Episode 58: “What is ADHD?” (Part 4): Unpacking ADHD Impulsive Traits

Show Notes

ADHD often brings unique challenges with impulsive behaviors which can make everyday interactions and tasks more complex. In an attempt to better understand the ways ADHD can present in daily life, this episode uses the DSM-5 diagnostic criteria as a framework for discussion—this is not an endorsement of the DSM-5.

In this episode, Patrick Casale and Dr. Megan Anna Neff, two AuDHD mental health professionals, discuss the intricate dynamics of impulsivity in ADHD, blending personal experiences with clinical insights.

Top 3 reasons to listen to the entire episode:

1. Explore the differences and connections between impulsivity and hyperactivity in the DSM-5, and understand how these traits can manifest differently in adults versus children.
2. Gain a deeper understanding of how impulsivity can impact various aspects of life, from relationships to career choices, and hear about ways to channel this energy positively.
3. Understand how the DSM-5 criteria is used to determine an ADHD diagnosis.

As you listen, you might find parts of these criteria and stories that resonate with your own life, whether you have ADHD or simply face similar struggles. We encourage you to stay curious about your own experiences and continue exploring these important topics.

DISCLAIMER: We're using the DSM-5 criteria as a framework for this conversation, but this is not our endorsement of the DSM-5.

Resources:

• ADHD DSM In pictures series: Blog post: neurodivergentinsights.com/blog/dsm-5-criteria-for-adhd-explained-in-pictures
• PDF: neurodivergentinsights.com/neurodivergentstore/p/adhd-dsm-in-pictures

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Transcript

PATRICK CASALE: Hey, everyone. You are listening to the Divergent Conversations podcast. We are two neurodivergent mental health professionals in a neurotypical world. I'm Patrick Casale.

MEGAN NEFF: And I'm Dr. Neff.

PATRICK CASALE: And during these episodes, we do talk about sensitive subjects, mental health, and there are some conversations that can certainly feel a bit overwhelming. So, we do just want to use that disclosure and disclaimer before jumping in. And thanks for listening.

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PATRICK CASALE: All right, everyone. Welcome back to our final part of our ADHD series. And today we are going to talk about impulsivity. Wait, impulsivity? Is that what you just said?

MEGAN NEFF: Mm-hmm (affirmative).

PATRICK CASALE: Yep, impulsivity. And we're going to go over those really quickly because we want to get the series wrapped up. We hope it was helpful for everyone listening.

We have so many ideas coming out of these episodes, which probably makes sense for the ADHD series to create a lot of creative ideas for us. And we're really looking forward to having a guest on next week, as well, who's going to be talking about ADHD and their experiences as well.

So, Megan, do you want to do the clinical side of this?

MEGAN NEFF: Yes, so we've been walking through the DSM criteria. And we just walked through hyperactivity last time. And as a refresher, hyperactivity and impulsivity are actually, like, clumped together, but also have distinct traits.

So, with impulsivity, and again, similar to the hyperactive, these are written with children in mind, so we have to kind of recontextualize them when thinking about adult ADHD.

So, the first one is, often blurs out answers before a question has been completed, completes people's sentences, cannot wait turn for conversation. I'm already smiling because I'm like, "Oh my gosh." Yeah, I did so much of this. And then, I'd always feel so much shame about it.

But like, when you feel like you know where a sentence is going, the urge to, like, finish that sentence it's something, you know, we talked about the self-monitor last time. Like, it's something my self-monitor has gotten better at. But it takes a lot of effort for me to not complete people's sentences.

PATRICK CASALE: Yeah, and agree, same, same here. And I mean, it was a lot harder for me in school to not blurt things out, to not finish sentences. I think, socially, now, it's become less challenging for me to not finish sentences.

But I do agree, especially, if you feel like I know where the sentence is going, I don't want to forget what I'm about to say, that's a big piece too because you're like, I've been waiting to interject for what feels like an eternity, and I have this great idea, and I'm like, holding my breath, or like clenching my fist, or doing whatever I need to do to not blurt the answer out or my response out. So, absolutely can relate, for sure.

MEGAN NEFF: The other time I'll do it is, like, if I'm really engaged in a conversation, then I will also do it. And it's a way of, like, showing my engagement. I actually didn't realize this was rude for a while because it was something that I was like, when I'm really engaged, I do. And like, I'd kind of be comfortable with people also hopping in and doing it with me. But, yeah. So, I actually didn't realize this was rude for a long time, even into my adult years. I think I only realized how much I did this a couple years ago.

You know, one of the reasons that helped train me to stop doing this is Zoom because when you finish someone's sentence in Zoom, there's that thing where, like, you can't hear both people. And so, that's actually what has taught me to stop finishing people's sentences.

PATRICK CASALE: Thanks, Zoom. I'm going to our sponsor for Zoom for this podcast. No, yeah, I agree 100%. It's easier for me if we're in a virtual setting because a lot of people will speak and like, put their thought out. And then, so if they mute themselves, I'm like, "Okay, now it's my turn to talk. So, it almost like retrains my brain on how that communication often goes. But yeah, I can definitely relate to that.

MEGAN NEFF: Yes, okay. And then, next one is, often has trouble waiting for their turn, like, while waiting in line. Oh, I hate waiting in line unless I'm doing, I almost always, like, would come prepared. And I think it's probably different now that folks have iPhones with them all the time. But like before that, in college, I'd always have a book with me. Like, wherever I go somewhere, I pretty much always have a book with me because the experience of waiting and doing nothing feels so dreadful to me.

PATRICK CASALE: Yes, I think about being in line for anything right now, bank, grocery store, wherever, where someone it's either moving really slowly and I'm like, I can't understand why it's moving really slowly, or the person ahead of you orders 40 items that, or is just like they're having their own conversation with the cashier. And I'm just like, "Okay, I'm about to put this stuff down and walk out of here and come back a different day." But yeah, it's very, very challenging for me as well.

MEGAN NEFF: First of all, I don't go to the grocery store much, but if I do, pretty much always do self-checkout, even if it's a ton of stuff, and I know it will take longer because there's something about even though it'll take longer I'm doing something, versus like, waiting in a line doing nothing. Even if I know that would be shorter, like, that feels way more stressful to me than just doing self-checkout. Do you do the counting thing? Like, counting, okay, there's four people ahead of me and like, I'm like, kind of recounting.

PATRICK CASALE: Yeah. Absolutely. And it also impacts my decisions. I'm like, "Okay, there's five people in that line. There's three over here. That person has more items, though. Like, that cashier looks like they're slower." Like, there's a lot going on right there before I make that decision about which line to jump into.

MEGAN NEFF: Oh, my gosh, yes, yes, yes, yes. Okay, another way that shows up for me, I think I briefly mentioned last time was like board games are hard for me. So, I feel some embarrassment about this, but like, as a parent, like, so sometimes I'll play board games. And again, this is pre-discovery of our whole family. You know, one of my kids might get distracted on their turn, and I'll, like, kind of poke him and be like, "It's your turn, it's your turn. Like, go." Like, I just, yeah like-

PATRICK CASALE: Well, I know. I'm just thinking about what I'm about to do. And you're like, "No, like, let's hurry this up."

MEGAN NEFF: Like, and so, this is, again, goes back to my spouse of like, "You just don't relax while, like, playing games with me." I don't think it's necessarily like a relaxing experience because I'm like, "Okay, go, go, go."

PATRICK CASALE: It's funny. I can definitely relate to that too. And it's often, like, I think it gets labeled as, like, you're being really impatient. Like, you're being kind of, like, borderline aggressive in this process. And I'm like, "No, I can't wait for you to take five minutes to roll the dice." Like, can we hurry this along? Isn't this fun?

MEGAN NEFF: The thing with, so like, my workaround for that is if I'm multitasking, then I feel okay with it. But then if I'm multitasking, like, the kids will be like, "But can you just play instead of like, multitasking?" And it's like, "Yeah." But then I want to be impatient.

So, this gets back to what we talked about last time, about, like, it's just so hard to be present because it's like, either I'm multitasking so that I'm not impatiently there, or I'm there but I have this like, "Let's keep it moving people."

PATRICK CASALE: And that even goes back to like, interrupting people, right? While they're speaking. I don't want to forget what I'm saying. I want to be a part of the conversation, but then it's like, "Well, I can't really be present with the conversation because I'm focused so much on interrupting because I need to get my point across, or I don't want to forget what I'm about to say." So, it's a interesting dynamic, for sure.

MEGAN NEFF: Yeah, fun stuff, fun stuff.

PATRICK CASALE: We had someone review us on our podcast about like your quote, or maybe it was my quote, I can't even remember of like, "Autistic body, zero out of 10, would not recommend." And someone wrote a five-star review about us, and it was like, "Zero out of 10 would not recommend." I feel like that would also sometimes sounds like socializing with Megan and Patrick is a zero out of 10, would not recommend. But I don't-

MEGAN NEFF: Wait. That was like a-

PATRICK CASALE: No, no. I'm just saying like, as we're talking about all these things that like we do, I'm like, "Is hanging out with us fun?" I'm starting to wonder [INDISCERNIBLE 00:09:56]-

MEGAN NEFF: Oh, interesting. I mean, if you set up the environment-

PATRICK CASALE: Right, [CROSSTALK 00:10:04]-

MEGAN NEFF: But yeah, no, I mean, like, yeah, I think there's probably hard, I don't know that I would, yeah, we should record parts about hanging out with us, for sure. That's funny.

So, it's interesting that that difficulty waiting turn is in the impulsivity. It also feels like that restlessness probably feeds into this, my guess. So, a part of the impulsivity is our brains often have, like, inhibition differences. So, like, there's an assessment that I do when I assess for ADHD. And I've done it on myself. And when I did it on myself, it was so fascinating.

So, basically, what it is, is you have a computer screen, and every time you see a certain letter you're supposed to hit the space bar and you're not supposed to hit it when it's a different letter.

And I kept hitting it when it wasn't the number. And I was like, "Stop, stop, stop. Like, why are you hitting it?" Like, and there's something about like, between the time my brain, like, if we start a movement, but the time the brain takes to tell you to stop and do it, that inhibition is harder for ADHDers.

So, a lot of us, also, it's not just about that hyperactivity, but that inhibition of, like, once we start, especially, like, if we start a movement it's harder for us to hit the brakes on that. And so, that inhibition piece is part of this impulsivity.

PATRICK CASALE: Yeah, that makes total, total sense. I struggle with that as well.

MEGAN NEFF: Yeah. My scores on that, my inhibition is like, I don't have great inhibition, it turns out, which also makes me super fun to hang out with.

PATRICK CASALE: I mean, this is, also, feeds into, like, prior gambling addiction history with impulsivity, and inhibition struggles. And also, feeds into misdiagnosis. When you're a young adult in their mid-20s and you're struggling with impulsivity, and inhibition, and all these other things, it's like, "Oh, well, clearly this looks like bipolar 2. This look like hypomanic episodes." Going back and forth. And I would attribute a lot of the gambling piece to ADHD.

MEGAN NEFF: Absolutely. I mean, I think, you know, we're kind of like pulling out funny stories, but there's a shadow side to this stuff, for sure. I mean, I was just writing something up about this yesterday of like this is part of what contributes to things like substance abuse, and gambling, and addiction, and dangerous driving, and unsafe sex practices that can, like, there's an increase of teenage pregnancy among ADHDers. That's not shocking.

I think, this is an older study, but it found 40% of men in prison have ADHD. Like, there is a shadow side to this stuff that… I know you and I, we've talked about it on other episodes that, like, this is not easy to live with.

PATRICK CASALE: No, not at all.

MEGAN NEFF: Yeah, that's interesting. If I could carve out the impulsivity part of my brain and, like, discard it, I think I maybe would.

PATRICK CASALE: I would say yes, like 90% of the time. And then, there's parts of the time, entrepreneurially, entrepreneurially…

MEGAN NEFF: It worked.

PATRICK CASALE: Like, impulsivity is quite useful in some instances where I'm like being more impulsive moving towards that stimulation-seeking behavior. And I'm also kind of more creative in those moments. But I do agree that 99% of the time I would like to get rid of that component, yeah.

MEGAN NEFF: Yeah, I guess we don't really get to know what our brains fully would be like if we carved out parts of it. So, we don't get to know like, the flip side of the impulsivity that can lead to creativity and innovation.

PATRICK CASALE: Yeah.

MEGAN NEFF: Absolutely. Okay. And then, this feels pretty similar to some of the other ones. But the last one is, often interrupts or intrudes on others. So, like butts into conversations, games, activities, using other people's things without asking or receiving permission. For adolescents and adults might intrude into or take over what others are doing.

PATRICK CASALE: That's such a fascinating reframe. You know, when you think about it that way because I'm like, "Damn, I used to do that a lot." Where I would just, like, take over for someone and like, and I never attributed it to being bored, or restless, or whatever the case may be, it's just like, "Oh, this needs to get done." And I see the opening, I might as well start the process.

MEGAN NEFF: So, that's kind of like taking control of a situation. yeah. What about though, the like, if someone's having a conversation, like the breaking into it, or is that also…

PATRICK CASALE: I mean, I can see instances of that. I don't feel like I do that as often. But again, circling back to what you said about us being probably people who just masked significantly more, being autistic as well, probably don't butt into the conversations as much because I'm constantly, like, reading the dynamics of the conversations, trying to figure out where to insert myself.

MEGAN NEFF: Yeah, yeah. I think I did more of that too partly because I'm hearing everything in the room. Like, I'd get curious about people's conversation and kind of want to be a part of it. And, like, sometimes I would try to break into it, but I think the shy, autistic, like, awkward parts of me, like, wouldn't feel comfortable doing that, so I…

PATRICK CASALE: It's interesting [INDISCERNIBLE 00:19:11] as I cut you off when I'm traveling. And maybe this is related to my ADHD, but I am way more likely to butt into conversations with strangers. Like, I'll be listening, I'll be absorbing everything in a room, and then I'll be like, "Oh, by the way."

And then start talking to people at like airport lounges or random towns in the middle of nowhere, at pubs and restaurants. And they're probably like, "What the hell is happening." But that happens a lot.

MEGAN NEFF: That's so interesting. I wonder if there's something about, I mean, I've heard autistic people talk about this, when you travel, there's not the expectation that you know all the social norms. So, there can be sometimes more comfort. I wonder if there's something about the comfort of you're already going to be breaking social norms. But because you're from a different culture, not because you're autistic. But I wonder if that kind of makes it easier to kind of initiate those?

PATRICK CASALE: Yeah. I mean, I think I find myself way more interesting when I'm traveling, so maybe I just feel like there's just that ability to just do that as well and have free flowing conversation, which I cannot do in my day-to-day life. I don't know why.

MEGAN NEFF: Traveling is such an interesting experience. I feel like a different human when I travel as well.

PATRICK CASALE: Yeah.

MEGAN NEFF: Yeah, so 10 out of 10 hanging out with Patrick is fun when you're traveling, but like, zero-star review at home.

PATRICK CASALE: I think that feels accurate. Yeah, Arielle was telling me the other day, she's like, "You have to stop telling people when they suggest new restaurants or places to go that those places suck because they're not going to want to invite you to places anymore."

And I was like, "Oh, yeah, I guess that's true." But I realized how often I do that where someone will just-

MEGAN NEFF: Like, you'll just be like, "That place sucks."

PATRICK CASALE: Yeah, they'll be like, "Hey, you want to go check out whatever coffee shop, or restaurant, or whatever?" I'm like, "No, that place is terrible." And they're like, "Oh, okay. Did you want to go to, like, the same three places we always go? And I'd be like, "Yeah, of course, I do." [CROSSTALK 00:21:22]-

MEGAN NEFF: The other thing, like, they're making a social bid, and you're reading it, you know, very literally, of like, "Do you want to go to this restaurant?" And you're answering it very factually. Like, "No, that restaurant sucks." But it sounds like you're kind of missing the social bit of like, "Do you want to hang out?" Right?

PATRICK CASALE: Yeah, exactly.

MEGAN NEFF: So, they're like, the non-autistic response would be, right? Like, "No, I don't want to go there, but do you want to go here?" But I love your very autistic response of, like, "No, that place sucks."

PATRICK CASALE: Yeah, that place is terrible. Why would we go there? And it's like, "Oh, okay. I'm not going to recommend things anymore, just ask you what you want to do." But then that's way too much pressure. And I'm like, "I don't know. Like, can you give me some ideas?" God!

MEGAN NEFF: We are hard to hang out with.

PATRICK CASALE: What a fun loop.

MEGAN NEFF: Yeah.

PATRICK CASALE: Anyway, I think we just covered all the criteria.

MEGAN NEFF: Yeah, so that's all the… So, those nine, again, are the… we did hyperactive last week and impulsivity, but they're clumped together. So, if an adult has five of those, that's enough for diagnosis, and then for children six.

And then there's always, when it comes to diagnostic criteria kind of the rule-out consideration so, like, criteria B would be that these traits have to have been present before age 12. This one's a little bit tricky because if a child has been really well supported in their environment, like maybe they are in a primary school that whole time where there's not a lot of like, different classes, and maybe they're really well accommodated for at home, these traits might not be super apparent yet.

And then, for females, our ADHD traits often become more exasperated after we go through puberty. So, there's some criticism of this, like 12. But I mean, it's classified as a neurodevelopmental condition. So, there has to be evidence that this was present in our early years, which just that makes sense.

And that is tricky because there's more and more adults seeking diagnosis right now. But then sometimes we don't have great memories, especially, if we're ADHD. Sometimes our memory of our childhood is really hard. Like, we don't have many memories, so that is a little bit tricky.

And then, the next criteria is that these, they call them symptoms, but traits have to be present in more than one setting. So, like, both at school and at home, or both at work and at home. If it's just in one setting, the idea is maybe there's something in that setting, versus like this is innate to the person.

There's also been some criticism of that because that misses some people, especially, people who mask their ADHD. But that is currently part of the diagnostic criteria.

So, like, there's different screeners we'll use or there're different ways to like, capture like, okay, what is work like? What are your relationships like? What's home like? Also, your emotional well-being, like that can be a domain of functioning, kind of your emotional, mental health.

PATRICK CASALE: Right.

MEGAN NEFF: And then, there's got to be evidence that this interferes with or impacts quality of life, work, school. Again, we're not talking about, like everyone has some restlessness, everyone has some distractibility. Like, we're not talking about, oh, yeah, I've got this or this trait. We're talking about something that really impacts how we experience moving through the world and impacts these spaces.

And then, the other specifiers of like, it's not attributed to things like psychotic disorder, or mood disorder, or anxiety, the rule outs. So, those are the other parts of the criteria.

PATRICK CASALE: Thanks for summing that up and great summarization per use. I hope this series was helpful. We are definitely going to do an episode on ADHD texts. We're going to do an episode on interest-based nervous systems. We have so many ideas, go figure. And that will change week by week and day by day.

But I like these collections. I'm really starting to enjoy having these. I think they help structure. And they're just really enjoyable. And I'm glad we waited so late into the game to do this instead of starting with it. But thanks for listening to Divergent Conversations. New episodes are out on Fridays on all major platforms and YouTube. Like, download, subscribe, and share. And goodbye.