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Emotional Impulsivity: The Tipping Point of Pediatric ADHD

June 16, 2020

By Sam Marzouk, Ph.D., L.P.

Pediatric attention-deficit/hyperactivity disorder (ADHD) is one of the most heterogeneous behavioral health diagnoses. In the current iteration of the diagnostic and statistical manual of mental disorders (DSM-5), ADHD is conceptualized by two broad dimensions of inattention and hyperactivity/impulsivity, each comprising an array of symptoms. Given the numerous possible symptom combinations and diagnostic profiles, individualizing the treatment approach of ADHD is a clinically necessary yet challenging task. Emerging signs and symptoms of pediatric ADHD are often first identified in a primary care setting. This makes pediatric primary care providers well-positioned to make important treatment planning decisions. It is therefore helpful for pediatric providers to not only identify core symptomatology but also key associated features of pediatric ADHD that correlate with a higher risk of associated functional impairment and more longitudinally adverse outcomes. 

One such feature that appears to uniquely contribute to heightened functional impairment in children with ADHD is emotional impulsivity (EI). Emotional impulsivity (also referred to as “emotional lability” or “emotional dysregulation” throughout the literature) refers to a diminished ability to modulate an emotional state precipitated by an environmental stressor. Not surprisingly, EI typically leads to subsequent maladaptive behavioral choices (e.g., fights, destruction of property, verbal aggression, etc.). While impulsivity in and of itself is typically understood in behavioral terms, the preceding emotional impulsivity is often overlooked. As a general clinical feature, EI cuts across numerous behavioral health diagnoses and is by no means specific to pediatric ADHD. What is important, however, is the relationship between EI and pediatric ADHD. Epidemiological research suggests that between 24 and 50 percent of children with ADHD also have clinically significant EI. What’s more, research has shown that children with ADHD and co-occurring EI often have greater core symptom severity, a higher risk for comorbid psychopathology, and poorer long-term outcomes. As a more specific empirical example, Russel Barkley (2010), one of the more prolific pediatric ADHD researchers, longitudinally followed a group of children with ADHD into early adulthood. Barkley found that those with comorbid EI at childhood evidenced greater functional impairment in adulthood across multiple domains (e.g., occupational, social, financial, etc.). Taken together, EI may represent the proverbial “tipping point” of pediatric ADHD in terms of functional impairment and adverse long-term outcomes.    

Emotional impulsivity appears to be a particularly important yet overlooked associated feature of ADHD. Given that EI is not identified as a core symptom of ADHD in the DSM-5, providers are more prone to underestimate its importance to the overall clinical picture and may, therefore, fail to assess for its presence. Pediatric providers play an important role in formulating and often coordinating an ADHD treatment plan. The evidence-base surrounding best practices for treating pediatric ADHD suggests that pharmacological and/or psychosocial treatment modalities have the highest efficacy. When EI enters the clinical picture, a more integrated approach inclusive of psychopharmacological interventions, psychotherapeutic interventions, and even occupational therapy may be indicated. 

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