Impulsivity and Adult ADHD
Impulsivity in adult ADHD can manifest as self-control issues, addictive tendencies, behaving in socially inappropriate ways, acting without thinking, interrupting others, not following through with tasks or having difficulty waiting in queues for example. It can have consequences across multiple domains including career, interpersonal relationships and mental well-being. There are however strategies that can help with impulsivity, some of which are set out below.
Adult ADHD and Type of Presentations
Adult ADHD symptomology is characterised by
persistent inattention, hyperactivity and/or impulsivity.
inattentive or hyperactive-impulse symptoms that were also present prior to the age of 12 yrs.
inattentive or hyperactive-impulse symptoms that are also present in two or more settings e.g., home, work.
clear evidence that the symptoms interfere with or reduce the quality of, social, academic, or occupational functioning.
There are three types of presentations in Adult ADHD:
Inattentive presentations (no hyperactivity, no impulsivity)
Hyperactive-impulsive presentation (no inattention)
Combined presentation (both hyperactivity and/or impulsivity and inattention)
This blog post is primarily concerned with the impulsivity symptomology.
What does impulsivity look like in Adult ADHD?
In general, impulsivity often looks like improvised behaviour that is not based on rational thinking. The individual is acting first and thinking later.
In adult ADHD the behaviours may become persistent over time and across multiple situations. Examples of the behaviour include:
quick decision making.
difficulty waiting/impatience e.g., easily frustrated when queuing, waiting turn to speak or getting a response, getting something done. This can trigger restlessness and other impulses such as verbal, financial and/or emotional.
risky behaviour e.g., seeking out activities and behaviours that could lead to dangerous and negative consequences (e.g., pranks, trespassing, reckless driving, gambling or substance abuse).
blurting out an answer before the question is completed or constantly interrupting conversations or saying things that one can later regret.
going out to have one drink and coming home with someone one does not know.
Financial impulsivity – e.g., going shopping for one item but returning home with multiple bags, or rushing a major purchase without considering need or usability. This is a form of reactive behaviour with one being more susceptible to deals, sales or limited-time offers or the easy access of heavily discounted websites. They are looking for the dopamine hit of purchasing something new.
hopping from one activity to the next or multi-tasking.
Emotional impulsivity can often stem from difficulties with emotional regulation, sensitivity to criticism and perfectionistic tendencies and can manifest in over reactions to situations, feeling overwhelmed with strong emotions and needing to immediately express them e.g., angry comments or temper outbursts.
What are the Consequences of Adult ADHD Impulsivity?
There can be many consequences to impulsivity some of which include:
Challenges to interpersonal relationships - e.g., easily angered, temper outbursts, misunderstandings, hurt emotions, not feeling heard, not taking ownership of own behaviour which can lead to conflicts and breakdown in relationships.
Levrini notes that adults with ADHD report that they are also likely to break-up relationships over trivial matters and have more difficulty keeping friendships.[1]
When one’s own role in the situation is not acknowledged and the choice is to simply move on and/or blame the other party there is no learning and no growth.
Challenges at work/university – e.g., blurting out a response before the other person is finished or simply interrupt which can cause difficulties with work colleagues; volunteering for something or taking on new tasks in an enthusiastic manner but encountering difficulty following through which can result in a reputation of not being reliable[2].
Difficulty focusing, difficulty prioritising, lecture or work meeting disruptions and talking too much can all lead to performance issues and on the extreme end, could result in being fired or expelled or one might simply quit or switch educational pathways.
Safety concerns when there is risky behaviour or instant decisions.
Inappropriate reactions can have physical, mental and even legal ramifications.
Financial difficulties due to erratic spending or overspending which can lead to difficulties managing finances, having savings and budgeting for necessities.
Mental wellbeing difficulties which can include regret over behaviour or social withdrawal which can lead to social isolation and loneliness
Causes of Impulsivity in Adult ADHD
There is currently no single attributional cause of impulsivity in adult ADHD.
It is believed to be a collection of neurobiological and environmental factors. Primarily, dysregulation in how the brain manages executive functions making it more difficult to adopt critical thinking and engage in inhibitory behaviour patterns around emotions and behaviour.
Executive Functioning broadly encompasses “various complex cognitive processes responsible for cognitive control of actions and thoughts that are necessary to maintain goal directed behaviour.”[3]
Recent research suggests that there are two broad domains of Executive Functioning:
Inhibition – the ability to control motor, cognitive, verbal and emotional responses by supressing extraneous or impulsive thoughts or actions. ADHD symptoms in adults may thus arise from a fundamental neurological impairment in both cognitive and motor inhibition.[4]
Metacognition – deficits in inhibition, contribute to deficits in metacognition (i.e., awareness and understanding of one’s own thinking processes aka “thinking about thinking”) which includes working memory, planning and problem solving and emotional self-regulation.[5]
“In adults with ADHD, lack of inhibition leads to dysregulation of self and overall [Executive Functioning], whether attentionally, by becoming distracted and off task easily, or emotionally, by being quick to angry outbursts or saying something, hurtful on impulse.”[6]
Neurotransmitter imbalances, especially those responsible for reward and pleasure such as dopamine, trigger dysregulation which can cause a reduction in dopamine increasing the likelihood of impulsive behaviour to get that sense of reward. People with ADHD are more likely to act impulsively as they are seeking the dopamine hit whilst struggling with halting their behaviour due to executive function challenges.
Note: impulsivity in ADHD can be exacerbated by comorbid conditions associated with ADHD such as Intermittent Explosive Disorder, Bipolar Disorder or Borderline Personality Disorder.
Strategies to help with impulsivity
The following strategies are not exhaustive; the idea is to try what resonates with you and find what works for you so that you can incorporate them into your own tool kit:
Journal - Identify how impulsivity is occurring in your life. What are the behaviours? What are the positive and negative consequences of the behaviours? Are there particular places where you might become more impulsive? What precipitates the behaviours?
Practice mindfulness - to sharpen your self-awareness – bring attention to your present and observe it without judging it.
“Mindfulness meditation can be broken down into three basic steps: (a) bringing attention to the “attentional anchor,” such as breathing; (b) noting that distraction occurred and letting go of distraction; and (c) refocusing back to the “attentional anchor.” Research has demonstrated that mindfulness meditation can reduce self-reported ADHD symptoms, improve attentional task performance, modulate the brain’s electrical activity, alter dopamine levels, and change neural activity.”[7]
Whilst practicing mindfulness, if you experience distraction and let it go but distraction reoccurs, simply gently repeat letting the distraction go and return to the “attentional anchor”. Do this as many times as needed.
Practice Emotional Regulation – when we emotionally regulate, we are able to better respond to life’s challenges without feeling overwhelmed and/or acting impulsively. Ideally, we want to build in space between the triggering event and how we wish to respond it. Key strategies to help with this include:
Acceptance – when we accept something is as it is and we let go of wanting it to be otherwise, we can regain equilibrium and re-deploy our energy in a calm and effective manner.
Slow Down and take notice – try stepping back and noticing and naming your emotional reactions. Ask what triggered them. You could try writing them down, if you wanted to. When we are mindful and take the time to observe and identify our emotions, we gain not only insight but also the space needed before formulating a response. It also allows us to become more empathic and understanding of others.
Identify your physiological responses – e.g., tension, pounding heart and suffusion of heat. if you are in a heightened state of arousal and do not have clarity, delay any response by taking some type of action that will give you some distance e.g., practice a breathing exercise, go for a walk; go to an art gallery, talk to a trusted friend; do some distracting task like deleting unwanted emails; washing your coffee cup; tidying your workspace.
Cognitive Reappraisal – this allows for a tempered response. In reappraising, you are stepping back from your thoughts and emotions and challenging your initial reactions. Evaluate your options and what information you might need to determine the right response for you.
People who are more resilient “tend to explain setbacks as temporary, local and controllable.”[8] “How tolerable a situation feels grows out of our belief about whether we can do anything to escape it.”[9] The optimum bias is the expectation of a favourable outcome. Being optimistic is also a predictor of physical and psychological resilience.
Communicate in a calm and assertive manner – communication is social currency. How we communicate then, is vitally important. When we communicate in a calm and assertive manner, we not only avoid lashing out and minimise potential regret and other negative consequences, but we also stand a greater chance of getting our needs met.
Problem solve – when we are in a calm state, we can better problem solve. When we problem solve, we are shifting our energy, focus and attention onto what is within our control to do something about.
These strategies will assist with proactively managing emotions and allow for more constructive and appropriate responses.
Practice self-compassion – be kind and compassionate with yourself. Give yourself time to process and reflect without using self-deprecating language.
“Compassion is the daily practice of recognising and accepting our shared humanity so that we treat ourselves and others with loving kindness, and we take action in the face of suffering.”[10]
Kristen Neff believes self-compassion has three core elements:
“Self-kindness vs self-judgement – self-compassion entails being warm and understanding to ourselves when we suffer, fail or feel inadequate, rather than ignoring our pain or flagellating ourselves with self-criticism. Self-compassionate people recognise that being imperfect, failing, and experiencing life difficulties [are] inevitable, so they tend to be gentle with themselves when confronted with painful experiences rather than getting angry when life falls short of set ideals.
Common humanity vs isolation – self-compassion involves recognising that suffering and personal inadequacy [are] part of the shared human experience – something we all go through rather than being something that happens to me alone.
Mindfulness vs over-identification – Mindfulness is a non-judgmental, receptive mind state in which one observes thoughts and feelings as they are, without trying to supress or deny them. We cannot ignore our pain and feel compassion for it at the same time. At the same time, mindfulness requires that we not be ‘over-identified’ with the thoughts and feelings so that we are caught up and swept away by negative reactivity.”[11]
Check in with yourself – take an inventory of how you are feeling and what your thoughts are prior to acting impulsively. If you can do this, you can then start to challenge your thinking.
Make it harder to act impulsively – once you have worked on your self-awareness and mindfulness, you’ll know when you typically act impulsively and can take proactive action e.g.,
if you usually overspend when you go shopping, leave your credit/debit card at home and take cash instead, and only take sufficient for your known purchases.
If you usually blurt out in meetings, take a notebook and write down your comments, read them and then mention relevant ones at the appropriate time.
Unsubscribe from marketing emails around sales periods.
Go to less stimulating places with friends.
Leave your car keys at home if you know you will be out drinking.
Place sticky notes in areas you will regularly see them to remind yourself to think and then act.
Learn emotional regulation skills (see above)
Employ mindfulness and breathing exercises when impulsive thoughts arise.
Take responsibility for your actions and behaviours - This should have a positive impact on your relationships interpersonal and work related - apologise for outbursts, take charge in mending situations
Plan and Think Ahead – e.g., if you know you have a big project ahead, ensure you try to moderate triggers, organise yourself better to tackle the project and create buffers.
Breakdown long term goals – breaking a goal down into manageable components can curb impulses and can help build motivation to do tasks. Engage others to help keep you accountable.
Get sufficient Sleep – Quality sleep is an overall component of good health. Creating appropriate sleep hygiene practices that include setting a structure around when you want to go to sleep and when you want to get up each day and maintaining this as consistently as possible along with a good winddown routine before bed is thus conducive for sleep.
Where this occurs, benefits include improved energy levels, improved mood, improved cognitive functioning which can lead to enhanced problem solving and better decision-making skills, improved cardiac functioning as during sleep the heart and vascular system are able to rest, and reduced blood pressure. Good quality sleep is also associated with less risky behaviour, reduced stress, lowered anxiety and/or depression levels. Ultimately, we cope better when we have had quality sleep.
Exercise – there are numerous benefits to regular exercise such as walking, going to the gym or swimming, for example regular exercise can tire the body out and prepare it better for sleep as well as provide increased energy levels, bone and muscle strength (better bone density and less muscle loss), cardiovascular health, improved skin health, improved mood, improved self-esteem.
Eat healthily and regularly – it is important to establish a sustainable mindful routine. Just like with exercise, there are numerous benefits to eating healthily and regularly. These include improved digestive functioning, enhanced immune system functioning as there is a steady nutrition supply, improved blood pressure regulation, stabilised blood sugar levels which aids mood regulation and strengthens bones.
Moderate caffeine intake – an over indulgence in caffeine can result in sleep difficulties, irritability, frequent urination, chest pain, rapid heart rate and/or altered heartbeat rhythm called atrial fibrillation, increased blood pressure due to the stimulatory effect on the nervous system, anxiety – it triggers the release of adrenaline; high doses well in excess of 250mg might result in caffeine intoxication ( DSM – 5 – TR) where symptoms such as restlessness, nervousness, excitement, insomnia, psychomotor agitation, gastrointestinal disturbances might occur.
Hydrate – when we regularly hydrate with water across the day, we garner multiple benefits some of which include improved cognitive functioning, improved energy levels, improved mood, improved physical performance, supportive of kidney function and detoxification, helps with body temperature regulation, healthy hair and skin and, it helps with waste elimination.
However, it is important to work out what is the right amount for you. Your need for hydration will depend upon things like the climate where you live, your age, your weight, your diet and how active you are.
Consider building a hydration habit and view it as an act of self-care. Consider carrying a water bottle around and setting alarms to remind you to take regular sips of water. You could also consider tracking your intake via an app or journal, if that would be easier for you.
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References
[1] Levrini, A. PhD (2023). Succeeding with Adult ADHD. APA Life Tools pg 113
[2] Ibid pg 189
[3] Ibid pg 8
[4] Ibid pg 8
[5] Ibid pg 8
[6] Ibid pg 8
[7] Ibid pg 265
[8] Rosen Kellerman, G and Seligman, M (2023). Tomorrowmind. Nicholas Brackley Publishing. London. Boston. pg 69
[9] Ibid pg 70
[10] Brown, B (2021). Atlas of the Heart. Vermillion. London
[11] Ibid pp 138-139
Mayo Clinic website; www.adhdsupportaustralia.com.au. The Mini ADHD Coach – Harnessing ADHD Fidgeting to Enhance Focus by Alice Gendron; ADHD Fidgeting: 14 Tips to Improve Focus by Choosing Therapy; Fidgeting Strategies that help People with ADHD Focus by Steph Coelho; How to Reset Boredom Intolerance in ADHD by Jenna Fletcher; How to manage ADHD in Adults: Coping Strategies for Adult ADHD by Max Von Sabler; Emotional Dysregulation and ADHD by Kirsten Weir; ADHD Symptom Spotlight: Emotional Dysregulation by Rachel Green, 21/12/2023. “Tomorrow Mind” by Gabriella Rosen Kellerman and Martin Seligman©2023; ADHD Impulse Control: 5 Tips to Help You Manage by Sandra Silva and Margarita Tartakovsky – updated March 1, 2021.Understanding and Managing Impulsivity in ADHD by SimplyPsychology. Epel, E, Dr,. ©2022. The Seven-Day Stress Prescription. Penguin Random House UK