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ADHD in Adolescence: A Focus on Impulsivity

Let me count the ways

Attention-Deficit Hyperactivity Disorder (ADHD) has as its core symptoms hyperactivity (which mostly applies to children), impulsivity and inattention (distractibility). Across the timeline, much of the hyperactivity drops away, but persistent impulsivity is a key feature in adolescents going forward into young adulthood.

Impulsive, according to the, is defined as “characterized by actions based on sudden desires, whims, or inclinations rather than careful thought” and “Inclined to act on impulse rather than thought”.

Changes in brain development, especially in the all-important frontal lobe regions of the brain, continue from adolescence into early adulthood. It is also of note that this particular time period is related to increased risk-taking behaviours. Risk taking can be understood in the context of impulsive behaviour.

During this important developmental phase, how could ADHD-related impulsivity emerge during adolescence? Impulsive physical activities and risk-taking (climbing up and jumping off!) has been documented. Bingeing is an impulsive behaviour and this can take the form of bingeing on alcohol, drugs and impulsive eating, leading to bulimia nervosa.

More graphic forms of impulsivity include stealing and fighting and this leads to higher rates of incarceration for young people with ADHD. What’s important and encouraging to know is that when you treat ADHD, criminality is reduced by 32% in males and 41% in females.

Untreated people with ADHD drive as poorly as non-ADHD intoxicated people. Clearly this can lower life expectancy and is part of the “why treat” in ADHD.

But impulsivity can have more subtle manifestations in a young person’s life. A good example of this would be impulsive spending. People with untreated ADHD often will see something that they want and give in to immediate gratification. Later they may feel remorseful about these purchases, but in the moment they cannot resist the impulse. Other people around them may have a more clear perspective on this kind of impulsivity.

More subtle versions in a teen’s life can take the form of impulsive decision making. Impulsively taking jobs or quitting jobs is over-represented in untreated adolescents with ADHD. Quitting school or leaving relationships impulsively can be problematic. Verbal impulsivity is jumping into conversations without waiting for the other person to finish. Sometimes this is because people will forget what they were going to say and need to simply get it out; other times teens with ADHD think they know what the other person is going to say and want them to get to the bottom line. Notwithstanding, verbal impulsivity does not enhance personal relationships. Verbal impulsivity may occur more often in the context of family relationships (moms and dads). Irritation and tension on the part of the teen can contribute to saying things without considering the consequences. Not running comments through “the filter” can create stressful relationships in families with ADHD members.

Up to 50% of people with ADHD have struggled with substance dependence at some time in their lives. Clearly, not considering the consequences of using drugs and alcohol can have a negative outcome. If someone has the biological wiring, making it more likely for them to be impulsive, taking drugs and alcohol may make them more impulsive, like “pouring gas on the fire”. In a recent study from The Netherlands by Crunelle et al., researchers found that people with ADHD who became cocaine dependent were much more impulsive when compared with people with ADHD who did not become cocaine dependent.

Finally, sexual impulsivity affects young people with ADHD. Females are much more likely to become accidentally pregnant and untreated males are much more likely to cause an accidental pregnancy. In a recent publication of the Journal of Family Violence, White et al. demonstrated that in a large population of female college students, ADHD “uniquely increased the risk of sexual victimization” through engaging in risky sexual behaviour.

Impulsivity may be a subtle symptom, but even a little bit of it can have significant impact on a young person’s life. Easy does it.

More from Tim Bilkey M.D.
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