Need to know

Do you have a child with ADHD who makes impulsive decisions or reacts without thinking? Then you probably have a few extra grey hairs from worrying about whether they will break a bone from all the risky climbing or from regularly mopping up a flooded bathroom!

Not everyone with ADHD experiences the same levels of impulsivity, hyperactivity, and distractibility, and to reflect that, an ADHD diagnosis is now categorised into three different presentations: predominantly inattentive; predominantly hyperactive-impulsive; and combined.

In all ADHD presentations, it is believed that parts of the brain work and look differently from typical brains. There is evidence to support that inattentive and hyperactive/impulsive presentations are each connected to different parts of the brain and influenced by different neurotransmitters (chemicals messengers that carry signals in your brain): impulsive/hyperactive type is affected specifically by dopamine and inattentive type by noradrenaline/norepinephrine. This discovery, along with evidence that shows stimulant medication is more effective for children with impulsive/hyperactive or combined type, is useful when evaluating the best treatments for your child

Scientists agree that ADHD impacts vital brain functions including attention, planning & organisation, mental flexibility, inhibition (impulse control), abstract reasoning, self-monitoring, and working memory. Our ability to meet daily and long-term goals is predicated on all these functions working well together to accomplish tasks. 

Inhibition, or inhibitory control, is defined as “the ability to control one’s attention, behaviour, thoughts, and/or emotions to override a strong internal predisposition or external lure, and instead do what is more appropriate or needed”.  

Scientists believe that inhibition can be broken down into two components that develop differently:

• Response inhibition – This relates to what you know as self-control and our ability to resist temptation (like wanting to eat another cupcake) and our capacity to resist acting impulsively (like retaliating physically or verbally immediately after we perceive we have been attacked); and
• Interference control – This refers to our ability to direct our attention where it is needed at a particular time in order to accomplish a task and not letting unnecessary or unwanted thoughts or memories bother us.

Research on inhibition control is evolving with various theories on the mechanics of inhibition control in children with ADHD. The key themes still being explored by researchers include: 

Difficulties processing information – Children with ADHD have been shown to have less capacity to process relevant environmental information which impacts their executive functioning and their ability to control impulses. 

Emotional control – Negative emotional situations, particularly those that trigger anger and frustration, have been shown to have a greater impact on children’s ability to control their responses. It’s thought that this is because emotional processing consumes mental resources, and potentially changes the dopamine response needed for self control. 

Processing emotional content – Some studies have looked specifically at a child’s ability to accurately infer how someone feels based on their face or non-verbal context clues. Not all scientists agree that children with ADHD struggle with recognising other people’s non-verbal emotion signals.

Delay aversion, working memory and hyperactivity – Children with ADHD often try to avoid waiting for things, and prefer for instance a small reward immediately than waiting to get something bigger later. When children have no choice but to wait, they might act quickly without thinking or become really active to make the waiting time feel shorter. Increased hyperactivity has been proposed as a self-stimulation strategy used by children to deal with periods of waiting for a reward and in situations that require high cognitive demand, like learning.

Difference in ADHD presentations – In recent times, scientists have been interested in looking more deeply into the brain differences and impact on individual executive functions like inhibition, to inform treatments. There is enough evidence to show that children with inattentive presentation differ from hyperactive/impulsive and combined presentations and therefore could benefit from different interventions.

Why it’s important

Self-control requires a child to manage their impulses, their emotions and their movements to achieve a goal and meet external expectations. The consequences of having an impaired ability to manage impulses can be profound:

• Academic challenges – Impulse control difficulties can hinder a child’s ability to focus in class, complete assignments, and follow instructions.

• Social struggles – Impulsivity can affect a child’s relationships. Children with low inhibition may have trouble taking turns, listening during conversations, or considering the feelings of others.

• Emotional regulation – Impulse control issues are associated with emotional dysregulation. Children with ADHD may be more prone to frustration, anger outbursts, and difficulty coping with stress.

• Risk taking – Studies have found that children with ADHD are more likely to take risks that can culminate in addiction, accidents and injury.

There are some positives to having impaired inhibition including creativity and entrepreneurship. Famous entrepreneurs have spoken about and credited their ADHD for their successes in business, including Richard Branson who said “Instead of allowing my diagnosis to limit my abilities, I overcame the stigma attached to ADHD and built a seven-figure business in just two years — and I’m not alone.”

All the research tells us that there are many elements that affect a child’s ability to control their impulses. The combination of factors like ADHD presentation, level of executive dysfunction, emotion regulation, situational context, etc, all contribute to your child making decisions without thinking.

What does all of this mean? From a parent’s perspective, it’s important to know that the evidence from years of research confirms that impulse control is a real and measurable trait of ADHD that can vary depending on what presentation your child has been diagnosed with. 

This knowledge can help you better assess situations when your child has done or said something that doesn’t meet your expectations, and guide you on how to respond and support them for better future outcomes. 

Tips & strategies

Be careful not to shame – For many children, an impulsive decision is quickly followed by intense shame as a result of their action. Watching your child hate themselves is heartbreaking, but it’s in this moment that you need to find a way to respond so the focus is on repair and problem solving.

Focus on building self-confidence – A child with ADHD receives 20,000 more negative messages than their peers by the age of 10. It is vital that you prioritise the things that will build your child’s self-confidence so they have the capacity to deal with negative situations.

Get a cognitive performance profile – Cognitive assessments are the only way to obtain an accurate picture of your child’s cognitive performance under standard conditions. The results are useful in clarifying the relationship between their cognitive functioning and behavioural symptoms so that you can create an individually tailored treatment plan.

Explore and decide on the appropriate treatment – Becoming intimately familiar with your child’s struggles is key to identifying the right treatments. Use the Keywell app to record your observations and share with your child’s health care team. A multimodal approach using a combination of treatments has shown to have the best outcomes. 

Medication – Methylphenidate is the most common and successful medication for ADHD, with years of evidence that show it reduces symptoms of inattention, hyperactivity, and impulsivity as well as improving executive functions. Keep in mind though, approximately 30 percent of children do not respond well to this treatment, have no long-term benefits, and experience side effects. There are other types of medications that are better tolerated by those who don’t respond to standard stimulant medications,

Psychosocial treatments – the following 3 have significant evidence supporting their use:

• Behaviour management interventions  – these include parent training, classroom interventions (advocate for your child to have an Individual Learning/Education Plan so that they are supported), and peer-based interventions.
• Training interventions – these include cognitive training, neurofeedback, organisation skills, cognitive behaviour therapy (CBT).
• Physiological treatments – physical activity like organised sport.

Non-pharmacological interventions – There is small to medium clinical effectiveness supporting these measures:

• Dietary interventions – This includes adding vitamins ( Vitamin D, Magnesium, and omega-3 fatty acids) and nutritional interventions like removing certain foods.
  
  
• Transcranial Direct Current Stimulation – A weak electrical current is applied directly and non-invasively to change how brain neurons work. 
  
  
• Mind-body interventions – These include meditation-based therapies like mindfulness and some yoga practices.