

may be connected with a lack of self-awareness, acceptance and validation of one’s emotions.

These results imply that when both individuals of a couple experience a lack of self-

awareness, an adverse synergistic effect occurs, possibly explaining their reported low quality

of life.

Goal setting is one factor that may partly explain some of the variation in quality of

life in the spouses’ group. This variation potentially results from the ADHD individual’s

deficiencies in organizing and achieving future goals, leading to the spouse taking on

additional responsibilities in organizing and planning everyday life (Fuster, 2009; Welsh &

Pennington, 1988). Reaching goals and individual needs are major aspects in achieving

lifestyle satisfaction (Felce & Perry, 1995).

Non-acceptance and ensuing emotional shame during periods of upset, is the one

factor that predicted some variation in the quality of life in both the spouses’ and the

comparison groups. Though no studies have directly examined this part of emotional
QUALITY OF LIFE 21

dysregulation in the general population, it can be expected that non-acceptance of feelings

directly contributes to negative behaviour in marriage and happiness in populations

(Levenson, Haase, Bloch, Holley, & Seider, 2014).

It has been stated that emotional dysregulation has a major impact on quality of life

within the ADHD group. Furthermore, the results indicate that the emotional dysregulation

subscales predict some variation of quality of life within ADHD spouses’ and comparison

groups. Our study reveals interesting results, confirming that it is vital to develop treatment

focusing on emotional dysregulation that can improve life satisfaction. To support this

argument, previous studies have indicated that emotional dysregulation is sensitive to

treatment, potentially more so than other ADHD symptoms (Reimherr et al., 2005, 2007;

Rösler et al., 2010; Surman et al., 2011, 2013).

There is some indication that the spouses of the ADHD individuals were different

from the comparison group. They valued their quality of life and romantic relationship less

than the comparison group and value their emotional dysregulation higher, possibly due to

influences from their ADHD partners. If so, it is important to develop treatment that targets

impaired emotional regulation in both ADHD individuals and their spouses.

There were some limitations with this study, including small sample sizes. To clarify

the impacts the DERS subscales have on quality of life, further research on the matter is

required, using larger sample sizes. In addition, the sample selection for each group should

preferably consist of individuals in current romantic relationships, instead of including both

individuals of the same couple. This could remove some of the potential synchronistic

influences formed between partners in long-term relationships, which may affect the outcome

of the participants’ responses to the questionnaires.

QUALITY OF LIFE

References

Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies

across psychopathology: A meta-analytic review. Clinical Psychology Review, 30(2),

217–237. https://doi.org/10.1016/j.cpr.2009.11.004

Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive functions:

Constructing a unifying theory of ADHD. Psychological Bulletin, 121(1), 65–94.

https://doi.org/10.1037/0033-2909.121.1.65

Barkley, R. A. (2010). Why emotional impulsiveness should be a central feature of ADHD.

The Guilford Press, 8(4), 1–4.

Barkley, R. A. (2011). Barkley Adult ADHD Rating Scale-IV (BAARS-IV). Guilford Press.

Barkley, R. A. (Ed.). (2015). Attention-deficit hyperactivity disorder: A handbook for

diagnosis and treatment (Fourth edition). New York: The Guilford Press.

Barkley, R. A., & Murphy, K. R. (2010). Deficient emotional self-regulation in adults with

attention defective/hyperactivity (ADHD): The relative contributions of emotional

impulsiveness and ADHD symptoms to adaptive impairments in major life activities.

Journal of ADHD & Relatied Disorder, 1(4), 5–28.

Barkley, R. A., Murphy, K. R., & Fischer, M. (2011). ADHD in adults: What the science says.

New York; London: Guilford.

Bruner, M. R., Kuryluk, A. D., & Whitton, S. W. (2015). Attention-deficit/hyperactivity

disorder symptom levels and romantic relationship quality in college students.

Journal of American College Health, 63(2), 98–108.

https://doi.org/10.1080/07448481.2014.975717

Burckhardt, C. S., & Anderson, K. L. (2003). The quality of life acale (QOLS): reliability,

validity, and utilization. Health and Quality of Life Outcomes, 1, 60.

https://doi.org/10.1186/1477-7525-1-60
QUALITY OF LIFE 23

Bush, G., Valera, E. M., & Seidman, L. J. (2005). Functional neuroimaging of attention-

deficit/hyperactivity disorder: A review and suggested future directions. Biological

Psychiatry, 57(11), 1273–1284. https://doi.org/10.1016/j.biopsych.2005.01.034

Cohen, R. J. (2013). Psychological testing and assessment: An introduction to tests and

measurement. New York, NY: McGraw-Hill.

Danckaerts, M., Sonuga-Barke, E. J. S., Banaschewski, T., Buitelaar, J., Döpfner, M., Hollis,

C., … Coghill, D. (2010). The quality of life of children with attention

deficit/hyperactivity disorder: A systematic review. European Child & Adolescent

Psychiatry, 19(2), 83–105. https://doi.org/10.1007/s00787-009-0046-3

Dixon, E. B. (1995). Impact of adult ADD on the family. In K. G. Nadeau (Ed.), A

Comprehensive Guide to Attention Deficit Disorder in Adults: Research, Diagnosis,

and Treatment (pp. 236–259). Psychology Press.

Eakin, L., Minde, K., Hechtman, L., Ochs, E., Krane, E., Bouffard, R., … Looper, K. (2004).

The marital and family functioning of adults with ADHD and their spouses. Journal

of Attention Disorders, 8(1), 1–10. https://doi.org/10.1177/108705470400800101

Farquhar, M. (1995). Definitions of quality of life: A taxonomy. Journal of Advanced

Nursing, 22(3), 502–508. https://doi.org/10.1046/j.1365-2648.1995.22030502.x

Felce, D., & Perry, J. (1995). Quality of life: Its definition and measurement. Research in

Developmental Disabilities, 16(1), 51–74. https://doi.org/10.1016/0891-

4222(94)00028-8

Fuster, J. M. (2009). The prefrontal cortex (4. ed., reprint). Amsterdam: Elsevier, Acad. Press.

Gameiro, S., Nazaré, B., Fonseca, A., Moura-Ramos, M., & Canavarro, M. C. (2011).

Changes in marital congruence and quality of life across the transition to parenthood

in couples who conceived spontaneously or with assisted reproductive technologies.

QUALITY OF LIFE 24

Fertility and Sterility, 96(6), 1457–1462.

https://doi.org/10.1016/j.fertnstert.2011.09.003

Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and

dysregulation: Development, factor structure, and Initial validation of the difficulties

in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment,

26(1), 41–54. https://doi.org/10.1023/B:JOBA.0000007455.08539.94

Haavik, J., Halmøy, A., Lundervold, A. J., & Fasmer, O. B. (2010). Clinical assessment and

diagnosis of adults with attention-deficit/hyperactivity disorder. Expert Review of

Neurotherapeutics, 10(10), 1569–1580. https://doi.org/10.1586/ern.10.149

Harpin, V. A. (2005). The effect of ADHD on the life of an individual, their family, and

community from preschool to adult life. Archives of Disease in Childhood, 90(suppl

1), i2–i7. https://doi.org/10.1136/adc.2004.059006

Hechtman, L. (1999). Predictors of long-term outcome in children with attention-

deficit/hyperactivity disorder. Pediatric Clinics, 46(5), 1039–1052.

https://doi.org/10.1016/S0031-3955(05)70171-1

Herrmann, M. J., Biehl, S. C., Jacob, C., & Deckert, J. (2010). Neurobiological and

psychophysiological correlates of emotional dysregulation in ADHD patients. ADHD

Attention Deficit and Hyperactivity Disorders, 2(4), 233–239.

https://doi.org/10.1007/s12402-010-0047-6

IBM SPSS Statistics 24. (2013). (Version IBM Corp) [Windows]. New York.

Jónsdóttir, K., & Sigurðardóttir, S. (2016). Próffræðilegir eiginleikar íslenskra þýðinga á

Sheehan disability scale, quality of life scale og the patient health questionnaire.

Háskóli Íslands, Reykjavík.

QUALITY OF LIFE 25

Kessler, R. C., Adler, L., Barkley, R., Biederman, J., & al, et. (2006). The prevalence and

correlates of adult ADHD in the United States: results from the national comorbidity

survey replication. The American Journal of Psychiatry; Washington, 163(4), 716–23.

Levenson, R., Haase, C., Bloch, L., Holley, S., & Seider, B. (2014). Emotion regulation

predicts marital satisfaction: More than a wives’ tale. In J. J. Gross (Ed.), Handbook

of Emotion Regulation (Guilfored Press, pp. 267–283). New York, N.Y.

Magnússon, P., Smári, J., Sigurðardóttir, D., Baldursson, G., Sigmundsson, J., Kristjánsson,

K., … Guðmundsson, Ó. Ó. (2006). Validity of self-report and informant rating scales

of sdult ADHD symptoms in comparison with a semistructured diagnostic interview.

Journal of Attention Disorders, 9(3), 494–503.

https://doi.org/10.1177/1087054705283650

Mannuzza, S., & Klein, R. G. (2000). Long-term prognosis in attention-deficit/hyperactivity

disorder. Child and Adolescent Psychiatric Clinics of North America, 9(3), 711–726.

Matte, B., Rohde, L. A., & Grevet, E. H. (2012). ADHD in adults: A concept in evolution.

ADHD Attention Deficit and Hyperactivity Disorders, 4(2), 53–62.

https://doi.org/10.1007/s12402-012-0077-3

Minde, K., Eakin, L., Hechtman, L., Ochs, E., Bouffard, R., Greenfield, B., & Looper, K.

(2003). The psychosocial functioning of children and spouses of adults with ADHD.

Journal of Child Psychology and Psychiatry, 44(4), 637–646.

https://doi.org/10.1111/1469-7610.00150

Murphy, K., & Barkley, R. A. (1996). Attention deficit hyperactivity disorder adults:

Comorbidities and adaptive impairments. Comprehensive Psychiatry, 37(6), 393–401.

https://doi.org/10.1016/S0010-440X(96)90022-X

Nigg, J. T. (2005). Neuropsychologic theory and findings in attention-deficit/hyperactivity

disorder: The state of the field and salient challenges for the coming decade.
QUALITY OF LIFE 26

Biological Psychiatry, 57(11), 1424–1435.

https://doi.org/10.1016/j.biopsych.2004.11.011

Ocares, J. H., & Magnúsdóttir, K. (2009). Próffræðilegir eiginleikar spurningalista um

tilfinningastjórn og tilfinninganæmi og tengsl þeirra við húðkroppunaráráttu. Háskóli

Íslands, Reykjavík.

Ochsner, K. N., Silvers, J. A., & Buhle, J. T. (2012). Functional imaging studies of emotion

regulation: A synthetic review and evolving model of the cognitive control of emotion.

Annals of the New York Academy of Sciences, 1251(1), E1–E24.

https://doi.org/10.1111/j.1749-6632.2012.06751.x

Pereira, R. F., Daibs, Y. S., Tobias-Machado, M., & Pompeo, A. C. L. (2011). Quality of life,

behavioral problems, and marital adjustment in the first year after radical

prostatectomy. Clinical Genitourinary Cancer, 9(1), 53–58.

https://doi.org/10.1016/j.clgc.2011.05.005

Reimherr, F. W., Marchant, B. K., Strong, R. E., Hedges, D. W., Adler, L., Spencer, T. J., …

Soni, P. (2005). Emotional dysregulation in adult ADHD and response to atomoxetine.

Biological Psychiatry, 58(2), 125–131.

https://doi.org/10.1016/j.biopsych.2005.04.040

Reimherr, F. W., Williams, E. D., Strong, R. E., Mestas, R., Soni, P., & Marchant, B. K.

(2007). A double-blind, placebo-controlled, crossover study of osmotic release oral

system methylphenidate in adults with ADHD with assessment of oppositional and

emotional dimensions of the disorder. The Journal of Clinical Psychiatry, 68(1), 93–

101.

Retz, W., Stieglitz, R.-D., Corbisiero, S., Retz-Junginger, P., & Rösler, M. (2012). Emotional

dysregulation in adult ADHD: what is the empirical evidence? Expert Review of

Neurotherapeutics, 12(10), 1241–1251. https://doi.org/10.1586/ern.12.109

QUALITY OF LIFE 27

Robin, A. L., & Payson, E. (2002). The impact of ADHD on marriage. The ADHD Report,

10(3), 9–14. https://doi.org/10.1521/adhd.10.3.9.20553

Rösler, M., Casas, M., Konofal, E., & Buitelaar, J. (2010). Attention deficit hyperactivity

disorder in adults. The World Journal of Biological Psychiatry, 11(5), 684–698.

https://doi.org/10.3109/15622975.2010.483249

Sæmundsdóttir, R. H., & Jónsdóttir, K. E. (2011). Samband tilfinningasemi, samvinnuþýði og

ánægju í ástarsamböndum: Er sambandinu miðlað í gegnum sjálfstraust,

samskiptahætti og tengslamyndun á fullorðinsárum? Háskóli Íslands, Reykjavík.

Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014). Emotion dysregulation in attention

deficit hyperactivity disorder. American Journal of Psychiatry, 171(3), 276–293.

https://doi.org/10.1176/appi.ajp.2013.13070966

Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of

marriage and similar dyads. Journal of Marriage and Family, 38(1), 15–28.

https://doi.org/10.2307/350547

Spanier, G. B. (1988). Assessing the strengths of the dyadic adjustment scale. Journal of

Family Psychology, 2(1), 92–94. https://doi.org/10.1037/h0080477

Surman, C. B. H., Biederman, J., Spencer, T., Miller, C. A., McDermott, K. M., & Faraone, S.

V. (2013). Understanding deficient emotional self-regulation in adults with attention

deficit hyperactivity disorder: A controlled study. ADHD Attention Deficit and

Hyperactivity Disorders, 5(3), 273–281. https://doi.org/10.1007/s12402-012-0100-8

Surman, C. B. H., Biederman, J., Spencer, T., Yorks, D., Miller, C. A., Petty, C. R., &

Faraone, S. V. (2011). Deficient emotional self-regulation and adult attention deficit

hyperactivity disorder: A family risk analysis. American Journal of Psychiatry,

168(6), 617–623. https://doi.org/10.1176/appi.ajp.2010.10081172

QUALITY OF LIFE 28

Wehmeier, P. M., Schacht, A., & Barkley, R. A. (2010). Social and emotional impairment in

children and adolescents with ADHD and the impact on quality of life. Journal of

Adolescent Health, 46(3), 209–217. https://doi.org/10.1016/j.jadohealth.2009.09.009

Welsh, M. C., & Pennington, B. F. (1988). Assessing frontal lobe functioning in children:

Views from developmental psychology. Developmental Neuropsychology, 4(3), 199–

230. https://doi.org/10.1080/87565648809540405