618789

research-article2015
JADXXX10.1177/1087054715618789Journal of Attention DisordersErsoy and Ersoy

Article
Journal of Attention Disorders

Gender-Role Attitudes Mediate the

1­–11
© The Author(s) 2015
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DOI: 10.1177/1087054715618789

Relationships jad.sagepub.com

Mehmet A. Ersoy1 and Hatice Topçu Ersoy2

Abstract
Objective: Adult ADHD has dramatic impacts on various aspects of life and relationships. This study investigates how
“gender roles” mediate the effects of ADHD on marriage. Method: Sixty-two heterosexual couples were included in the
study. The Marital Impact Checklist is used to assess the effects of ADHD on marriage. The Gender Roles Attitude Scale
is used to measure gender roles in both the patient and the spouse. Results: The Turkish version of the Marital Impact
Checklist is found to have good internal consistency and utility in research and clinical work with ADHD couples. The
female non-ADHD partners reported feeling of “Unloved” and “Negative Impact” more than their male counterparts.
Some subdomains of the gender roles of both the patient and their non-ADHD spouse seem to mediate the effect of
adult ADHD’s impact on marriage. Conclusion: Sex and gender roles diversify how ADHD affects marriage. (J. of Att. Dis.
XXXX; XX(X) XX-XX)

Keywords
adult attention deficit hyperactivity disorder, gender, relationship quality

Introduction (2002) devised the “Marital Impact Checklist” (MIC) ques-

Adult ADHD is increasingly more recognized and treated
(Deberdt et al., 2015; Faraone, Biederman, & Mick, 2006;
Simon, Czobor, Bálint, Mészáros, & Bitter, 2009). ADHD
may have destructive effects on marriage and relationships
as it distorts executive functions, impulse control, and atten-
tion (Bouchard & Saint-Aubin, 2014). Due to their forget-
fulness, disorganization, and distractibility, the ADHD
partner fails to fulfill their responsibilities in a relationship
and may convert simple matters to big fights quickly as a
consequence of their impulsivity. The communication prob-
lems they experience due to their difficulty in listening to
what the other party says exacerbate the already hard to
settle issues, and their partner may feel that they are not
valued. Compared with control groups, higher numbers of
divorces and marriages have been reported in groups where
one of the spouses has ADHD (Biederman et al., 1994;
Biederman et al., 1993; Murphy & Barkley, 1996). There
are reports associating ADHD with lower satisfaction and
success levels in romantic relationships (Canu, Schatz, &
Haslag, 2007; Ebejer et al., 2012).
Although the negative effects of ADHD on relationships
have attracted the attention of clinicians (Fowler & Fowler,
1995; Haverstadt, 1998), the number and scope of the studies
on this matter are far from being adequate. Robin and Payson
tionnaire and reported that problems in communication
(e.g., “says things without thinking”); shortcomings in
completing tasks, working memory, and managing time
(e.g., “doesn’t remember being told things,” “has trouble
getting started on a task”); and deficits in self-regulation of
affect (e.g., “Has trouble dealing with frustration”) are
mostly articulated by couples to negatively impact their
marriage. Robin and Payson report that “Male non-ADHD
spouses rated their female ADHD partners to be displaying
many more ADHD-related behaviors, which exert a greater
negative impact on their marriages, than those female non-
ADHD spouses reported about their male ADHD partners”
(p. 11). These researchers suggest that sex-role issues may
contribute to the level of dissatisfaction in a marriage when
the female partner has ADHD.
Gender roles can be described as how the behaviors and
roles of women and men are differentiated within a
community. These may roughly be defined as traditional
1
Ege University, İzmir, Turkey
2
Gediz University, İzmir, Turkey
Corresponding Author:
Mehmet A. Ersoy, Department of Psychiatry, Faculty of Medicine, Ege
University, Bornova Izmir 35100, Turkey.
Email: akifersoy@gmail.com

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2 Journal of Attention Disorders 
and egalitarian roles (Zeyneloğlu, 2008). Roles attributed to
women in the traditional distribution of gender roles include
childbearing and childcare; being responsible of household
chores such as cleaning, washing, and cooking; meeting the
needs of their spouses and children before their own needs;
compromising their desires in favor of their families; and
considering entering work life only after meeting the needs
of their family or not participating in the labor force at all.
The traditional roles of men, however, are such nonegalitar-
ian responsibilities as having a job, providing the livelihood
of the household, protecting their families, have the final
say in decisions taken at home, and being the head of the
house. Conversely, in the egalitarian distribution of the gen-
der roles, men and women share equal responsibilities in
the family, work life, marriage, and education (Atış, 2010;
Hunter et al., 2004).
The impact of gender roles on gender relations and par-
ticularly on satisfaction in marriage has been the focus of
many studies. The study by Demaris, Sanchez, and
Krivickas (2012) established that couples adopting more
traditional roles are less satisfied. Amato and Booth (1995)
have found that husbands with more egalitarian attitudes
are happier in marriage and marital problems and disputes
are reduced in such marriages while just the opposite hap-
pens when females are egalitarian.
Various scales are developed determining the attitudes
toward gender roles in different cultures such as “Attitude
Toward Women Scale” (AWS; Damji & Lee, 1995),
“Islamic Attitudes Towards Women Scale” (IAWS; Khalid
& Hanon Frieze, 2004), Suzuki Egalitarian Sex Role
Attitudes scale (SESRA; Uji, Shono, Shikai, Hiramura, &
Kitamura, 2006), and Neosexism scale (Tougas, Brown,
Beaton, & Joly, 1995). As the McHugh and Frieze (1997)
reviewed the issue, “the current questions and issues may
not be the same ones we were interested in measuring in the
1970s” or a scale regarding gender-role attitudes developed
in one culture may not be “adequate or appropriate for use
in other parts of the world” (p. 3). Thus, selecting a measure
among the available scales may be a tedious task. The
Gender Roles Attitude Scale (GRAS) developed by
Zeyneloğlu and Füsun (2011), which is the only instrument
available in Turkish language with proven validity and reli-
ability on this subject matter, is used in this study. GRAS
adequately covers various dimensions of culturally relevant
gender-role attitudes which we hypothetically proposed to
mediate ADHD’s effect on marital problems.
In this study, to run a test on how “gender-role issues”
reflect on the effect of ADHD on marriage differentially for
men and women, as Robin and Payson (2002) suggested,
we have examined “gender roles” in couples, where one of
the partners has ADHD, in an attempt to find out whether gen-
der roles mediate the negative effects of ADHD on relation-
ships. Under the light of the existing literature, we set out to
test a number of hypotheses expecting the following results:
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Hypothesis 1: The severity and negative marital impact
of ADHD are correlated.
Hypothesis 2: The marital impact of ADHD is greater in
couples where the ADHD partner is female.
Hypothesis 3: The impact of ADHD is greater among
those with more traditional gender roles.
Hypothesis 4: Gender roles mediate the impacts of
ADHD on marriage.
Method
Participants
Married couples from among the patients who admit to the
Psychiatry Department of a University Hospital, where the
researcher works, for ADHD evaluation and treatment were
successively included in the study. Before passing on to the
treatment phase, pre-evaluations were made during the ini-
tial application using the measurement tools introduced
below. A total of 61 ADHD patients, 18 (29.5%) females
and 43 (70.5%) males, and their partners, were included in
the study. The average age of the ADHD spouses was 38.03
(range: 21-62) while that of the non-ADHD spouses was
36.71 (range: 18-65). Eighteen (29.5%) ADHD spouses had
the Inattentive Subtype, nine (14.8%) had the Hyperactive–
Impulsive Subtype, and 34 (55.7%) had the Combined
Subtype. Out of 61 patients, two (both woman) received
ADHD diagnosis in childhood that persisted in adulthood.
Twenty of the patients (35.1%) had been previously diag-
nosed having generalized anxiety disorder (4.9%), major
depression (18%), depression and anxiety disorder (3.3%),
obsessive compulsive disorder (1.6%), obsessive compul-
sive disorder and depression (1.6%), and panic disorder
(3.3%). In terms of current comorbid psychiatric disorders,
21.3% received diagnosis of major depression (6.6%), dys-
thymic disorder (8.2%), and generalized anxiety disorder
(8.2%). As an initial psychopharmacological treatment,
75.4% were prescribed with long-acting methylphenidate,
16.4% with short-acting methylphenidate, 1.6% with atom-
oxetine/long-acting methylphenidate combination, and
1.6% with citalopram. Combination treatment with various
antidepressant and antipsychotic drugs were prescribed to
13.1% and 4.9% of the patients, respectively.
Measures
GRAS.  The validity and reliability studies of GRAS for the
Turkish language was performed by Zeyneloğlu and Füsun
(2011). The Cronbach’s alpha reliability coefficient of the
GRAS was .92. The GRAS is a 38-item, 5-point Likert-type
scale with the options of strongly disagree, disagree, unde-
cided, agree, and strongly agree. The maximum and mini-
mum scores that can be taken from the scale are “190” and
“38,” respectively. The higher values obtained from the scale
Ersoy and Ersoy 3
indicate an egalitarian attitude toward gender roles, while
lower ones point out to a more traditional attitude toward
the same. Gender roles are examined in five dimensions in
the scale, including egalitarian gender roles (Statements 4,
8, 12, 13,18, 20, 22, and 27), female gender roles (State-
ments 1, 5, 16, 19, 21, 29, 31, and 37), marriage gender
roles (Statements 2, 6, 9, 10, 14, 15, 26, and 36), traditional
gender roles (Statements 3, 7, 11, 17, 23, 24, 25, and 32),
and male gender roles (Statements 28, 30, 33, 34, 35, and
38). “Egalitarian gender roles,” “female gender roles,”
“marriage gender roles,” and “traditional gender roles”
dimensions can receive a maximum score of “40” and a
minimum score of “8.” The maximum score that the “male
gender role” dimension can receive is “30,” whereas the
minimum is “6.”
The DSM-IV-Based Diagnostic Screening and Rating Scale. The
“Turgay’s Adult ADD/ADHD DSM IV-Based Diagnostic
Screening and Rating Scale” consists of the “Attention Def-
icit” (AD) and “Hyperactivity/Impulsivity” (HI) sections
based on the 18 signs/symptoms as specified by the DSM-
IV diagnostic criteria and the “ADHD-related characteris-
tics” (RC) subscales that the clinician developed taking
their own clinical experiences and observations as a starting
point (Turgay, 1995). There are nine questions in each of the
AD and HI sections and 30 questions in the ADHD-related
problems (RC) section of the scale. This is a 5-point Likert-
type rating scale where the statements/questions have scores
of 0 to 3 points based on the severity of the symptom that is
probed into. The AD score is obtained by totaling the points
taken from the nine questions in the first section. According
to the Diagnostic and Statistical Manual of Mental Disor-
ders (5th ed.; DSM-5; American Psychiatric Association,
2013) criteria, if a person submits a response of 2 or 3 to at
least five of the nine questions in Section 1, they are given
the diagnosis of ADHD-AD. The total HI score is obtained
by summing up the points obtained in the second section.
According to the DSM-5 criteria, if a response of 2 or 3 is
given to at least five of the nine questions in Section 1, a
diagnosis of ADHD-HI is established. A diagnosis of
ADHD-C is established when a response of 2 or 3 is pro-
vided to at least five questions in both sections. Günay et al.
(2006) conducted a research on the validity and the reliabil-
ity of the scale in the Turkish language. In this study, the
researchers state that score less than 20 in the grand total
have mild signs of ADHD, score between 20 and 59 have
moderate signs of ADHD, and score over 59 have high lev-
els of ADHD symptoms.
MIC.  The MIC is a questionnaire of 34 items devised by
Robin and Payson (2002) to assess both ADHD and non-
ADHD partners’ perception of the effects of ADHD-related
behaviors on marriage. The items tapping ADHD-related
behaviors are articulated appropriately for the patient and
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their partner (i.e., “I don’t respond when spoken to,”
“Doesn’t respond when spoken to”). The MIC consists of
three sections. The first section inquiries whether an ADHD-
related behavior is present or not (no, yes); the second and
the third section asks whether this behavior “makes you feel
unloved, unimportant, or ignored?” and “How negatively
does this impact your marriage?” respectively, in the Likert-
type format (1 = not at all; 2 = a little; 3 = somewhat; 4 = a
lot; 5 = very much). Three types of scores are calculated for
each partner: the “Number of Issues” score, the “Unloved”
score, and the “Negative Impact” score. The minimum and
maximum scores in the “Number of Issues” scale is 0 to 34;
in the “Unloved” and “Negative Impact” scales, the average
means are calculated, and the minimum and maximum
scores range from 1 to 5. Several difficult-to-understand
items are back translated into English and discussed with
the author of the original questionnaire to decide upon the
final wording. The psychometric properties of the Turkish
version are given below.
Results
Psychometric Properties of the MIC–Turkish
Version
To determine the internal consistency of the Turkish version
of the MIC, the Kuder–Richardson coefficient is computed
for the “Number of Issues” scores, and the Cronbach’s
alpha is computed for the Unloved and Negative Impact
scores. This calculation is performed for both the ADHD
patient and their spouse as respondents. The alpha coeffi-
cient for the Number of Issues is .905 for the ADHD patient
and .876 for the Spouse. The alpha coefficient for the
Unloved Scale of the ADHD respondent is .959, whereas
the same is .950 for the Negative Impact Scale of the ADHD
respondent. The alpha coefficient computed for the Unloved
Scale of the Spouse is .950, and for the Negative Impact
Scale of the Spouse, it is .955.
The item-total correlations of the “I don’t respond when
spoken to,” “I can’t sit still for very long,” and “I get easily
bored” statements are lower than .2 in the Number of Issues
Scale for the ADHD respondent. The item-total correlations
of the “Doesn’t respond when spoken to,” “Tolerates too
much and then blows up inconsistently,” “Loses temper
over unimportant things,” “Takes out frustrations on me,”
“Has trouble dealing with frustration,” and “Can’t sit still
for very long” statements are lower than .2 in the Number of
Issues Scale for the non-ADHD respondent. The item-total
correlations of the “I don’t respond when spoken to” and “I
have difficulty making eye contact during conversations”
statements in the Unloved and Negative Impact Scales are
found to be low for the ADHD respondent. The item-total
correlations in the Unloved and Negative Impact Scales for
the non-ADHD respondent ranged between .317 and .827
4 Journal of Attention Disorders 

Table 1.  Marital Impact Checklist Scores of ADHD Respondents and Non-ADHD Respondent Spouses.

ADHD respondent Non-ADHD respondent

  Number of issues Unloved Negative impact Number of issues Unloved Negative impact
N (valid) 62 62 62 62 62 62
M 20.82 1.90 1.81 19.73 2.01 1.99
SD  7.06 0.75 0.75  7.37 0.87 0.92
Minimum  4.00 0.76 0.32  1.00 0.85 0.09
Maximum 34.00 4.44 4.21 33.00 4.03 4.15

and between .334 and .803, respectively. Taking into Table 2.  The Top 10 Ranked Items and Mean Scores That
account the clinical usability and importance of the items, Make the Non-ADHD Spouse Feel Unloved, Unimportant,
internal consistency values, and sound item-total correla- Ignored.
tions for the non-ADHD spouse, none of the items of the ADHD Non-ADHD
scale has been deleted in the Turkish Version. partner partner
Two of the items related to raising children are irrelevant
for some of the couples, and the total scores of these cou- The items in the Top 10 as rated by  
both the ADHD and non-ADHD
ples were incomparable with those of couples with children.
partners
Thus, we preferred calculating the mean scores instead of   Loses temper over unimportant 2.35 2.78
the total scores for the “Unloved” and “Negative Impact” things
scales. Table 1 represents the total and mean scores of the   Makes the same mistakes over and 2.30 2.63
ADHD respondents and non-ADHD respondent spouses. over again
Tables 2 and 3 present the 10 highest ranked Unloved   Doesn’t remember being told things 2.47 2.58
and Negative Impact items, respectively. Six of the 10 high-   Tolerates too much and then blows 2.92 2.44
est ranked items in the “Unloved” list and seven of the items up inconsistently
in the “Negative Impact” list were identical on each spouse’s   “Zones out” in conversations 2.60 2.36
list. The “Losing temper over unimportant things” state-   Gets easily bored 2.28 2.35
ment, which is an affective dysregulation symptom, is rated The items in the Top 10 as rated only by the ADHD partner
by both partners as the most important ADHD-related   Has trouble getting started on a task 2.49 —
symptom making “the non-ADHD spouse feel unloved,   Says things without thinking 2.27 —
unimportant, and ignored” and having a “negative impact”   Tries to do too much in a short time 2.34 —
  Forgets to record checks in the 2.17 —
on marriage.
check register
The items in the Top 10 as rated only by the non-ADHD
The factor structure of the MIC.  We used a series of explana- partner
tory factor analysis for ADHD and non-ADHD spouses’ rat-   Doesn’t respond when spoken to — 2.31
ings of the “Number of Issues,” “Unloved,” and “Negative   Takes out frustrations on me — 2.27
Impact” subscales of the MIC with varimax rotation to   Depends on me to keep organized — 2.22
extract factors. Repeated analyses yielded eight to 10 fac-   Doesn’t finish household projects — 2.20
tors, while items loading variably to factors. We analyzed
the five factors of “Communication,” “Time Management,”
“Impulsivity/Emotionality,” “Poor Task Completion,” and factors in both the “Unloved” and “Negative Impact” rat-
“Disorganization” based on our clinical observations. Using ings of both the ADHD patient and the spouse. “Doesn’t
the ratings of the non-ADHD spouses, the items were dis- respond when spoken to,” “‘Zones out’ in conversations,”
tributed to these factors reasonably and with communalities “Doesn’t remember being told things,” and “Has difficulty
that ranged between 0.416 and 0.901. An item was consid- making eye contact during conversations” were loaded in
ered to load onto a factor if its factor loading score exceeded Communication; “Forgets appointments or other commit-
0.30. In the factor analysis of the ratings of the non-ADHD ments,” “Can’t get things done unless there is an absolute
spouses, five items loaded more than one factor. (An item deadline,” “Has trouble getting started on a task,” and
was considered to be loaded onto more than one factor if its “Depends on me to keep organized” in Time Management;
factor loading score exceeded 0.30 on more than one factor “Loses temper over unimportant things,” “Takes out frustra-
and if the difference between the factor loadings was less tions on me,” and “Has trouble dealing with frustration” in
than 0.10.) Fifteen of the items loaded similar to the same Impulsivity/Emotionality; “Is chronically late” and “Takes on

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Ersoy and Ersoy 5

Table 3.  The Top 10 Ranked Items and Mean Scores That parameters. In terms of spouses’ report of Marital Impact,
Were Stated to Have a “Negative Impact” on Marriage. only spouses’ report of “feeling unloved, unimportant, or
ADHD Non-ADHD ignored” is found to be negatively correlated with total AD
partner partner score of the patient (r = −.268; p < .037).

The items in the Top 10 as rated by  

both the ADHD and non-ADHD Testing the Hypothesis: Is the Marital Impact of
partners ADHD Is Greater in Couples Where the ADHD
  Loses temper over unimportant 2.46 2.82
things
Partner Is Female?
  Makes the same mistakes over and 2.32 2.73 We compared the three MIC scores of the male versus
over again female spouses of ADHD patients. As summarized in Table
  Tolerates too much and then blows 3.14 2.64 4, we found no differences between the patients’ ratings of
up inconsistently
all three scores, but there was a statistically significant dif-
  Doesn’t remember being told things 2.32 2.41
ference between the ratings of the female and male non-
  Has trouble getting started on a task 2.40 2.34
ADHD spouses. Female non-ADHD spouses rated a higher
  Says things without thinking 2.38 2.36
number of ADHD-related behaviors and rated higher mean
  Gets easily bored 2.14 2.27
The items in the Top 10 as rated only by the ADHD partner
scores of “feeling unloved, unimportant, or ignored” and
  Tries to do too much in a short time 2.40 — “negative impact on their marriage.”
  “Zones out” in conversations 2.26 —
  Has trouble dealing with frustration 2.13 —
The items in the Top 10 as rated only by the non-ADHD Testing the Hypothesis: Is the Impact of ADHD
partner Is Greater Among Those With More Traditional
  Doesn’t watch our children carefully — 2.35 Gender Roles?
  Can’t get things done unless there is — 2.33
an absolute deadline The relationship between Gender Roles scores and Marital
  Leaves a mess — 2.30 Impact Scale scores of both ADHD patients and non-ADHD
  Doesn’t respond when spoken to — 2.30 spouses has been analyzed. First of all, we investigated
ADHD spouses’ ratings of Gender Roles. The egalitarian
Gender Roles, Female Gender Roles, Male Gender Roles,
too many commitments” in Poor Task Completion; “Tries and total Gender Role scores of the ADHD patients are cor-
to do too much in a short time” and “Underestimates the related with the Mean Unloved rating of the patients (r =
time needed to complete a task” in Disorganization factors .276, p < .05; r = .414, p < .001; r = .427, p < .001; r = .365,
similarly in “Unloved” and “Negative Impact” subscales of p < .01). The Female Gender Roles, Male Gender Roles,
both the patient and the non-ADHD partner. The other items and total Gender Role scores are correlated with the Mean
loaded in various factors in the subscales of MIC. The Negative Impact ratings of the patients as well (r = .412,
details of these series of factor analyses are not given p < .001; r = .356, p < .01; r = .334, p < .01). Interestingly,
because we decided that further data and studies are required the Marriage Gender Role Scores and Male Gender Role
to identify the factor structure of the MIC. As a final consid- Scores of the patients are negatively correlated with the
eration, we decided to use the scale as a single-factor scale number of ADHD-related behaviors articulated by the non-
in this study. ADHD partners (r = −.282*, p < .05; r = −.274*, p < .05).
The Marriage Gender Roles of the patients are also nega-
tively correlated with the Mean Unloved and Mean Negative
Testing the Hypothesis: Is the Severity and
Impact ratings of the non-ADHD spouses (r = −.281, p <
Negative Marital Impact of ADHD Correlated? .05; r = −.259, p < .05).
To test the hypothesis, the correlations of the severity The non-ADHD spouses’ ratings of Gender Roles seem
parameters of ADHD (Number of AD criteria met; number to be less effective on the Marital Impact of ADHD. The
of HI criteria met; total number of AD + HI criteria met; total Male Gender Roles of the non-ADHD spouses are corre-
AD score; total HI score; total ADHD-RC score; total AD + lated with a number of ADHD-related behaviors stated by
HI score; and total AD + HI + RC score) with MIC scores the patients (r = .295, p < .05), and Traditional Gender
(number of ADHD-related behaviors; mean scores of “feel- Roles of the non-ADHD spouses are correlated with the
ing unloved, unimportant, or ignored” and “negative impact mean Negative Impact rating of the patients (r = .256, p <
on their marriage”) have been calculated. Severity of ADHD .05). On the other side, none of the Gender Role subdomain
is found to be correlated significantly (p < .001) with reported ratings of the non-ADHD spouses is related to the Marital
marital impact of the patient in all calculations of mentioned Impact ratings of the non-ADHD spouses.

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6 Journal of Attention Disorders 

Table 4.  The Relationship Between Non-ADHD Spouses’ Sex and Each Partner’s Ratings of Marital Impact.

Male non-ADHD spouse Female non-ADHD

(n = 18) spouse (n = 43)

  M SD M SD t Significant
ADHD spouse ratings
  Number of issues 21.06 5.05 20.60 7.84 −.225 .823
  Mean unloved rating  1.89 0.83  1.89 0.73 0.003 .997
  Mean negative impact rating  1.84 0.72  1.84 0.72 0.491 .625
Non-ADHD spouse ratings
  Number of issues 16.61 7.82 20.88 6.90 2.119* .038
  Mean unloved rating  1.42 0.54  2.23 0.87 3.611** .001
  Mean negative impact rating  1.31 0.60  2.25 0.90 4.085*** .000

*p < .05. **p < .01. ***p < .001.

Table 5.  The Relationship Between Sex and ADHD Symptom Severity of Patients.

Females (n = 18) Males (n = 43)

Patients’ ADHD criteria met and scores in
the adult ADD/ADHD scale M SD M SD t Significant
Number of AD criteria met 6.56 2.09 4.84 3.12 2.136* .037
Number of HI criteria met 4.72 2.84 4.14 3.10 0.686 .496
Total number of AD + HI criteria met 11.28 3.82 8.98 5.42 1.636 .107
Total AD score 18.39 5.33 14.67 5.98 2.282* .026
Total HI score 15.00 7.19 12.37 6.58 1.384 .171
Total RC score 54.06 15.33 42.02 16.92 2.601* .012
Total AD + HI score 33.39 10.40 27.05 10.96 2.092* .041
Total AD + HI + RC score 87.44 24.20 69.07 26.86 2.506* .015

Note. Adult ADD/ADHD scale = Turgay’s Adult ADD/ADHD DSM IV-Based Diagnostic Screening and Rating Scale; AD = Attention Deficit;
HI = Hyperactivity/Impulsivity; RC = ADHD-related characteristics.
*p < .05.

Other Variables Related With the Sex of the
Patient
Sex and severity of ADHD.  There are other variables seem to
be effected by sex. As depicted in detail in Table 5, female
patients present with more severe symptoms of ADHD, in
this study population. The total numbers of items of inatten-
tion present and total inattention scores are significantly
higher in female patients. The total inattention and HI
scores are also significantly higher in female patients.
Sex and gender roles. As portrayed in detail in Table 6,
female patients are more egalitarian than male patients,
while there is no difference in sex roles between non-ADHD
male and female spouses. A closer look at Table 6 reveals
that although women in general are more egalitarian than
men, female patients are more egalitarian than their male
nonpatient spouses, and male patients are less egalitarian
than their female non-ADHD spouses.
The Relationship Between Gender Roles and
Severity of ADHD
We analyzed the relationship between severity of ADHD
and Gender Roles of the patients and spouses. As shown in
detail in Table 7, the severity of ADHD is correlated with
most of the subdomains of the Gender Roles of the ADHD
patient. The more severe the ADHD, the more egalitarian
the patients become. Only the “Male Gender Role” subdo-
main rating of the non-ADHD Spouses is correlated with
the ADHD severity scores.
Testing the Hypothesis: Do Gender Roles
Mediate the Marital Impacts of ADHD?
Whatever the reason is, male patients’ being less egalitarian
than female patients (Table 6) may have caused the female
non-ADHD spouses’ rating a higher number of ADHD-
related behaviors and higher mean scores of “feeling unloved,

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Ersoy and Ersoy 7

Table 6.  The Relationship Between the Sex and Gender Roles of the Patients.
GR scores

Female patients (n = 18) Male patients (n = 43)

Patients’ GR scores M SD M SD t Significant
Egalitarian 36.00  4.50  32.49  6.25 2.106* .040
Female 33.88  4.47  28.72  7.09 2.783** .007
Marriage 37.29  3.12  32.63  4.16 4.178 .000
Traditional 33.71  4.61  26.14  5.92 4.724*** .000
Male 25.65  3.89  23.30  4.22 1.980 .052
Gender Roles−Total Score 166.53 16.89 143.28 22.32 3.871*** .000

Male spouse Female spouse

GR scores of non-ADHD
spouses M SD M SD t Significant
Egalitarian 35.28  4.03  36.57  3.82 −1.183 .242
Female 31.56  6.00  31.45  6.54 0.057 .954
Marriage 35.61  3.70  36.93  2.80 −1.514 .135
Traditional 31.44  5.46  30.57  5.50 0.565 .574
Male 26.00  3.68  25.74  3.60 0.256 .798
Gender Roles−Total Score 159.89 19.27 161.26 18.24 −.263 .794

Note. GR = gender roles.

*p < .05. **p < .01. ***p < .001.

unimportant, or ignored” and “negatively impact on their
marriage” (Table 4). To test this hypothesis taking Marital
Impact Scores as a dependent variable, we conducted a
series of linear regression analysis and sex and Gender Role
subscale scores entered into model as independent vari-
ables. The “Number of Issues,” “Mean Unloved Rating,”
and “Mean Negative Impact Rating” scores of the patient
and non-ADHD spouse are used as dependent variables in
repeated regression analyses. The results of the regression
analyses are given in Table 8.
In the light of the regression analyses, female and male
Gender Roles of the patients seem to explain the patients’
ratings of their partners’ feeling unloved; female Gender
Roles of the patients seem to explain the patients’ ratings of
“Negative Impact” on marriage, irrespective of sex. Patients’
Male Gender Role explains non-ADHD partners’ reported
Number of Issues, irrespective of sex; Patients’ Traditional
Gender Role along with the Sex explains non-ADHD
spouses’ ratings of feeling unloved; and Sex of the patient
seems to explain non-ADHD spouses’ rating of Negative
Impact.
After the regression analyses,
1. Egalitarian Gender Role attitudes of the patients are
no more significantly related to the patients’ reports
of their spouses’ feeling “Unloved”;
2. Male Gender Role attitudes of the patients are no
more related to the patients’ reports of the “Negative
Impact”;
3. The patients’ Marriage Gender Role is no more
related to the number ADHD-related behaviors
reported by non-ADHD spouse; and no more related
to non-ADHD spouses’ ratings of feeling “Unloved”
and the “Negative Impact”;
4. The non-ADHD spouses’ reported Traditional
Gender Roles are no more related to the patient
reports of “Negative Impact”;
5. After controlling for gender, the Traditional Gender
Role attitudes reported by the patients became sig-
nificantly related to non-ADHD spouses’ ratings of
feeling “Unloved”; and finally
6. The Sex of the patient is no more significantly
related to the number of ADHD-related behaviors
reported by the non-ADHD partner.
Discussion
In this study, the Turkish version of the MIC is found to
have good internal consistency. Four items tapping deficits
in completing tasks, working memory, and managing time
(“Doesn’t remember being told things”; “Has trouble get-
ting started on a task”; “Tries to do too much in a short
time”; “Doesn’t finish household projects”); three items
tapping communication (“‘Zones out’ in conversations”;
“Says things without thinking”; “Doesn’t respond when
spoken to”); and one item tapping self-regulation of affect
(“Tolerates too much and then blows up inconsistently”), as
identical to the Robin and Payson’s (2002) report, are in the

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8 Journal of Attention Disorders 

Table 7.  The Relationship Between “Gender Roles” and Severity of ADHD.
Egalitarian GR Female GR Marriage GR Traditional GR Male GR Total GR score

  r Significance r Significance r Significance r Significance r Significance r Significance

ADHD spouses’ ratings of Gender Roles

  No. of AD criteria met .143 .274 .313* .015 .064 .628 .173 .185 .084 .525 .204 .117
  No. of HI criteria met .213 .102 .317* .014 .155 .238 .247 .057 .319* .013 .304* .018
  Total number of AD + HI .210 .107 .371** .004 .129 .325 .248 .056 .238 .067 .300* .020
criteria met
  Total AD score .137 .297 .314* .015 .074 .576 .221 .090 .083 .529 .218 .095
  Total HI score .232 .074 .299* .020 .209 .108 .259* .045 .322* .012 .318* .013
  Total RC score .252 .053 .369** .004 .292* .024 .307* .017 .259* .045 .361** .005
  Total AD + HI score .217 .096 .353** .006 .169 .197 .279* .031 .243 .061 .313* .015
  Total AD + HI + RC score .248 .056 .378** .003 .253 .051 .308* .017 .263* .042 .356** .005
Non-ADHD spouses’ ratings of Gender Roles
  No. of AD criteria met −.103 .432 .067 .613 .064 .628 .159 .224 .269* .037 .112 .395
  No. of HI criteria met −.049 .710 .020 .878 .107 .417 .105 .424 .303* .019 .105 .424
  Total number of AD + HI −.089 .497 .051 .699 .100 .445 .155 .236 .337** .009 .127 .332
criteria met
  Total AD score −.109 .408 .064 .630 .113 .388 .220 .091 .313* .015 .145 .270
  Total HI score −.041 .755 .048 .717 .074 .572 .152 .247 .338** .008 .131 .317
  Total RC score −.079 .549 .020 .879 .004 .977 .159 .226 .249 .055 .087 .511
  Total AD + HI score −.085 .521 .064 .628 .107 .415 .213 .102 .377** .003 .159 .225
  Total AD + HI + RC score −.085 .521 .039 .769 .046 .726 .187 .151 .311* .015 .120 .362

Note. GR = gender roles; AD = Attention Deficit; HI = Hyperactivity/Impulsivity; RC = ADHD-related characteristics.

*p < .05. **p < .01.

top 10 list of ADHD behaviors rated by either the patient or
non-ADHD spouse that make the non-ADHD spouse feel
unloved, unimportant, ignored.
Female non-ADHD spouses in this study reported a
more negative impact in their marriage than males. This
finding is along the same line with the results of other stud-
ies stating that problems in marital relationships affect
women’s psychological well-being more than men’s
(Hafner & Spence, 1988; Whitton & Kuryluk, 2012).
However, our finding is just opposite to Robin and Payson’s
(2002) preliminary findings on the “MIC.” These authors
supposed that the gender difference in their study may be
related to ADHD behaviors impeding females more than
males from fulfilling gender-role expectations imposed on
them by the modern Western society, as suggested by
Solden (1995). Although the city of Izmir in Turkey, where
this study was conducted, is culturally similar to most
Western countries, there may still be some cultural differ-
ences that may help explain our results. The way the patients
recruited to the study may have affected the difference of
our results from Robin and Payson’s study, as well. It is our
clinical observation that women mostly have the primary
role in leading the couple to therapy in a marriage. This may
explain why in our sample the female non-ADHD partners
report feeling of “Unloved” and “Negative Impact” more
than their male counterparts.
The severity of ADHD does not seem to explain gender
differences in our study as female patients in this study pre-
sented with more severe symptoms of ADHD. Gender-role
variables of the patients were negatively correlated with
non-ADHD spouses’ ratings of the MIC; that is, the less
egalitarian the patient is, the more negative impact of
ADHD on the marriage has been reported by the spouse.
However, the more egalitarian the patient is, the more nega-
tive impact is felt by the patient himself or herself. These
findings point out clearly that community gender roles
affect how ADHD-related behaviors convert to negative
feelings in the patient and the spouse.
Interestingly, male patients in our study are married to
egalitarian women, while female patients and their hus-
bands are equally egalitarian. Other studies made in non-
clinical groups regarding Gender Roles in Turkey revealed
that females clearly have more egalitarian role attitudes
than males (Öngen & Aytaç, 2013; Vefikuluçay, Zeyneloğlu,
Eroğlu, & Taşkın, 2007). In our study, we did not have a
comparison group of couples without any ADHD partner,
so it is not possible to say whether this difference is specific
to women with ADHD and their non-ADHD partners.
Nevertheless, we suggest two possible explanations to this
gender difference. Either having ADHD makes females
more egalitarian and males less egalitarian, or female ADHD
patients prefer marrying to more egalitarian males. ADHD
women and their more egalitarian male partners probably
accommodate better to difficulties of ADHD due to women’s
incapacity to comply with traditional gender roles. Many
researchers argue that men and women differentially prefer
certain characteristics when evaluating a potential partner. It is
reported that men express greater preference for physical

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Ersoy and Ersoy 9

Table 8.  The Results of the Regression Analyses.

Dependent variables

  ADHD patient Non-ADHD spouse

No. of issues Unloved Negative impact Number of Unloved Negative impact

(R2 = .068; (R2 = .282; (R2 = .252; issues (R2 = .180; (R2 = .268; (R2 = .242;
  significance = .693) significance = .006) significance = .014) significance = .091) significance = .009) significance = . 019)

Independent variables Beta significance Beta significance Beta significance Beta significance Beta significance Beta significance

Sex −.076 .646 .011 .940 .063 .672 .273 .084 .496** .001 .485** .002
ADHD patient
  Egalitarian GR .040 .842 −.079 .656 −.115 .525 .205 .281 .242 .180 .247 .178
  Female GR .312 .213 .472* .035 .570* .013 −.102 .661 −.268 .229 −.153 .498
  Marriage GR −.211 .301 −.203 .258 −.133 .467 −.262 .174 −.210 .246 −.209 .257
  Traditional GR −.158 .556 −.231 .326 −.255 .290 .430 .090 .560* .021 .272 .262
  Male GR .062 .759 .455* .013 .328 .076 −.385* .048 −.312 .088 −.076 .679

  ADHD patient Non-ADHD spouse

Number of issues Unloved Negative impact Number of issues Unloved Negative impact
(R2 = .117; (R2 = .091; (R2 = .107; (R2 = .147; (R2 = .223; (R2 = .240;
  significance = .097) significance = .516) significance = .398) significance = .191) significance = .031) significance = .020)

  Beta Significance Beta Significance Beta Significance Beta Significance Beta Significance Beta Significance

Sex −.032 .807 .025 .857 .109 .434 .353* .012 .462** .001 .489*** .000
Non-ADHD spouse
  Egalitarian GR .138 .365 .032 .840 −.034 .829 −.020 .897 .092 .534 .079 .587
  Female GR −.304 .147 −.180 .413 −.163 .453 −.241 .257 .059 .770 −.094 .638
  Marriage GR −.116 .518 −.156 .406 −.171 .360 −.233 .204 −.152 .382 −.100 .561
  Traditional GR −.127 .589 .270 .278 .347 .162 .223 .355 .009 .967 .015 .946
  Male GR .605** .004 .246 .243 .215 .304 .061 .766 −.070 .718 .078 .684

Note. R2 and the significance of the model for subscales of the Marital Impact Checklist as dependent variables are given at the top of the columns; Gender Role subdomain
scores of the ADHD patients are taken as independent variables. GR = gender roles.
*p < .05. **p < .01. ***p < .001.

attractiveness than women, and women value social status or
position more than men (Feingold, 1992; Kenrick, Sadalla,
Groth, & Trost, 1990; Regan & Berscheid, 1997; Sprecher,
Sullivan, & Hatfield, 1994). Parallel to the general preferen-
tial differences of men and women, it is also probable that
female ADHD patients in our study group choose egalitarian
men that would tolerate their ADHD behaviors. However,
men did not make a similar consideration of the marital
choice the way their female counterparts did.
In this study, the gender-role attitudes of the ADHD
patients were correlated with the severity of ADHD. This
was true only for the “Male Gender Role” subdomain in the
non-ADHD partners. One of the long-time consequences of
untreated ADHD may be the change in gender roles. When
the non-ADHD partner is considered, we suggest that living
together with an ADHD partner may have affected “Male
Gender Role Attitudes” of the non-ADHD partner.
Finally, we conducted a series of regression analyses to
investigate the “Gender Roles” as a mediating factor of the
ADHD’s impact on marriage. As a result of the regression
analyses performed, we can assert that some subdomains of
the Gender Roles of both the patient and their non-ADHD
spouse seem to mediate the effect of adult ADHD’s impact on
marriage at least to some extent. A recent study investigating
the mediator role of gender-role attitudes stated that gender-
role attitudes mediate the relationship between psychological
well-being and marital adjustment (Yüksel & Dağ, 2015).
That is, gender-role attitudes affect psychological health of
women along with the quality of marital relationship.
Although not directly related to adult ADHD, findings of
Yüksel & Dağ support our results that gender roles mediate
marital outcome of daily stressors provoked by ADHD.
As Murphy (2005) stated, “exploring the marital rela-
tionship from an ADHD standpoint can offer renewed hope
for real change” (p. 613). Although psychoeducational fam-
ily programs targeting children and adolescents with ADHD
have been conducted (Montoya, Colom, & Ferrin, 2011),
research about psychosocial interventions designed for
adults with ADHD, involving significant others, is scarce.
Study done by Hirvikoski, Waaler, Lindström, Bölte, and

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10 Journal of Attention Disorders 
Jokinen (2015) involving spouses among significant others
reported “a reduction in the subjective burden of care, such
as worry and guilt” (p. 89). Findings in our study suggest
such studies of psychosocial interventions designed in the
future should also take into account the gender-role atti-
tudes as a contributing factor to the problems in the relation-
ship. There are some limitations in our study. First, the
clinic-based participants were recruited in a university hos-
pital in a culturally Westernized city of Turkey; thus, the
results might not be generalized to other geographic areas in
Turkey. Second, because of successive inclusion and lack of
comparison group, couples in this study may not represent
all couples with an ADHD spouse. Third, a structured clini-
cal interview is not used to evaluate the current or past
comorbid psychiatric diagnoses. Comorbid Axis II disorders
are also not evaluated in our study. Compared with adults
without ADHD, adults with ADHD are reported to have
higher rates of both Axis I (46.9% and 27.31%) and Axis II
(50.7% and 38.2%) disorders (Cumyn, French, & Hechtman,
2009). Comorbidity is proposed to lead to misdiagnosis and
underdiagnoses of ADHD in adults (Ginsberg, Quintero,
Anand, Casillas, & Upadhyaya, 2014; Newcorn, Weiss, &
Stein, 2007). Despite its limitation, our study group seem to
have lower rates of Axis I diagnoses. Thus, it is difficult to
draw conclusions about how ADHD with comorbid other
psychiatric disorders may influence the relationship. Future
studies taking into account comorbidity, especially Axis II
comorbidity, can make valuable contributions.
Conclusion
This study investigated the psychometric properties of the
Turkish version of the MIC, which is the only instrument
available in Turkish on this subject matter. Although further
validation and investigation of the factor structure of the
MIC are required, this study suggests that the checklist has
utility in research and clinical work with ADHD couples.
This is the first study investigating the “Gender Roles”
as a mediator of ADHD’s negative impacts on marriage.
Although the results of this study require further validation,
we conclude that clinicians and psychotherapists working
on marital problems in couples with an ADHD partner
should pay attention to gender roles. Further studies about
effectiveness of psychosocial interventions should consider
involving issues related to gender roles.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Downloaded from jad.sagepub.com at Middle East Technical Univ on April 29, 2016
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Author Biographies
Mehmet A. Ersoy, MD, is an professor of Department of
Psychiatry at Ege University, Izmir, Turkey. Dr. Ersoy is leading
the outpatient clinic and he is the coordinator of ADHD Program
of Department of Psychiatry at University Hospital. His research
interests include the study of ADHD in adulthood.
Hatice Topçu Ersoy, PhD, is psychologist of Psikoaktif Center of
Family Counselling and Assistant Professor and Lecturer at
Faculty of Health Sciences, Department of Social Work, Gediz
University, Izmir, Turkey. Her research is focused on marrital
counselling.