DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY INVITED REVIEW

Inhibitory control and impulsive responses in neurodevelopmental

disorders
GIOVANNI MIRABELLA 1,2

1 Department of Clinical and Experimental Sciences, University of Brescia, Brescia; 2 Istituto di Ricovero e Cura a Carattere Scientifico Neuromed, Pozzilli, Italy.
Correspondence to Giovanni Mirabella at Department of Clinical and Experimental Sciences, Brescia University, Viale Europa, 11, 25123 Brescia, Italy. E-mail: giovanni.mirabella@unibs.it

Plain language summary: https://onlinelibrary.wiley.com/doi/10.1111/dmcn.15451

The impairment of inhibitory control is often assumed to be the core deficit of several neu-
PUBLICATION DATA rodevelopmental disorders characterized by poor impulse control. However, could the same
Accepted for publication 13th November deficit explain different clinical phenotypes? Evidence from behavioural studies is very mixed.
2020. This is partly because inhibition is a highly complex executive function. Thus, the different
Published online 19th December 2020 types of tasks that generically tap into inhibitory control are likely to provide different out-
comes. Additionally, sample inhomogeneity in terms of age, comorbidity, and medical treat-
ABBREVIATIONS ment are confounding factors. Therefore, to make a reliable assessment of the deficit of
ASD Autism spectrum disorder inhibitory control in a given disorder, the same task and samples with similar characteristics
OCD Obsessive–compulsive disorder must be employed. This article reviews and discusses studies on five neurodevelopmental
disorders with impaired impulse control where these criteria have been used: Tourette syn-
drome; obsessive–compulsive disorder; attention-deficit/hyperactivity disorder; primary motor
stereotypies; and autism spectrum disorder. Overall, they suggest that the mechanisms
underlying the inability to control urges are extremely heterogeneous and cannot be ascribed
to a general impairment of inhibition. These findings do not support the hypothesis that inhi-
bitory deficits represent a transdiagnostic feature of neurodevelopmental disorders with poor
impulse control.

The relationship between the impairment of inhibitory
control and neurodevelopmental disorders characterized by
poor urge control is a hotly debated subject. Movement
inhibition allows the gating of inappropriate response ten-
dencies, thereby ensuring the emergence of context-appro-
priate, goal-directed behaviours. Therefore, impairments in
motor inhibition have often been considered the core defi-
cit of neurodevelopmental disorders characterized by pre-
mature, impulsive, and out-of-context motor behaviours.1–4
However, the picture emerging from studies that address
this issue is extremely mixed. Tourette syndrome repre-
sents a paradigmatic example. In fact, while some studies
revealed impaired inhibitory control in Tourette syndrome
compared to typically developing controls,5 others found
no differences,6 and a few studies paradoxically found
enhanced inhibitory control.7 This is partly because inhibi-
tory control is multifaceted and includes several domains.
Confounding factors, such as the behavioural task used
and/or differences in sample characteristics (presence of
comorbid disorders, age of patients, presence or absence of
medical treatment), can explain such conflicting results.
Consequently, at present, it is difficult to draw any firm
conclusions about the role of deficits in inhibitory control
in disorders where patients show poor urge control.
This review aims to explore whether and how inhibition
deficits can explain different clinical phenotypes after
controlling for several confounding factors. First, the
review focuses on one domain of inhibition, that is, motor
inhibition. Since people with pathological control of
impulses tend to produce inappropriate movements, motor
inhibition is likely to be the most affected domain of inhibi-
tory control. In line with this reasoning, only the results of
studies where the stop-signal task was employed have been
considered. Second, only studies with participants of similar
age (children/adolescents) have been included. Third, the
review focuses only on behavioural studies because, despite
differences in task design and sample selection, they repre-
sent a set of more homogeneous data than those obtained
with other techniques (e.g. neuroimaging) where the num-
ber of confounding variables is higher. By applying such
strict criteria, a clearer picture of the role of inhibitory con-
trol in neurodevelopmental disorder emerges.
THE MANY FACETS OF INHIBITORY CONTROL
Inhibitory control is not a single executive function;
instead, it encompasses several different components. A
generally accepted distinction is the one between motor
and interference inhibition.8 Motor inhibition refers to the
ability to inhibit a preplanned motor response, and it is
usually measured using the go/no-go9 or stop-signal
tasks.10 The two tasks differ because the former measures
the ability to suppress a potential action (action restraint)

520 DOI: 10.1111/dmcn.14778 © 2020 Mac Keith Press

 14698749, 2021, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/dmcn.14778 by CAPES, Wiley Online Library on [31/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
while the latter measures the ability to inhibit an action What this paper adds
that has already been initiated (action cancellation). • The mechanisms underlying the inability to control urges in neurodevelop-
In contrast, interference inhibition assesses the ability to mental disorders are heterogeneous.
resolve response conflict due to irrelevant but incompati- • Inhibition impairments cannot generally explain all neurodevelopmental dis-
ble, and therefore interfering, stimulus characteristics that orders characterized by poor urge control.
must be inhibited to avoid erroneous responses. This type
feel less self-confident and more anxious.1,18 As discussed
of inhibitory control is usually studied with the Simon,11
in the next section, the cognitive mechanisms subserving
Eriksen flanker,12 and Stroop13 tasks. The response-related
reactive and proactive control can be affected selectively,
interference in the Simon and Eriksen flanker tasks is the
thereby determining the emergence of the phenotypes of
consequence of the simultaneous activation of two poten-
different disorders.
tial responses. What the Stroop task really assesses is a
Therefore, when assessing motor inhibition, it is crucial
matter of debate. It has been suggested that it involves a
to employ a paradigm that allows the measurement of both
different type of response-related interference than the
reactive and proactive inhibition. The stop-signal task, but
other two tasks because response-related interference in
not the go/no-go task, has this potential. In the stop-signal
the Stroop task is due to the involuntary activation of a
task, reactive inhibition is always quantified by measuring
prepotent response, for example, the automatic tendency to
the time it takes to inhibit an action when the stop-signal
read a word.14
is presented, that is, the stop-signal reaction time.10 By
There are also other types of cognitive inhibition, such
contrast, how to estimate proactive control is more contro-
as inhibition of memory retrieval, which can be assessed
versial.
using the think/no-think task,15 or verbal inhibition, which
On the one hand, some researchers have modified the
can be assessed using the Hayling task.16
stop-signal task by introducing cues that inform the partic-
Even though all these tasks share the requirement to
ipant about the probability of an upcoming stop-signal as
suppress the processing of a prepotent, bottom-up-gener-
in the conditional stop-signal (Fig. 1)19 or stop-signal
ated inappropriate response, it is possible that the cognitive
anticipation tasks (Fig. 1).20 In the conditional stop-task,
abilities required for a given type of inhibition could be
all trials begin with a cue circle’s appearance, with the left
differently affected in different disorders. In particular,
half of one colour and the right half of another colour
given that people with poor impulse control are likely to
(Fig. 1). The cue instructs the participants that one direc-
perform out-of-context movements, it seems reasonable to
tion is ‘critical’ (e.g., black), and the other is ‘non-critical’
suppose that motor inhibition could be the most affected
(e.g., grey). Then, an arrow appears within the circle. If
component of inhibitory control. Thus, the present review
the arrow points to the critical direction, the participants
focuses only on this domain.
have to press the right key as soon as possible (no-stop tri-
als, 66% of total trials) unless a tone occurs after a delay
THE COMPLEXITY OF MOTOR INHIBITION (stop-signal delay). In this instance, the participants have
Motor inhibition is defined as the ability to suppress a pre-
to withhold the response (stop trials, 34% of total trials).
potent motor response. This inhibition domain is no less
However, if the arrow points to the non-critical direction
complex than other, sometimes defined as more cognitive,
(towards the left side in Fig. 1), the participants have to
forms of inhibitory control (e.g. interference inhibition).
press the left key irrespective of whether a tone occurs
Suppressing an action that is about to be generated implies
(no-stop trials type 1, 66% of total trials) or whether it
the evaluation of the pros and cons of several dimensions
occurs (no-stop trials type 2, 34% of total trials). Thus, in
that are part of the decision-making process.17 Action
the non-critical direction, participants must ignore the stop
withholding involves the retrieval of past experiences,
signals. In the stop-anticipation task, most trials are no-
exploitation of task instructions, evaluation of the current
stop trials. A bar moves at a constant speed from the bot-
context, and internal states.
tom up in those trials, reaching the black line (the target)
Of relevance, motor inhibition is not a unitary construct;
in 800ms (Fig. 1). Participants have to stop the bar as close
at least two neuropsychological domains have been distin-
to the black line as possible by pressing a button with the
guished: (1) reactive inhibition, that is, the ability to stop a
right index finger. In fewer trials (stop trials), the bar stops
response immediately when a stop instruction is presented;
before reaching the target line, and participants are
and (2) proactive inhibition, that is, the ability to adapt the
instructed to withhold pressing the key. The probability of
motor strategy according to the context where an individ-
stop-signal occurrence changed across trials (0%, 27.5%,
ual is embedded. Both components probably play a role in
32.5%, 37.5%) and is indicated by the characteristics of
diseases characterized by poor urge control. Deficits in
the target line (in Fig. 1, indicated by the different line
reactive inhibition are likely to be directly linked to the
hatchings). These two tasks are cognitively very demanding
inability to suppress unwanted actions. In contrast, since
since participants must remember the meaning of cues and
proactive control strategies are tightly linked to one’s
task instructions. Under these conditions, it is likely that
short-, medium-, and long-term goals, which are retrieved
the load on attentional and working memory is high.
from stored memories according to the current context,
Therefore, outcome measures cannot be easily ascribed to
impairment of this component could lead the individual to

Review 521
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CONDITIONAL STOP-SIGNAL TASK
(a) CRITICAL DIRECTION (50%) NON-CRITICAL DIRECTION (50%)
NO-STOP TRIAL (66%) NO-STOP TRIAL: TYPE 1 (66%)

Reaction time Reaction time

STOP TRIAL (34%) NO-STOP TRIAL: TYPE 2 (34%)

SSD SSD

STOP-SIGNAL ANTICIPATION TASK

(b) NO-STOP TRIAL STOP TRIAL STOP-SIGNAL PROBABILITY

0% 27.5% 32.5% 37.5%

Time (ms) Time (ms)

ARM REACHING STOP-SIGNAL TASK

(c) GO-ONLY TASK STOP-SIGNAL TASK

NO-STOP TRIAL (66%)
Go-signal Success

STOP TRIAL (34%)

Go-signal Success Go-signal Stop-signal Success
SSD

MASKED PRIMING TASK

(d) PRIME MASK TARGET CORRECT RESPONSE
Press right
COMPATIBLE

Press left
INCOMPATIBLE

Time (ms)

Figure 1: The many facets of inhibitory control. (a) Schematic representation of the conditional stop-signal task. Adapted from Aron et al.19 with per-
mission. (b) Schematic representation of the stop-signal anticipation task. Adapted from van Hulst et al.20 with permission. (c) Schematic representation
of the reaching arm version of the go-only and stop-signal tasks. Adapted from Mancini et al.6 with permission. (d) Schematic representation of the
masked priming task. Adapted from Keute et al.24 with permission. SSD, stop-signal delay

proactive strategies because of the concurrent cognitive
demands on other executive functions.
An alternative approach is the one based on comparing
the behavioural parameters of the very same movements
executed in two different contexts, that is when individuals
are aware of an upcoming stop-signal versus when they
know that a stop-signal is not going to be presented.6,21,22
Exploiting the reaching arm version of the stop-signal task
(Fig. 1) has shown that proactive control can be assessed
by comparing the reaction (i.e. the time to initiate a
response; reaction time) and movement timing (i.e. the
time to execute the motor response; movement time) of
no-stop trials (i.e. trials employing the stop-signal task
where participants have to perform a movement) with
those measured during the execution of the same action in
the context of a simple reaction time task (go-only
trial6,21). In the reaching arm version of the stop-signal
task, participants are comfortably seated in front of a
touchscreen placed within a reachable distance; visual stim-
uli are presented on the touchscreen. The go-only task

522 Developmental Medicine & Child Neurology 2021, 63: 520–526


consists only of go-only trials, while the stop-signal task
consists of a pseudorandom mix of no-stop (66%) and stop
trials (34%). All trials begin with the appearance of a cen-
tral stimulus; participants have to reach the stimulus and
hold it for a variable period (500–800ms). Then, a periph-
eral target appears (go-signal). In the go-only and no-stop
trials, participants have to reach and hold the target for
300 to 400ms. On the other hand, in the stop trials, before
movement onset, the central stimulus (stop-signal) reap-
pears at a variable stop-signal delay, prompting the partici-
pant to withhold the incipient movement. To succeed,
participants must keep the index finger on the stop-signal
(Fig. 1). It has been shown that when participants perform
a no-stop trial, reaction time is lengthened, and movement
time is shortened compared to when they perform a go-
only trial. This phenomenon has been named the ‘context
effect’ and represents an example of motor strategy opti-
mization. In fact, during the execution of no-stop trials,
participants tend to lengthen reaction time to increase the
opportunity to stop the response in case a stop-signal is
presented. At the same time, longer reaction times allow
better coding of the target parameters and hence faster
movement times. By contrast, during the execution of go-
only trials, participants react very quickly to go-signals to
the detriment of the target parameter coding. Thus, move-
ment execution must be completed during the movement
phase, thereby lengthening movement times.23 The advan-
tage of this approach over the use of cues indicating the
probability of a stop-signal being presented lies in the fact
that attentional and working memory demands are kept to
a minimum. Therefore, results can be promptly linked to
changes in proactive strategies.
Even though proactive mechanisms have attracted atten-
tion only relatively recently,1 there is no doubt that this
component serves a complementary function to reactive
inhibition and that motor inhibitory control emerges from
the interplay between these two domains. The different
phenotypes characterizing the many types of impulse disor-
ders are most likely generated by combinations of impair-
ments affecting reactive and proactive inhibition.
Recent work has suggested that a critical aspect of the
stop-signal task is that motor inhibition is an explicit goal;
thus, it requires participants to maintain the task set while
performing the task. Under these conditions, a failure to
remember the instructions or inattention to relevant stim-
uli may be interpreted erroneously as poor inhibitory con-
trol.24 To overcome these potential limitations, a type of
inhibition that does not require an explicit stop-signal and
the conscious awareness of participants, that is automatic
motor inhibition, has been measured.24 Automatic inhibi-
tion has been assessed using a subliminal masked priming
task (Fig. 1). In this task, all trials begin with the presenta-
tion of a fixed dot. Then, participants are shown an arrow
for the shortest possible time, that is, one refresh rate of
the monitor, followed by a random pattern mask (in Fig. 1,
this is a random mix of vertical and horizontal lines) which
lasts for a longer time, making the perception of the
14698749, 2021, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/dmcn.14778 by CAPES, Wiley Online Library on [31/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
previous stimulus (the prime) unconscious. Finally, a
supraliminal arrow target is shown. Participants have to
press the right key if the supraliminal arrow target points
to the right and the left key if it points to the left. When
the prime arrow points in the same direction as the arrow
target, the trial is defined as compatible; otherwise, it is
defined as incompatible (Fig. 1). When the delay between
the prime and target is short, compatible priming allows
faster and more accurate responses, whereas incompatible
priming impairs motor performance. However, when the
delay between the prime and target delay is long enough,
the effect reverses, a phenomenon known as the negative
compatibility effect. This phenomenon has been inter-
preted as an effect of automatic delayed inhibition process-
ing occurring in the motor system, which reverses the
priming-induced response activation.25
Given these premises, the results of studies providing
measures of reactive, proactive, and automatic motor inhi-
bition in neurodevelopmental disorders characterized by
poor urge control are reviewed and compared in the next
section of the review.
SPECIFIC PATTERNS OF MOTOR INHIBITION
IMPAIRMENT SHAPE THE PHENOTYPES OF
NEURODEVELOPMENTAL DISORDERS WITH POOR
URGE CONTROL
To identify studies that assessed the impairment patterns
of proactive, reactive, and automatic motor inhibition in
neurodevelopmental disorders, two different literature
searches were conducted in PubMed according to the rec-
ommendations described in the Preferred Reporting Items
for Systematic Reviews and Meta-Analysis (PRISMA)
guidelines.26 Two systematic searches up to September
2020 were conducted using the terms described in Figs S1
and S2 (online supporting information). The results are
summarized in Table 1. The five neurodevelopmental dis-
orders studied in the articles identified by these searches
were: Tourette syndrome; obsessive–compulsive disorder
(OCD); attention-deficit/hyperactivity disorder (ADHD);
primary motor stereotypies; and autism spectrum disorder
(ASD). Motor stereotypies are repetitive, rhythmic, appar-
ently purposeless movements that interfere with activities
of daily living. They have a fixed pattern, are triggered by
some states of mind (e.g. stress, fatigue, boredom), and can
be stopped by diverting attention. These are all conditions
where movements are not adequately controlled and per-
formed despite the willingness of the individual. Even
though all these disorders are characterized by poor urge
control, their phenotypes are different, suggesting that they
represent independent disorders arising from different
pathophysiological mechanisms. Thus, at least when these
disorders are not comorbid with one another, the defi-
ciency in impulse control is likely to be generated by dif-
ferent cognitive mechanisms. The identification of such
cognitive mechanisms represents a crucial step towards
understanding disorder aetiology and the development of
effective treatments. The generic claim that the core
Review 523
 14698749, 2021, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/dmcn.14778 by CAPES, Wiley Online Library on [31/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
feature of all these disorders lies in the impairment of

Drug-na€ıvea
Medication

Drug-na€ıve

Drug-na€ıve
Drug-na€ıve
motor inhibition1–4 is unlikely to provide an exhaustive

Table 1: Summary of the main findings from studies assessing deficits in proactive and reactive inhibitory control and/or in automatic inhibition in disorders characterized by poor impulsivity control in

Mixed

Mixed
status
explanation of the disorder.
Given this, it is crucial to establish a bridge between
inhibitory control deficits and their clinical manifestations.

range (y)
Therefore, before discussing the results of single studies,

10–17
7–15

8–12
6–10

5–28

7–10
Age
the potential effects of deficiencies in each type of inhibi-
tion on cognitive-motor processes will be described.

Drug-na€ıve patients did not receive any drugs. OCD, obsessive–compulsive disorder; ADHD, attention-deficit/hyperactivity disorder; ASD, autism spectrum disorder.
Impairment of reactive inhibition should make an individ-
16, 13, 8

39, 32
20

28
121
50
Sample

ual incapable of resisting from moving on exogenous or

size

endogenous trigger presentation, despite the action being

inappropriate. On the other hand, a deficit in proactive

Proactive inhibition only

Reactive inhibition only
Reactive inhibition only

Reactive inhibition only

inhibitory control would affect an individual’s ability to
exploit environmental or mental cues to maintain informa-
inhibition in OCD
Deficits in motor

tion about which actions are most appropriate in a given

Reactive and

context. Finally, a possible effect of damage to the auto-

No deficits
proactive
inhibition

matic inhibition domain is that individuals cannot stop

actions triggered by object affordances when those objects
are not behaviourally relevant.24 These potential move-
ments are normally suppressed without conscious aware-
Reactive and proactive inhibition

Reactive and proactive inhibition

Reactive and proactive inhibition

Reactive and proactive inhibition

Reactive and proactive inhibition

Type of motor inhibition studied

ness. A loss of this ability would induce impulsive

behaviours that are simply triggered by the sight of objects
in the individual’s surroundings.
With this frame of reference, it is possible to interpret
Automatic inhibition

the results from Mirabella et al.21 regarding drug-na€ıve

children with primary motor stereotypies (i.e. stereotypies
not associated with other neurological conditions; primary
motor stereotypies). Mirabella et al.21 found that these
children had a marked deficit in reactive inhibition com-
pared to typically developing children. However, proactive
control was similar to the typically developing control
stop-signal task and go-only task

stop-signal task and go-only task

group. This evidence might explain the two key features of

Stop-signal and go-only tasks
Reaching arm version of the

Reaching arm version of the

Stop-signal anticipation task

the phenotype of primary motor stereotypies. On the one

hand, impairment of reactive inhibition could be the rea-
son for patients’ inability to refrain from performing
Masked priming task

stereotypic movements when triggered by excitement,

Stop-signal task

stress, boredom, or fatigue.27 On the other hand, an intact

proactive control should allow patients to be aware of the
context and thus to stop when their attention is diverted.27
Task(s)

Interestingly, the results from the study by Mirabella

et al.21 are in contrast with those of Schmitt et al.,22 who
tested a large cohort of patients with uncomplicated ASD
and Tourette syndrome + OCD

(i.e. patients with ASD without comorbid psychiatric disor-

Primary motor stereotypies

ders; Table 1), finding a deficit in proactive control strate-

Tourette syndrome, OCD,

ADHD and ASD + ADHD

gies whereas reactive inhibition was similar to that of

typically developing controls. Interestingly, impairment in
proactive control scaled with the severity of restrictive
repetitive behaviours and, in particular, with motor stereo-
Disorder(s)

typies. Schmitt et al.22 used an experimental approach sim-

ilar to that of Mirabella et al.,21 that is, in both cases, the
ADHD
ADHD
ASD
children and adolescents

version of the stop-signal paradigm was minimally

demanding in terms of attentional and working memory
van Hulst et al.20
Mirabella et al.21

requirements. Thus, apart from the fact that in the former

Schmitt et al.22
Mancini et al.6

Keute et al.24

study participants had to inhibit key-press movements,

Pani et al.31

whereas in the latter participants had to suppress arm-

Study

reaching movements, the contrasting findings are unlikely

to be explained by experimental design. A more relevant
a

524 Developmental Medicine & Child Neurology 2021, 63: 520–526


difference lies in the age range of participants, which is
much wider in the Schmitt et al.22 sample than in the
study by Mirabella et al.21 (Table 1). Since inhibitory
control changes over the lifespan,28 a wide age range is
more likely to produce large variability. Indeed, Schmitt
et al.22 showed that proactive control matures throughout
childhood and adolescence to early adulthood in individ-
uals with ASD and typically developing individuals.
However, the ability to exert proactive strategies is
impaired since childhood and it develops slower in indi-
viduals with ASD than in typically developing individuals.
In light of these considerations, it is more likely that
ASD and primary motor stereotypies might be character-
ized by a different pattern of inhibitory control impair-
ment. The deficit in proactive inhibition in individuals
with ASD could clinically manifest in an inability to
learn using contextual cues to inhibit inappropriate repet-
itive behaviours. A phenotypical feature of ASD is beha-
vioural inflexibility, especially in novel or unexpected
situations.29 Impairment of proactive control may also
reflect an intolerance to uncertainty to which patients
with ASD respond with the execution of restrictive,
repetitive behaviours.30 All these intriguing hypotheses
need to be tested in further research.
Another important piece of evidence about the complex-
ity of the outcome of deficits in inhibitory control comes
from the study by van Hulst et al.,20 who showed a selec-
tive deficit in reactive inhibition but an intact proactive
control in children with ASD with comorbid ADHD and
ADHD only compared to typically developing children
(Table 1). The discrepancy between these results and those
of Schmitt et al.22 can be explained by the fact that van
Hulst et al.20 included patients with ASD showing marked
ADHD symptoms. Thus, at least as far as inhibitory con-
trol deficits are concerned, ADHD symptomatology was
likely to be prevalent. Selective impairment of reactive
inhibition seems to be a hallmark of ADHD, as found by
Pani et al.31 using a standard key-press version of the stop-
signal task. This feature is common to both inattention
and hyperactivity ADHD subtypes.20,31 In addition,
patients with ADHD do not seem to suffer from low-level
automatic motor inhibition deficits.24 In principle, reactive
inhibitory deficit may explain a number of ADHD pheno-
type features, such as being unable to stick to tasks and
constantly changing activity, being unable to wait for one’s
turn, and performing actions impulsively. These beha-
vioural traits should not depend on stimulus affordances24
but on environmental or internal cues that children with
ADHD cannot resist even though, given the intact proac-
tive control, they should be aware of the inappropriateness
of their actions. In a sense, this pattern of inhibitory con-
trol deficits could resemble that of primary motor stereo-
typies, even though the simultaneous deficit in other
executive functions, mainly attention, makes the ADHD
phenotype much more complex and debilitating.
The other two examples of syndromes characterized by
poor urge control are Tourette syndrome and OCD.
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Relevant to the topic of this review, it has been shown that
cognitive mechanisms underlying tic and compulsion con-
trol are completely different. Mancini et al.6 assessed reac-
tive and proactive inhibitory control using a reaching arm
version of the stop-signal task in a very large cohort of
drug-na€ıve children/adolescents affected by Tourette syn-
drome, OCD, and in those where the two disorders co-oc-
curred (Table 1). They found that both reactive and
proactive inhibition were impaired; the impairment scaled
with the severity of OCD symptoms. By contrast, inhibi-
tory control in patients with uncomplicated Tourette syn-
drome was similar to that of typically developing controls.
The simultaneous deficit in proactive and reactive inhibi-
tion makes patients with OCD unable to resist performing
compulsive actions triggered by their obsessive thoughts,
thereby severely decreasing their ability to learn how to
controls urges in the same or similar situations. The
awareness patients with OCD have of a less efficient cogni-
tive control of motor responses in the short and long term
might play a major role in the emergence of anxiety,
depression, and maladaptive beliefs, such as beliefs about
threat overestimation, intolerance of uncertainty, and fear
of losing control over their behaviour.32 The severe dam-
age to inhibitory control mechanisms might also explain
why OCD symptoms tend to persist in adulthood much
more than tic symptoms.33
All this evidence strongly suggests that the cognitive
mechanisms underlying impulse control are very heteroge-
neous and that detailed measurement of inhibition may
help to differentiate distinct disorders qualitatively. This
evidence goes against the view suggesting that inhibitory
impairments represent a transdiagnostic feature of neu-
rodevelopmental disorders with poor impulsivity control.34
In other words, the findings of the current review make
implausible the notion that a common cognitive mecha-
nism underlies inhibitory deficit across different disorders.
CONCLUSIONS
The evidence stemming from the studies reviewed is that
the correspondence between poor impulse control and a
generic deficit in inhibitory control is untenable. This
review focused on the deficit in motor inhibitory control
because this is presumably the most affected domain for
people with poor impulse control. Motor inhibitory con-
trol is a multifaceted process with several subdomains (re-
active, proactive, and automatic inhibition) that, when
damaged, seem to produce unique disorder phenotypes.
Thus, identifying specific inhibitory impairments in urge
control disorders might be extremely important in defining
the disorder and suggesting the most appropriate therapeu-
tic strategies. To conclude, the features of complex neu-
rodevelopmental disorders, such as OCD and ADHD, are
unlikely to depend exclusively on the alteration of the inhi-
bitory function, but also on the way it interacts with the
other executive functions, that is, working memory and
selective attention. The interplay between these executive
functions is what ultimately shapes the agent’s behaviour.
Review 525

A CK N O W L E D G E M E N T S
The author has stated that they have no interests that might be
perceived as posing a conflict or bias.doi: 10.1111/dmcn.14778
SUPPORTING INFORMATION
The following additional material may be found online:
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DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY INVITED REVIEW

CONTROL INHIBITORIO Y RESPUESTAS IMPULSIVAS EN TRASTORNOS DEL NEURODESARROLLO

A menudo se asume que el deterioro del control inhibitorio es el de
ficit central de varios trastornos del neurodesarrollo caracteri-
zados por un control deficiente de los impulsos. Sin embargo, ¿podr
ıa el mismo de
ficit explicar diferentes fenotipos cl
ınicos? La
evidencia de los estudios de comportamiento es muy variada. Esto se debe en parte a que la inhibicio
n es una funcio
n ejecutiva
muy compleja. Por lo tanto, es probable que los diferentes tipos de tareas que generalmente aprovechan el control inhibitorio pro-
porcionen diferentes resultados. Adema
s, la falta de homogeneidad de la muestra en te
rminos de edad, comorbilidad y trata-
miento me
dico son factores de confusio
n. Por tanto, para realizar una valoracio
n fiable del de
ficit de control inhibitorio en un
determinado trastorno, se debe emplear la misma tarea y muestras con caracter
ısticas similares. Este art
ıculo revisa y analiza estu-
dios sobre cinco trastornos del desarrollo neurolo
gico con alteracio
n del control de los impulsos en los que se han utilizado estos
criterios: s
ındrome de Tourette; trastorno obsesivo compulsivo; deficit de atencio
n y trastorno de hiperactividad; estereotipias
motoras primarias; y trastorno del espectro autista. En general, sugieren que los mecanismos subyacentes a la incapacidad para
controlar los impulsos son extremadamente heteroge
neos y no pueden atribuirse a un deterioro general de la inhibicio
n. Estos
hallazgos no apoyan la hipo
tesis de que los de
ficits inhibitorios representen una caracter
ıstica transdiagno
stica de los trastornos
del neurodesarrollo con control deficiente de los impulsos.

CONTROLE INIBITORIO E RESPOSTAS IMPULSIVAS EM TRANSTORNOS NEURODESENVOLVIMENTAIS
A deficie ^ ncia do controle inibito
rio e

frequentemente assumida como o de
ficit central de va

rios transtornos neurodesenvolvimen-
tais caracterizados por pouco controle do impulso. No entanto, o mesmo de
ficit pode explicar diferentes feno
tipos cl
ınicos?
Evide ^ncias de estudos comportamentais sa ~ o muito diversas. Isso se deve parcialmente ao fato de que a inibicßa ~o e
uma funcßa ~o
executiva altamente complexa. Assim, os diferentes tipos de tarefas que genericamente abordam o controle inibito
rio sa~o
prova
veis de fornecer resultados diferentes. Ale
m disso, a falta de homogeneidade das amostras em termos de idade, comorbida-
des, e tratamentos me
dicos sa
~ o fatores de confusa ~o. Portanto, para se fazer uma avaliacßa ~ o confia

vel do de
ficit de controle ini-

rio em uma dada desordem, a mesma tarefa e amostras com caracter
ısticas similares devem ser empregadas. Este artigo
bito
revisa e discute cinco transtornos neurodesenvolvimentais com deficie ^ ncia do controle do impulso em que estes crite
rios foram
empregados: s
ındrome de Tourette; transtorno obsessivo compulsivo; estereotipias motoras prima
rias; e transtorno do espectro
autista. Em geral, eles sugerem que os mecanismos subjacentes a  capacidade de controlar
ımpetos sa ~ o extremamente hete-
roge ^neos e na ~ o podem ser circunscritos a uma deficie ~o Estes achados na
^ncia geral de inibicßa ~o sustentam a hipo
tese de que os
de
ficits inibito
rios representam um aspecto transdiagno
stico dos transtornos neurodesenvolvimentais com pouco controle dos
impulsos.