ADHD-PI and Impulsive or Not?

I recently received the registration material for the 22nd Annual International Conference of ADHD which is being sponsored by CHADD. I hope to attend the conference and while looking through the program I noticed that Russell Barkley, PhD will be giving the opening keynote address. Dr. Barkley is one of the most respected authorities on ADHD and the title of his keynote address is "The Importance of Emotion in Understanding and Managing ADHD."

Dr Barkley has been recently lecturing on the role on the anterior cingulate on impulse control in ADHD. Studies have shown that in people with Impulsive symptoms and ADHD the anterior cingulate fails to control emotions as it does in non-impulsive ADHD controls. This lack of activity in this part of the brain leads to aggression, increased displays of anger and frustration, excitability and impatience. Many of the poor outcomes associated with ADHD which include substance abuse, difficulty in maintaining relationships, social difficulties and conduct disorders can be attributed to this biological inability to control or inhibit emotions.

I have recently been thinking about impulse control and ADHD treatment and about a Consumer Report article that stated that while over 80% percent of parents of children with ADHD noticed an improvement in ADHD symptoms when their children were on medication, only slightly more than 50% were happy with the treatment. There are many reasons for parents to feel ambivalent about medicating their children but I believe that sometimes it is an absolute necessity to medicate and it boils down to a simple question. The question is, does the ADHD diagnosis includes impulsive behavior or not?

Animal models have shown that Ritalin positively engages the anterior cingulate and promotes impulse control. I have written in this post about why impulse control is where the 'rubber meets the road' in ADHD and why ADHD with an impulsive behavior component MUST be treated.

People with Predominantly Inattentive ADHD (ADHD-PI) often have fewer problems with impulse control. A Developmental Psychopathology study published in 2009 (please see abstract below) describes people with ADHD-PI as being, with respect to reflexively controlled inhibition (impulse control), considerably less impaired.

Dr. Ari Tuckman, another well known ADHD authority has proposed an integrative approach to ADHD therapy, an approach which includes Behavioral Therapy and ADHD coaching to completely treat ADHD. I completely agree with this and also believe that in individuals with ADHD-PI symptoms without behavioral impulsiveness, behavior and coaching interventions should be implemented and only after these interventions have failed should medication therapy be initiated.

Developmental Psychopathology. 2009 Spring;21(2):539-54.
Inhibitory deficits in children with attention-deficit/hyperactivity disorder: intentional versus automatic mechanisms of attention. Fillmore MT, Milich R, Lorch EP.


  1. For me, dealing with the difficulty of emotional control is much more challenging than the inattention. I have never come across a good source to help me teach my son a tolerance for frustration or emotional impulsiveness. It probably impacts his social functioning the most, too, unfortunately.

  2. Thanks for your comment. The lack of emotional control can be much more disabling than inattentiveness. I totally agree with you. The only up side of this is that the stimulants seem to really help this lack of emotional control. Researchers also say that emotional control is one of the areas where Cognitive Behavioral Therapy is very helpful. I am still trying to find a CBT in my city that works with kids so I know that this resource is difficult to come by.

    Thanks again for reading! Tess


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