If someone doesn’t value spending time with me as much as I value spending time with them, I feel rejected. Last month, I said to one of my closest friends that I would like to hang out with him more like we used to. He said that he was cool with the way things are. This hurts a lot. What can I do to make this less painful?”

When teens with ADHD struggle with rejection sensitive dysphoria, it affects their relationships — and their self-esteem. Often, they don’t know how to cope with their intense emotions and, feeling overwhelmed, they may lash out at friends and/or family members.

[Read: Why ADD Makes You Feel. So. Much.]

One of my teen clients told me: “When I come home from school, sometimes I just can’t hold it all together. I yell at my mom and then I feel bad afterward, but I know that I can’t get kicked out of my family.” Other kids will withdraw quietly into their rooms and swallow their pain. As parents, there’s a fine line between supporting your adolescent in managing their big feelings and intervening to diminish their distress.

While some ADHD non-stimulant medications or antidepressants, such as SSRIs, can reduce sensitivity and overwhelm, the following behavioral tools can be very effective to quiet the inner critic, shift perspectives, and develop self-confidence.

Sharon Saline, Psy.D., a licensed clinical psychologist, is an expert in how ADHD, learning disabilities, and mental health issues affect children, teens, and families. She is the author of What Your ADHD Child Wishes You Knew.

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Social anxiety is a debilitating fear of judgment, humiliation, or rejection by others in social situations. Socially anxious adults carry distorted, negative self-perceptions driven by a core belief of deficiency. This restricts their participation in activities, relationships, and other areas of life.

We know that anxiety and ADHD frequently co-occur. Experiences common to ADHD, like rejection sensitive dysphoria, shame, and emotional dysregulation, may exacerbate social anxiety. ADHD symptoms, like hyperactivity and inattention, may also undermine social skills and cause difficulties. Social anxiety treatment often involves behavioral interventions and working to improve social skills.

Signs of Social Anxiety

Intense fear of negative judgment from others is a common marker of social anxiety disorder. Other signs include:

• Discomfort interacting with people outside the immediate family
• Difficulty making or keeping friends
• Excessive worry in the days or weeks leading up to an event
• Fear of being observed (e.g., when eating and drinking)
• Fear of performing in front of others
• Avoiding places or events that involve socializing
• Nausea, shaking, or excessive perspiration in social environments

Fear, anxiety, or avoidance of social situations must cause clinically significant impairment and persist for at least six months to merit a diagnosis.

[Self-Test: Does My Child Have Generalized Anxiety Disorder?]

Social Anxiety Treatment: Behavioral Interventions

Cognitive behavioral interventions effectively target the distorted thoughts that fuel social anxiety. Medication for anxiety may help, but as with ADHD, pills don’t teach skills. To cope with social anxiety, find ways to reduce your worries.

1. Shift your thinking. Identify limiting core beliefs and notice negative self-talk. What social situations trigger those thoughts and worries?
2. Recall positive social experiences. Anxiety erases memories of courage and success. Think back to times when you rose to a challenge despite your fears. What steps did you take?
3. Stay in the moment. Show curiosity about others and practice reflective listening, such as nodding. Notice your surroundings. Take deep breaths to quell physical symptoms.
4. Build up tolerance. Gradually expose yourself to low-risk, uncomfortable social situations. Join a hiking group, for example, and smile at a few new faces. On the second hike, talk to a few people. You might feel awkward and nervous, but you’ll see that you’ve survived.
5. Foster connection. Pay attention to body language that signals interest (like a relaxed posture) versus discomfort (looking away). Ask open-ended questions to encourage conversation and let others know that you’re listening.

[Download: Social Anxiety Facts and Falsehoods]

Improve Social Skills with an APPLE

To navigate social situations:

• Ask to join in a conversation.
• Physical proximity and volume. Are you too close? Too loud?
• Participate with curiosity. Use reflective statements and ask open-ended questions.
• Listen and lay off the self-criticism.
• Enjoy connection. Share what’s special and fun about you.

Social Anxiety in Children: Next Steps

• Download: Get a Grip on Tough Emotions
• Watch: Anxiety in Children: Overlooked Signs and Effective Supports
• Read: How Can I Help My Son Overcome Social Anxiety?

Sharon Saline, Psy.D., a licensed clinical psychologist, is an expert in how ADHD, learning disabilities, and mental health issues affect children, teens, and families. She is the author of What Your ADHD Child Wishes You Knew.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

• The ability to inhibit inappropriate responses triggered by strong emotions
• The ability to self-soothe to reduce the severity of an intense emotion
• The ability to refocus attention from emotionally provocative events
• The ability to substitute healthier responses in the interest of long-term welfare

Though it’s not included in the condition’s DSM-5 criteria, DESR and emotional impulsivity are fundamental components of ADHD that shape an individual’s experiences and challenges throughout their lifetime.

Because DESR is a novel concept to many, questions abound. Below, I answer several posed during my recent ADDitude webinar titled “Deficient Emotional Self-Regulation: The Overlooked ADHD Symptom That Impacts Everything.”

Q: Does emotional dysregulation change over time? Does it ever improve?

Emotional dysregulation does change and it can improve, but it depends on the individual and the factors involved. For instance, emotional self-regulation is rarely elevated as an issue in toddlers. We don’t expect 4-year-olds to manage their emotions very well. Parents are typically more concerned with the impulsive aspect of emotion at this stage.

But by the time we get into late adolescence, and especially adulthood, we do expect individuals to have developed that second stage of emotional control: top-down executive management (or moderating emotional reactions to evocative events). However, DESR impairs just that —processes related to emotional self-regulation. And that leads to more disparaging moral judgment about adults with ADHD than it would in much younger individuals.

It’s almost like the two components of this emotion problem in ADHD — emotional impulsivity (EI) and DESR — trade places as individuals age. The former is more problematic in children, while the latter becomes a more compelling deficit for the adult individual.

[Get This Free Download: 5 Emotional Control Strategies for Kids with ADHD]

We also know that ADHD symptoms fluctuate over time for many individuals, which may mean that issues like emotional dysregulation also change in severity or degree of impairment. And keep in mind that ADHD mostly persists to some degree from childhood to adulthood for 90% of people.

But can emotional regulation be “trained?” In children, the chances of that are quite slim because they haven’t yet developed the appropriate self-regulation skills that such training would require. Interventions like medication, parent training, and controlling for environmental triggers may be most helpful for this stage. Adults, however, may benefit from cognitive behavioral therapy (CBT) and mindfulness-based programs especially reformulated for adult ADHD in recent books, both of which help the individual deal with many aspects of emotional dysregulation.

Q: Do men and women with ADHD experience emotional dysregulation differently?

Generally, we know that males are more prone to exhibit aggression and hostility, which are associated with externalizing disorders, while females are more prone to anxiety and mood disorders. Both, however, do struggle with impatience and frustration, and the emotional dysregulation component in ADHD will only exacerbate that.

Q: When might DESR symptoms start to appear in children?

DESR usually appears between ages 3 and 5, though it may be quite obvious in a younger child who is significantly hyperactive and impulsive. Still, many families write off this behavior, believing it to be developmentally normal (i.e. the terrible twos), only realizing later on that the child is quite hot-headed and emotional compared to peers. Some of these children will go on to develop oppositional defiant disorder (ODD). If we accept DESR as a core feature of ADHD, we can see why the disorder poses such a significant risk for ODD and related disorders.

[Read: Why Is My Child So Angry and Defiant? An Overview of Oppositional Defiant Disorder]

Q: Can parents manage DESR in children with ADHD without medication?

It will be very, very difficult to do so. With ADHD in children, we’re looking at a dysregulated brain with a highly variable, immature executive circuitry — part of which includes this problem with emotional expression and regulation. To expect to try to find some other social or psychological intervention that can change that underlying neural network problem is asking for too much of psychotherapy. It may be best to work with the aforementioned interventions as parents await the greater maturity of these neurological systems that comes with further development.

Q: Is there residual emotional difficulty in children and adults even after taking ADHD medication?

Yes — sometimes medications can create their own problems. Stimulants, for example, may create emotional blunting, which is the absence of natural emotion in some children or adults. As stimulants wear off, it’s not uncommon for the emotional brain to go through a rebound. In some cases, that may look like irritability, a proneness to weepiness or crying, and sadness.

These experiences with stimulants are not universal, but remember that you’ve been suppressing an emotional brain and, as medication wears off, that could come to the fore. We don’t see this issue with non-stimulants so much because they’re not suppressing the emotional circuitry of the brain. Ultimately, each drug works on the brain a little differently, and therefore works on emotion a little differently. It’s why some clinicians sometimes opt to combine these medications to get much broader coverage over patient symptoms than any single drug could do alone.

Q: You noted that a parent’s own ADHD symptoms could exacerbate their child’s symptoms and thus make emotional dysregulation worse. Can you give some examples?

Let’s say a child is engaging in some defiant, oppositional behavior. A parent with ADHD may experience a much stronger reaction to that compared to a typical parent. They might exhibit a more impulsive reaction of anger or hostility toward the child, or they may arrive at that level of emotional upset faster than would a parent without ADHD.

When a parent exhibits these behaviors, they are, in effect, modeling these reactions to their child. They are also provoking the child, who has their own emotional regulation problems. What you have, I think, is an emotional tornado in the family — each person is triggering the other to higher levels of conflict.

Q: Does trauma exacerbate DESR? What about PTSD?

It’s bi-directional. Research suggests that ADHD, because of the emotional dysregulation factor, especially, puts children at a higher risk for exposure to trauma. And once trauma has occurred in a child with ADHD, it’s more likely to progress to a PTSD reaction. This is why ADHD is one of the strongest predictors of who will develop PTSD if exposed to trauma. Once PTSD develops, it will only worsen existing emotional regulation problems.

Q: Is it ever too late to get help for emotional dysregulation?

Absolutely not. It is never too late to get help for ADHD and its symptoms, even if emotional dysregulation has been an impairing factor for a long time. Multiple studies show that a diagnosis in late life and subsequent treatment only benefits the individual.

DESR and Emotional Dysregulation: Next Steps

• Free Download: 9 Truths About ADHD and Intense Emotions
• Read: How’s Your Emotional Resilience? Learning to Cope with Intense ADHD Feelings
• Read: The ADHD-Anger Connection: New Insights into Emotional Dysregulation and Treatment Considerations

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Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Deficient emotional self-regulation (DESR) is a relatively new term used to describe the problem of impulsive emotion coupled with emotional self-regulation difficulties — issues long associated with attention deficit hyperactivity disorder (ADHD or ADD). DESR may be new to the ADHD lexicon, however I argue that it is a core and commonly overlooked component of the disorder — and one that can help predict a patient’s impairments, and even improve diagnostic and treatment practices.¹

Emotional dysregulation is noticeably missing from diagnostic criteria for ADHD. However, most patients and experts recognize that it is central to the disorder². DESR, a manifestation of emotional dysregulation, specifically refers to deficiencies with these four components of emotional self-regulation³:

• Ability to inhibit inappropriate behavior triggered by strong emotions. I argue that this emotional impulsiveness (EI) is an aspect of poor inhibition associated with ADHD that is illustrated by low frustration tolerance, impatience, being quick to anger, aggression, greater emotional excitability, and other negative reactions, all of which are related to the impulsivity dimension of the disorder
• Ability to self-soothe and down-regulate a strong emotion to reduce its severity
• Ability to refocus attention from emotionally provocative events
• Ability to organize or substitute more moderate, healthier emotional responses in the service of goals and long-term welfare

To understand the role of EI and DESR in ADHD is to acknowledge the prominent role of emotional control difficulties in the disorder’s appearance and outlook, including understanding the following:

• Why these issues are prevalent in individuals with ADHD
• Why major comorbid disorders often develop as a result of these challenges
• The major life impairments not adequately explained by traditional symptoms of ADHD

A wealth of compelling evidence — from ADHD’s clinical conceptualization over time to neuroanatomical and psychological research — clearly shows that EI and DESR are key components of ADHD and should be incorporated into the disorder’s diagnostic criteria and treatment practices.

[Free Download: 15 Ways to Disarm (and Understand) Explosive ADHD Emotions]

EI and DESR: Evidence of Its ADHD Ties

1. EI and DESR in Historical Concepts of ADHD

Conceptualizations of ADHD have included emotional control problems for centuries. One of the earliest references to attention disorder in western medical literature⁴, a textbook written by German physician Melchior Adam Weikard in 1770, characterizes those who have a “lack of attention” as “unwary,” “flighty,” “careless,” mercurial,” and “bacchanal.”

EI and DESR through history⁴:

• 1798: Alexander Crichton, a Scottish-born physician, includes emotional frustration in his description of disorders of attention, especially problems with persistent attention
• 1902: George Still, a British physician widely considered to be the “founder” of ADHD, includes emotional impulsiveness and poor regulation of emotions in his conceptualization of “defective moral control of behavior” (the precursor to ADHD)
• 1960s-1970s: Major clinical researchers at the time — including Mark Stewart, Dennis Cantwell, and Paul Wender — include emotion as a core feature in their concepts of “hyperactive child syndrome (now ADHD).”

So why isn’t emotion considered in the diagnostic criteria for ADHD today?

• 1968: DSM-II references ADHD for the first time (as hyperkinetic impulse disorder) but fails to list EI or DESR as a feature of the disorder. It is excluded from all future DSMs, for unknown reasons, despite continuing research linking emotion to ADHD.

2. EI and DESR and the Neuroanatomy of ADHD

The brain structures and networks implicated in ADHD are also involved in emotion and would thus logically be expected to give rise to EI and DESR and be part of the disorder.
The frontal lobe, the anterior cingulate, the ventral striatum, and the amygdala all comprise the executive circuitry that has been repeatedly shown to be involved in causing ADHD². Some of these structures also form the brain’s emotional circuitry — the amygdala and larger limbic system to which it is connected is where emotion is generated, and the prefrontal cortex and related structures attend to these generated emotions. Thus, how we feel also influences how we think, and the dorsolateral PFC is where some thinking occurs, as well as working memory (or what we are holding in mind).

[The ADHD-Anger Connection: New Insights into Emotional Dysregulation]

3. EI and DESR in Neuropsychological Theories of ADHD

The frontal-limbic circuit — one of the four executive networks of the brain — is associated with ADHD and with symptoms of emotional dyscontrol, motivation deficits, hyperactivity-impulsivity, and aggressive tendencies. This emotional regulation network is also known as the “hot” circuit. I also refer to it as the “why” circuit, because it’s absolutely crucial in decision making.

This network is also connected to the other executive networks that we know are implicated in ADHD. ADHD, of course, would be expected to disrupt this emotional regulation network substantially.

4. EI and DESR in ADHD Psychological Research

Emotional self-regulation is a major dimension of executive functioning required for daily life activities. It is also one of the most impaired dimensions in children and adults with ADHD^{5 6}. Ample evidence from an abundance of psychological research shows that children and adults with ADHD are highly likely to manifest EI-DESR² including low frustration tolerance⁷, anger, poor inhibition of emotion, and emotional excitability^{8 9}.

Additional research on EI-DESR and ADHD:

• Meta-analysis: Emotional dysregulation is a core feature of ADHD’s psychopathology in adults¹⁰
• Developmental studies on preschool children find that negative temperament, irritability, and poor emotional regulation are strong predictors for ADHD later in life^{11 12}
• Studies on family genetics and ADHD show that the genes implicated in ADHD are also responsible for associated emotional problems¹³

5. EI and DESR Underpinning ADHD Comorbidities

Putting impulsive emotion and emotional self-regulation problems back into the realm of ADHD also helps us understand the basis for several of the comorbid conditions commonly associated with ADHD, especially that of oppositional defiant disorder (ODD)¹⁴.

ODD is two-dimensional, comprising aspects of social conflict and emotion dysregulation. These two dimensions significantly contribute to the risk for later disorders. The emotional dimension, for example, in children contributes to the later risk for anxiety and mood disorders in teens.

Given ADHD’s prevalence in ODD, we can assume that the emotional component of ODD arises biologically from ADHD. That is, ADHD likely creates one of the two dimensions involved in ODD. Indeed, the longer ADHD goes untreated and emotions remain dysregulated, the greater the odds that comorbid conditions, particularly anxiety disorders, will develop¹⁵. This framework helps us understand why emotion and ODD are managed so well by ADHD medication, but only if ADHD is also present¹⁶.

Meanwhile, the social component of ODD predicts later conduct disorder and antisocial behavior. This component of ODD, contrary to the biological aspect of emotionality, is likely learned, most often within family interactions.

6. EI and DESR and Impairment in Major Life Activities

Centering the role of emotion in ADHD predicts a variety of impairments that are not similarly associated with the traditional symptoms of ADHD: hyperactivity, inattention, and/or impulsivity.

Emotional dysregulation has been shown to uniquely predict the following⁶

• social rejection in children with ADHD
• interpersonal hostility and marital dissatisfaction in adults with ADHD
• greater parenting stress and family conflict in parents of children with ADHD; greater stress in parents with ADHD
• road rage, DUIs, and crash risks during driving
• job dismissals and workplace interpersonal problems
• dating/cohabiting relationship conflict
• impulse buying; poor finances

EI and DESR: Diagnostic Implications

Elevating EI-DESR’s place in ADHD would greatly assist with differential diagnosis of the disorder from mood disorders and other conditions involving emotional dysregulation. In other words, it would reduce the odds of misdiagnosis for patients who are simply experiencing what is central to ADHD itself. (Individuals with ADHD are commonly misdiagnosed with mood disorders.¹⁷)

Mood disorders, however, are common in individuals with ADHD, so comorbidity must be considered¹⁸. Duration could be a guiding diagnostic principle used to distinguish a legitimate mood disorder from the emotional dysregulation associated with ADHD. Emotions, unlike moods, are of short duration, setting-specific, provoked, and easily traced to the source. EI-DESR is a “top-down” deficit in regulating rational emotional responses to events; its impact is typically shorter in duration than that of a mood disorder.

Mood disorders are generally “bottom-up” excessive expressions of emotions likely attributed to underlying amygdala-limbic system activities. Moods are of long duration — lasting hours, days, or weeks. Moods are cross situational, and irrational in the case of mood disorders (it is often not clearly understood, for example, what triggers a patient with bi polar disorder to become manic, or the opposite).

EI and DESR: Treatment Considerations

Re-centering ADHD on emotions also helps us understand treatment outcomes. It’s why we often observe that ADHD medications impact core EI and DESR problems in patients with ADHD, albeit in different ways¹⁹. Stimulants appear to quell and even dampen the limbic system, sometimes leading to complaints from patients about having robot-like, bland emotions. Non-stimulants like atomoxetine, on the other hand, act on a different part of the brain. They help to up-regulate the executive brain, giving patients more self-control of emotion. Prescribers sometimes utilize different drug combinations to allow patients more control over ADHD, including emotional problems.

Other treatment implications:

• Secondary impairments from EI-DESR on major life activities may also be improved by ADHD medication.
• Cognitive behavioral therapy (CBT) programs that target EF deficits, along with mindfulness-based approaches, might help with emotional regulation in adults with ADHD, especially if they are taking ADHD medication.
• In children, emotional dysregulation is better handled through medication and then, to some extent, through behavioral parent training programs that focus on restructuring situations and interactions so as not to trigger strong impulsive emotions.
• Parental ADHD could contribute to emotional dysregulation in children with ADHD, not just genetically through inheritance, but through modeling of poor emotional control and by engaging in emotionally provocative encounters with the child. Clinicians should screen parents for ADHD and treat their symptoms as well.

EI and DESR: Conclusions

Impulsive emotion and emotional dysregulation are core facets of ADHD. Impulsive emotion is linked to the impulsivity dimension of ADHD, and difficulties with emotional control is part of the large inattentive/executive dimension of ADHD. Historical concepts of ADHD include EI-DESR, and research in the fields of neuroanatomy, neuropsychology, and psychology also link ADHD to EI and DESR. This core relationship may help to explain, at least in part, why the disorder poses high risk for ODD and mood disorders, as well as the unique impairments some patients experience.

By recognizing that EI and DESR are involved in ADHD, we can significantly improve diagnostic and treatment practices.

DESR and EI with ADHD: Next Steps

• Essential Reading: New Insights Into Rejection Sensitive Dysphoria
• Free Download: 9 Truths About ADHD and Intense Emotions
• Read: Why We Feel So Much — and Ways to Overcome It
• Read: Learning to Cope with Intense ADHD Feelings

The Clinicians’ Guide to Differential Diagnosis of ADHD from Medscape and ADDitude

• How can I better understand ADHD, its causes, and its manifestations?
• What do I need to understand about ADHD that is not fully represented in the DSM?
  • How does ADHD impair the areas of the brain responsible for executive function?
  • Why does ADHD impact a patient’s sleep?
  • What is complex ADHD?
  • Is rejection sensitive dysphoria a symptom of ADHD?
  • What do I need to know about the latest research on ADHD and emotional dysregulation?
  • How can clinicians address the stigma around ADHD in Black communities to ensure better healthcare?
  • Free Webinar: Deficient Emotional Self-Regulation (DESR) and ADHD?
  • Free Webinar: Understanding Complex ADHD
  • Free Webinar: How ADHD Shapes Your Perceptions, Emotions & Motivation
• How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
• How can I best consider psychiatric comorbidities when evaluating a patient for ADHD?
• How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
• How can I best consider trauma and personality disorders through the lens of ADHD?
• What diagnostic criteria and tests are recommended for performing a differential diagnosis of ADHD?

The content for this article was derived from the ADDitude Expert Webinar Deficient Emotional Self-Regulation: The Overlooked ADHD Symptom That Impacts Everything [Video Replay & Podcast #369] with Russell Barkley, Ph.D., which was broadcast live on August 26, 2021.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Sources

¹Barkley, R. A. (2015). Emotional dysregulation is a core component of ADHD. In R. A. Barkley (Ed.), Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (pp. 81–115). The Guilford Press.

²Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014). Emotion dysregulation in attention deficit hyperactivity disorder. The American journal of psychiatry, 171(3), 276–293. https://doi.org/10.1176/appi.ajp.2013.13070966

³Koole, S. et.al. (2011). The self-regulation of emotion. In Vohs, K., Baumeister, R. (Eds).Handbook of self-regulation, second edition: research, theory, and applications.(pp 22-40). Guilford Press.

⁴Barkley, R. A., & Peters, H. (2012). The earliest reference to ADHD in the medical literature? Melchior Adam Weikard’s description in 1775 of “attention deficit” (Mangel der Aufmerksamkeit, Attentio Volubilis). Journal of attention disorders, 16(8), 623–630. https://doi.org/10.1177/1087054711432309

⁵Barkley, R. A. (2012). The Barkley Deficits in Executive Functioning Scale: Children and Adolescents.New York: Guilford Press.

⁶Barkley RA, Fischer M. The unique contribution of emotional impulsiveness to impairment in major life activities in hyperactive children as adults. Journal of the American Academy of Child & Adolescent Psychiatry. 2010;49(5):503–513.

⁷Seymour, K. E., Macatee, R., & Chronis-Tuscano, A. (2019). Frustration Tolerance in Youth With ADHD. Journal of attention disorders, 23(11), 1229–1239. https://doi.org/10.1177/1087054716653216

⁸Jensen, S. A., & Rosén, L. A. (2004). Emotional reactivity in children with attention-deficit/hyperactivity disorder. Journal of attention disorders, 8(2), 53–61. https://doi.org/10.1177/10870547040080020.

⁹Barkley, R. A. & Murphy, K. R. (2011). Deficient emotional self‐regulation in adults with ADHD: The relative contributions of emotional impulsiveness and ADHD symptoms to adaptive impairments in major life activities. Journal of ADHD and Related Disorders, 1(4), 5‐28.

¹⁰Beheshti, A., Chavanon, M. L., & Christiansen, H. (2020). Emotion dysregulation in adults with attention deficit hyperactivity disorder: a meta-analysis. BMC psychiatry, 20(1), 120. https://doi.org/10.1186/s12888-020-2442-7

¹¹Dougherty, L. R., Smith, V. C., Bufferd, S. J., Kessel, E., Carlson, G. A., & Klein, D. N. (2015). Preschool irritability predicts child psychopathology, functional impairment, and service use at age nine. Journal of child psychology and psychiatry, and allied disciplines, 56(9), 999–1007. https://doi.org/10.1111/jcpp.12403

¹²Vogel, A. C., Jackson, J. J., Barch, D. M., Tillman, R., & Luby, J. L. (2019). Excitability and irritability in preschoolers predicts later psychopathology: The importance of positive and negative emotion dysregulation. Development and psychopathology, 31(3), 1067–1083. https://doi.org/10.1017/S0954579419000609

¹³Merwood, A., Chen, W., Rijsdijk, F., Skirrow, C., Larsson, H., Thapar, A., Kuntsi, J., & Asherson, P. (2013). Genetic association between the symptoms of attention‐deficit/hyperactivity disorder and emotional lability in child and adolescent twins. Journal of the American Academy of Child and Adolescent Psychiatry, 53(2), 209‐220.

¹⁴Connor, D. Steeber, J. et.al.(2010) A review of attention-deficit/hyperactivity disorder complicated by symptoms of oppositional defiant disorder or conduct disorder. Journal of Developmental & Behavioral Pediatrics, 31(5), 427-440. doi: 10.1097/DBP.0b013e3181e121bd

¹⁵Geffen, J., & Forster, K. (2018). Treatment of adult ADHD: a clinical perspective. Therapeutic advances in psychopharmacology, 8(1), 25–32. https://doi.org/10.1177/2045125317734977

¹⁶Newcorn, J. H., Spencer, T. J., Biederman, J., Milton, D. R., & Michelson, D. (2005). Atomoxetine treatment in children and adolescents with attention-deficit/hyperactivity disorder and comorbid oppositional defiant disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 44(3), 240–248. https://doi.org/10.1097/00004583-200503000-00008

¹⁷Ginsberg, Y., Quintero, J., Anand, E., Casillas, M., & Upadhyaya, H. P. (2014). Underdiagnosis of attention-deficit/hyperactivity disorder in adult patients: a review of the literature. The primary care companion for CNS disorders, 16(3), PCC.13r01600. https://doi.org/10.4088/PCC.13r01600

¹⁸Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC psychiatry, 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3

¹⁹Schulz, K. P., Fan, J., Bédard, A. C., Clerkin, S. M., Ivanov, I., Tang, C. Y., Halperin, J. M., & Newcorn, J. H. (2012). Common and unique therapeutic mechanisms of stimulant and nonstimulant treatments for attention-deficit/hyperactivity disorder. Archives of general psychiatry, 69(9), 952–961. https://doi.org/10.1001/archgenpsychiatry.2011.2053

Maybe it sounds strange to label my diagnosis as a good thing. But it is – because knowing that I have an ADHD brain explains so much about my life and my experiences that previously didn’t make sense. My diagnosis was like a blurry lens suddenly coming into focus.

It was a long, four-year journey from thinking I could have ADHD to finally getting an official diagnosis. Learning about RSD was actually one of the first dominos to fall.

You see, I had spent nearly 40 years unknowingly masking and compensating for what I now know are ADHD symptoms. As I had done all my life, I felt I could continue to learn new strategies to work with time blindness, executive dysfunction, and other issues. But something was amiss – the emotional component seemed to be getting worse, not better, with age.

As I researched ADHD and intense emotions during those pre-diagnosis years, I learned that guanfacine and clonidine, both blood-pressure medications, are sometimes used to treat RSD symptoms in ADHD patients. And as I learned about people’s experiences on these medications and how their emotional symptoms dissipated, I thought, That’s what I want.

[Read This: New Insights Into Rejection Sensitive Dysphoria]

The Rejection Sensitive Dysphoria Experience

For anyone who doesn’t experience RSD, let me try to describe it.

Let’s say I read something directed toward me that isn’t really a rejection or criticism, but feels like it could be. Before I can even think, my guts immediately feel like they are in a giant blender. My veins feel like they are on fire. Then, my brain clicks into full panic mode, spinning scenarios about how the person on the other end of the message doesn’t like me. My brain then decides that no one, in fact, likes me.

Even if I know these thoughts to be objectively false, I worry that they could be true. The episode comes on quickly, and it consumes my entire day. Efforts to “calm down” barely seem to make a dent.

It’s not that people with RSD want to feel this way. It very much feels out of our control, which is why it’s frustrating to hear advice like, “Everyone is in control of their feelings.” That’s just not true for those of us with RSD, and for many other people with the emotional dysregulation associated with ADHD.

[Click to Read: Shame – The Devil on My Shoulder]

Besides, my reactions feel valid to me. They are an appropriate response to the situation, according to my brain in that moment.

I think of RSD and emotions like tsunamis versus regular waves. If you are neurotypical, the waves in your emotional sea could be calm, or choppy, or even harrowing. But, for the most part, you can ride out the waves, maybe even swim or play or surf on them.

With RSD, you have a fairly calm sea interrupted by frequent tsunamis. They come on suddenly, without warning, triggered by things you cannot control. And once you realize what’s about to happen, you have two choices – get out of Dodge, or stay and risk drowning. Either way, you are displaced, and left to deal with the destruction left behind. 

Plus, no one ever talks about controlling a tsunami.

Coming to Terms with Rejection Sensitive Dysphoria

Despite all the problems inherent to RSD, it is not the worst thing in the world, even when I believe it to be in the moment. Just as a force of nature can be powerful and destructive, RSD can also bring me to my knees in awe and wonder. It feels amazing and special to be able to contain such enormous, intense feelings – and come out on the other side.

I’ve also realized that it’s not me who feels most uncomfortable with RSD – it’s those around me. For them, it would be easier if I could just make my feelings “smaller.” But I don’t always have that option. Over the years, RSD has wreaked havoc on my relationships — friendships, family, and even professional connections. The memories and the losses are painful to think about.

Thankfully, guanfacine has been an absolute game-changer for my RSD.

Nothing changed overnight, but slowly I noticed that situations and remarks that normally would have sent me over the edge were not doing so. I was perceiving them as neutral.

Don’t get me wrong – I still feel the pain sometimes. It’s just not as excruciating.

Is this how “normal” people feel all the time? Who knew! No wonder they were so confused by me before.

But also, how sad. How much of my life have I spent feeling physically ill and mentally anguished over situations that perhaps were not as threatening as they seemed to be? How many of us have endured “helpful” critiques about controlling feelings — ones that suggested our reactions were a personal failing — when we weren’t failing at all? We were doing the best we could.

Now that I am starting to see RSD in the rearview mirror, I feel grateful that I have a little bit of extra mental space, the “spoons” to deal with the challenges in my life. But at the same time, I can look back and feel grateful for my RSD.

I was blessed with an immense capacity for feeling, and I love that. It has made me a stronger person, a more empathic person. Though the painful moments were plentiful, I can’t deny that those powerful feelings probably steered me away from situations that were not beneficial to me in the long run.

Ultimately, I know that what might have appeared like “weakness” to some was actually, all along, my greatest source of strength.

ADHD Rejection Sensitive Dysphoria: Next Steps

• Self-Test: Could You Have Rejection Sensitive Dysphoria?
• Download: Understanding Rejection Sensitive Dysphoria
• Read: Why ADD Makes You Feel. So. Much.

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Academia is founded on criticism. A crucial and unavoidable part of this process is receiving feedback from my committee. So, I recently sent out an email requesting necessary revisions so I can be done with this. This is time-sensitive stuff. To defend my dissertation this semester, and avoid additional financial expense, I have to implement the feedback to get the project ready for defense. So, when responses to my email started coming in, I hurried to open them so I could see what my mentors said.

Not really. I was terrified of the content of those emails. Despite my intense desire to complete my degree and the ticking clock on defending this semester, I spent hours, if not days, working up the nerve to read what my advisors think of my work. This was followed by hours, if not days, of recovering from the criticism they provided, no matter how constructive, no matter how kindly it may have been offered.

The Surprise of RSD

When I started the Ph.D. program, I assumed that the forgetful, inattentive aspect of my ADHD would be the most difficult part to overcome. And it has been difficult — sitting through classes, reading boring books, and consistently attaining and maintaining a level of focus and concentration necessary for this work. But I’ve spent the last 15 to 20 years developing strategies to overcome these challenges of ADHD. So instead, my greatest challenge is something I didn’t know existed until a couple years ago: Rejection Sensitive Dysphoria (RSD), the intense emotional discomfort and pain I feel due to criticism or rejection (perceived or real) from others.

RSD is a disabling feature of ADHD. Like all other aspects of ADHD, it’s a feeling that everyone feels at various times. Yet the frequency, and intensity of these feelings, separate these feelings from typical responses to perceived rejection. It is difficult to find words to describe the intense emotional discomfort that rejection or criticism produce. As with much of my experience with ADHD, it is when I research and see how intensely this can affect people that I realize how fortunate I am to experience a version of it that is manageable.

[Do I Have Rejection Sensitive Dysphoria? Take This Test]

The Pain of RSD

Almost all teens and adults with ADHD are more sensitive than others to perceived criticism, and nearly a third report that this is the most difficult aspect of ADHD to live with. While RSD is not ubiquitous — like inattentiveness, forgetfulness, impulsivity, and the features most commonly associated with ADHD — it is, for me, the most painful symptom.

RSD can dominate people’s lives, driving them to please and impress those around them. Or it can produce the opposite effectt, leading individuals to withdraw from social interactions. When it is internalized, its effects range from low self-esteem to suicidal ideation. When it is externalized, it often results in intense and inexplicable anger directed at the source of the rejection.

Those of us with RSD are more sensitive to criticism, often perceiving it where none exists. Yet, it is not always imagined, since most of us grew up labeled the “problem child,” receiving more than our fair share of criticism from those we looked to for approval. It can degenerate into a self-fulfilling prophesy, with our sensitivity to criticism causing us to act in ways that draw the very criticism we fear.

For me, RSD often manifests as general anxiety, caused by a subconscious fear of embarrassment. It also results in my feeling that those in my life me don’t like me as much as they seem to (pretend to). The feelings can be acute. The knowledge that I am overreacting does nothing to alleviate the crippling agony that criticism can produce, especially when it comes from a source that is important to me and touches on important subjects.

[Use This Free Resource: Understanding Rejection Sensitive Dysphoria]

The Way Forward with RSD

Which brings me back to those emails, written by people I respect and admire, written about a project into which I have invested so much of myself that it feels like an actual part of me. That reluctance to confront the criticism contained in these messages suddenly makes a bit more sense. Soon, I will tear off the bandage — a metaphor that seems so inadequate in describing the intense, personal, emotional discomfort I feel.

If I’m lucky, it will turn out to be a good day, and I’ll be able to set aside that pain and feel inspired to improve my dissertation. If it’s not a good day, I’ll take my embarrassment and my certainty that, no matter what they say, these folks are deeply disappointed in me. I’ll climb into a hole somewhere while I go through the routine of pain, embarrassment, anger, and eventual acceptance.

Assuming I can overcome the sense that I am simply not good enough to do this — the feeling that this perfectly ordinary struggle to bring a dissertation to defense is a sign that my reach has exceeded my grasp — I’ll sit down and write. If I go through this process enough times, I will soon defend and earn a Ph.D. in history. It will be worth it.

Overly Sensitive with RSD: Next Steps

• Understand: Exaggerated Emotions: How and Why ADHD Triggers Intense Feelings
• Read: New Insights into Rejection Sensitive Dysphoria
• Learn: Why You Feel Rejection So Intensely

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Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Rejection sensitive dysphoria is not a formal diagnosis, but rather one of the most common and disruptive manifestations of emotional dysregulation — a common but under-researched and oft-misunderstood symptom of ADHD, particularly in adults. Rejection sensitive dysphoria is a brain-based symptom that is likely an innate feature of ADHD. Though the experience of rejection sensitive dysphoria can be painful and even traumatic, RSD is not thought to be caused by trauma.

Dysphoria is the Greek word meaning unbearable; its use emphasizes the severe physical and emotional pain suffered by people with RSD when they encounter real or perceived rejection, criticism, or teasing. The emotional intensity of RSD is described by my patients as a wound. The response is well beyond all proportion to the nature of the event that triggered it.

One-third of my adult patients report that RSD was the most impairing aspect of their personal experience of ADHD, in part because they never found any effective ways to manage or cope with the pain.

What Triggers Rejection Sensitive Dysphoria?

Sometimes called hysteroid dysphoria in Europe, rejection sensitive dysphoria is characterized by intense mood shifts triggered by a distinct episode, typically one of the following:

• rejection (the real or perceived withdrawal of love, approval, or respect)
• teasing
• criticism, no matter how constructive
• persistent self-criticism or negative self-talk prompted by a real or perceived failure

The new mood sweeps in immediately and it matches the individual’s perception of the trigger. If these triggered emotions are internalized, the person can instantaneously appear as if they have a full Major Mood Disorder syndrome complete with suicidal thinking. If the feelings are externalized, they are commonly expressed as a rage at the person or situation that wounded them so severely. The moods return to normal very quickly so that a person with ADHD can have multiple episodes of mood dysregulation in a single day.

[Self-Test: Rejection Sensitive Dysphoria in Adults]

Many people with RSD say it’s always been a part of their lives, however some report growing significantly more sensitive in adolescence.

What Are the Outward Signs of Rejection Sensitive Dysphoria?

Individuals suffering from rejection sensitive dysphoria may exhibit the following behaviors:

• Sudden emotional outbursts following real or perceived criticism or rejection
• Withdrawal from social situations
• Negative self-talk and thoughts of self-harm
• Avoidance of social settings in which they might fail or be criticized (for this reason, RSD is often hard to distinguish from Social Anxiety Disorder)
• Low self-esteem and poor self-perception
• Constant harsh and negative self-talk that leads them to become “their own worst enemy”
• Rumination and perseveration
• Relationship problems, especially feeling constantly attacked and responding defensively

What Does Rejection Sensitive Dysphoria Feel Like?

The excruciating pain of RSD is often beyond description. Patients describe the intensity of RSD as “awful,” “terrible,” “catastrophic,” or “devastating,” but they cannot verbalize the quality of the emotional experience.

[Watch This: The Emotional Dysregulation of ADHD]

No one likes to be rejected, criticized, or to be seen as a failure. It is unpleasant, so people avoid those situations if they can. RSD is distinguished by its extreme, unbearable intensity, which sets it apart from normal emotional responses familiar to people who are neurotypical.

This intense pain is often experienced as a physical “wound;” the patient feels as if they were stabbed or punched in the chest. Commonly, people will hunch over, grimace, and clutch their chests when they describe their RSD experience.

How Is Rejection Sensitive Dysphoria Different from a Mood Disorder?

RSD is characterized by intense but short-lived emotional pain triggered by a distinct event of real or perceived rejection, criticism, or teasing. Mood disorders, on the other hand, are characterized by the following:

In other words, the moods of ADHD and RSD are normal in every way except their intensity.

Is Rejection Sensitive Dysphoria a Symptom of ADHD?

Rejection sensitive dysphoria is not included in the DSM-5 for attention deficit hyperactivity disorder (ADHD or ADD); it is not a formal symptom of ADHD in the United States, however emotional dysregulation is one of the six fundamental features used to diagnose ADHD in the European Union.

It’s widely understood that the diagnostic criteria for ADHD in the DSM-5 only fit well with elementary school age children (6-12) and have never been validated in a group of people over the age of 16.¹ They are based on only observational or behavioral criteria that can be seen and counted. The traditional diagnostic criteria intentionally avoid symptoms associated with emotion, thinking styles, relationships, sleeping, etc. because these features are hard to quantify. For clinicians who work with later adolescents and adults, the DSM-V criteria are almost useless because they ignore so much which is vital to understanding how people with an ADHD nervous system experience their lives.

When people started writing and researching the concepts of RSD and emotional dysregulation about 5 years ago, this new awareness of the emotional component of ADHD was enthusiastically accepted by patients and their families because they matched their life experiences so exactly. The reception from clinicians and many researchers, however, was decidedly cool. Many professionals did not fully grasp that the emotional component of ADHD had always been there but intentionally not pursued. It appeared to them that the concept had no real and historical basis. What’s more, there was very little published research just 5 years ago and most studies came from the European Union, which used the term emotional dysregulation (ED), not RSD.²

These obstacles to recognizing RSD/ED as a major and defining characteristic of adult ADHD and to using medications to offer some relief from the disruptions and pain of this feature of ADHD are being rapidly addressed. There has been a rapid increase in available research in a very short period of time.³ The redefinition of adult ADHD in the EU — adding emotional self-regulation as a fundamental part of the criteria for the diagnosis of ADHD — has furher assured that RSD/ED is really “a thing” that cannot be ignored any longer.

Still, there are at least three reasons why emotional dysregulation or RSD may never be included in the diagnostic criteria for ADHD, no matter how prevalent:

1. RSD/ED are not always present. It comes in triggered episodes.
2. People with RSD/ED are usually ashamed of their over-reactions and hide them so that they will not be further embarrassed and thought of as mentally or emotionally unstable
3. Even when RSD/ED is present, it can’t be measured, and, therefore, can’t get published in research.

As a consequence, emotional dysregulation was consciously excluded from the diagnostic criteria for ADHD and effectively forgotten for many years. Over the last decade, researchers have developed several new ways of looking at ADHD through the lifecycle. By the end of 2019, this re-evaluation of the very fundamental aspects of ADHD led the European Union to issue its 10-year update of the Consensus Guidelines on Adult ADHD⁴, which redefined adolescent and adult ADHD to include difficulty with emotional regulation as one of only six fundamental features in the ADHD syndrome:

1. inattention and hyperfocus
2. impulsivity
3. hyperactivity
4. emotional dysregulation
5. excessive mind wandering
6. behavioral self-regulation (which they equated with executive function deficits)

Although the EU has chosen the more inclusive term of emotional dysregulation (ED) instead of RSD, the concepts are fundamentally the same. Emotional dysregulation is described as:

“The type of emotional dysregulation seen in ADHD has been characterized as deficient self-regulation of emotional symptoms such as irritability, frustration and anger and low frustration tolerance, temper outbursts, emotional impulsivity, and mood lability.⁵ Emotional dysregulation in ADHD is different from episodic symptoms such as marked sustained irritability occurring within the context of altered mood states, such as an episode of extreme sadness or mania. In ADHD, emotional symptoms tend to reflect short-lived exaggerated changes, often in response to daily events, with rapid return to baseline within a few hours”.⁶

Is Rejection Sensitive Dysphoria a New Concept?

Rejection sensitive dysphoria and emotional dysregulation are old concepts associated with ADHD that are gaining new exposure in research and clinical settings. Dr. Paul Wender, who spent four decades conducting the pioneering studies on ADHD beginning in the 1960s, was the first to recognize emotional dysregulation as a persistent, prevalent, and highly impairing component of what we now call ADHD.

The most recent contribution to this new thinking about the mood regulation component of ADHD comes from Dr. Fred Reimherr, one of the founding fathers of ADHD who established the current childhood criteria for ADHD along with Wender more than 50 years ago (the original criteria for what we now call ADHD were originally called the Wender-Reimherr Criteria). His recent replication⁷ of his study of the validity of each diagnostic criterion has led him to now conceptualize ADHD as being divided into only two subtypes: the well-known inattentive type and an emotional dysregulation type.

This is a huge change in thinking. A feature of ADHD that was ignored for 50 years now is rapidly becoming one of the defining features of the syndrome in both the European Union and North America.

In 2019, Faraone published “Emotional dysregulation in attention deficit hyperactivity disorder – implications for clinical recognition and interventions” in the Journal of Child Psychology and Psychiatry.⁸ It states that there is “solid theoretical rational” for emotional impulsivity and deficient emotional self-regulation “as core symptoms of ADHD.”

How is Rejection Sensitive Dysphoria Treated?

Although the alpha agonist medications, guanfacine and clonidine, have been FDA-approved for the treatment of ADHD for decades, they were not directly associated with the terms of rejection sensitivity and emotional dysregulation for all of the reasons noted above. Nonetheless, it has been my clinical experience and the experience of others that the symptoms of RSD/ED can be significantly relieved with clonidine and guanfacine in about 60% of adolescents and adults. To me, this observation strongly indicates that RSD is neurological and not something that is due to a lack of skills. Skills do not come in pill form.

There currently exists no formal research on using alpha agonist medications to treat symptoms of RSD or ED on patients with ADHD.

If a patient benefits from an alpha agonist medication, they describe the new experience as one of “putting on emotional armor.” They still see the same things happening that would have emotionally devastated them last week, but now on medication they just watch these triggers fly past them “without being wounded.” Often people report that, with time, they come to realize that this armor is not needed after all “because I came to see that the arrows I was protected from were not arrows to begin with.” They are very clear, however, that they would never have developed this emotional control unless they had had some initial protection from the pain of RSD.

If a patient does not benefit from medication, they have little control over an episode of RSD once it begins. The incidents have to run their course. Some people with ADHD, however, report that getting interested in something new and fascinating can help to end an RSD episode more quickly than it would otherwise. In my clinical experience, neither coaching nor traditional psychological or behavioral therapies — like CBT or DBT — offer any prevention or relief from impairments. Nonetheless, many people report that it is very helpful for them to know that this highly disruptive experience is real, common, and shared by other people with ADHD. “It helps me to know what is happening to me and that it is ultimately going to end.”

Rejection Sensitive Dysphoria: Next Steps

• Read: ADHD, Women, and the Danger of Emotional Withdrawal
• Download: Understanding ADHD and Rejection Sensitive Dysphoria
• Understand: How to Distinguish ADHD’s Rejection Sensitive Dysphoria from Other Disorders

References

¹ Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/Hyperactivity Disorder. AACAP Official Action. (2007). Journal of the American Academy of Child and Adolescent Psychiatry. 46 (7):894-921. This article is in the public domain and can be accessed at
http://www.aacap.org/galleries/PracticeParameters/JAACAP_ADHD_2007.pdf

² Kooij Sandra JJ, et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BioMedCentral – Psychiatry (2010), 10:67. Pages 1-24. http://www.biomedcentral.com/1471-244X/10/67

³ Graham J, Banaschewski T, Buitelaar J, Coghill D, Danckaerts M, Dittmann RW, et al. European guidelines on managing adverse effects of medication for ADHD. European Child and Adolescent Psychiatry (2011) 20:17–37. DOI 10.1007/s00787-010-0140-6

⁴ Kooij J.J.S., Bijlenga D, Salerno L, Jaeschke R, Bitter I, Balázs J, Thome J, Dom G, Kasper S, Nunes C, Filipe S.Stes. Mohr P, Leppämäki S, Casas M, Bobes J, Mccarthy JM, V.Richarte, Philipsen AK, et al. Updated European Consensus Statement on diagnosis and treatment of adult ADHD. (2019) European Psychiatry 56: 14–34. http://dx.doi.org/10.1016/j.eurpsy.2018.11.001

⁵ Skirrow C, Asherson P. Emotional lability, comorbidity and impairment in adults with attention-deficit hyperactivity disorder. Journal of Affective Disorders, (2013);147 (1-3):80–6. https://pubmed.ncbi.nlm.nih.gov/23218897/

⁶ Surman CB, Biederman J, Spencer T, Miller CA, McDermott KM, Faraone SV. Understanding deficient emotional self-regulation in adults with attention deficit hyperactivity disorder: a controlled study. Attention Deficit Hyperactivity Disorders2013;5(3):273–81. https://pubmed.ncbi.nlm.nih.gov/23413201/

⁷ Reimherr FW, Roesler M, Marchant BK, et al, Types of adult Attention Deficit/Hyperactivity Disorder: A Replication Analysis. (2020) Journal of Clinical Psychiatry 81 (2) e1-e7.

⁸ Faraone SV, Rostain A, Blader J, et al. Practitioner Review: Emotional dysregulation in attention deficit hyperactivity disorder – implications for clinical recognition and interventions. Journal of Child Psychology and Psychiatry (2019) 60(2): 133-150.

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One of the most difficult — and under-appreciated — challenges of ADHD is managing the intense emotions and moods that hijack our everyday lives. Emotional dysregulation — or the inability to properly modulate and regulate feelings — is often seen in people with ADHD, starting in childhood and lasting into adulthood. It is cited by many patients as a formidable problem, yet emotional instability isn’t even listed as a core symptom of ADHD in the DSM-V.

Emotional instability is not unique to people diagnosed with ADHD, but it presents a unique source of impairment in patients with attention deficit. Tantrums, anger, and emotionality related to ADHD increase stress, decrease positive connections, and generally make life difficult. This pattern, in turn, erodes the resilience required to manage ADHD in the first place.

It is important for clinicians to recognize that emotion control problems may be the most important and disruptive challenge faced by both children and adults with ADHD. The good news is that there are effective treatments that address it head-on.

Listen and learn from Joel Nigg, Ph.D., about:

• Recent research studying the role of emotion in managing ADHD
• The latest science explaining how anger problems fit into the core ADHD syndrome
• Common clinical misunderstandings about emotions and ADHD, and the challenges of distinguishing between those emotions and bipolar disorder symptoms
• The most effective treatments for managing emotional dysregulation
• How clinicians can determine if uncontrolled anger stems from ADHD or another condition
• How to manage ADHD when anger regulation is the main problem for children or adults

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Read More on Emotional Dysregulation and ADHD from Dr. Nigg:

• “How ADHD Amplifies Emotions”
• “The ADHD-Anger Connection: New Insights into Emotional Dysregulation and Treatment Considerations”

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Joel Nigg, Ph.D., is a clinical psychologist and a professor in the departments of psychiatry and behavioral sciences at Oregon Health & Science University. He directs the OHSU ADHD Research program and is also director of the division of psychology. Dr. Nigg is the author of Getting Ahead of ADHD. He has published nearly 200 peer-reviewed scientific papers related to the neuropsychological, cognitive, and temperamental correlates of child ADHD, to ADHD genetics, and to MRI- based research and theoretical interpretations of brain development in ADHD. | See expert’s full bio »

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While my children and I laughed over the truth serum scenes and the calming glitter kitties, I found myself most attracted to the “inflatable hug,” which is an endearing device easily activated to surround and protect an individual from an explosion or detonation.

An inflatable hug sounds like just the right solution these days for children and families with attention deficit hyperactivity disorder (ADHD) who could use some protection from the emotional explosions taking place in their homes. As a clinical psychologist, I frequently work with children diagnosed with ADHD — and their parents, siblings, and other family members as well. Despite the number of executive functioning deficits inherent in ADHD, most parents find themselves in my office due to one specific challenge: emotional control.

Children with ADHD can often become flooded with emotions; they struggle to regulate those feelings in order to control their words and actions. In addition, children with ADHD may be hypersensitive to perceived disapproval, slights, and social embarrassments. Pair that with a brain that struggles to differentiate between small and large problems, and you can have yourself an explosive situation quite frequently in the home. Hence, the need for an inflatable hug.

Tips to Help You and Your Child Recover from ADHD Anger

I use a number of strategies to help children develop an increased understanding of their ADHD brains and emotions and to find strategies that help them express themselves more effectively. At the same time, I also try to educate parents (and provide reassurance) that, while there are no quick fixes, things will improve with time and development. It is critical to remember that children with ADHD have a 30 to 40% delay in their executive functioning development, which may mean they seem 3 to 4 years younger than same-aged peers in terms of emotional control.

[Read This Next: Never Punish a Child for Behavior Outside Their Control]

I often tell parents that, while we are waiting and supporting their child’s brain development, we are just trying to keep the house from burning down — quite literally these days! Below are a few tips for managing emotional explosions with an inflatable hug — and without burning down your home:

1. Watch the clock: Moments of intense anger or emotional dysregulation can feel so overpowering that they “contaminate” the entire day. While it’s true these episodes often last longer than we would like, it can help to physically watch the clock for a number of reasons. One, it can help you gauge your own emotional reactions and the amount of time you will have to wait this out. If your child normally flies into a rage that lasts 30 minutes, you can coach yourself to push pause until it de-escalates in a half hour. This can help you manage your own internal thoughts such as “I can’t stand this” or “This will never end.”

Watching the clock can also help you to create more realistic thoughts about your child’s behavior. While a very difficult emotional outburst is not easy to manage, it may be helpful to put this amount of time in the context of the entire day.

2. Conjure and cue your best self. Think about a time when you handled a situation with your child well. Write out the details and describe how you behaved, what you were thinking, and how you felt during and after. Find a way to remind yourself of this moment and your “best parent self.” Tape up this writing on the fridge or put a picture on your bathroom mirror that reminds you of this “best self.”

If you cannot recall a time when you handled a situation with your child well, then imagine what a successful interaction would look like. Be specific in writing out how you would behave, what your face would look like, and what you would say. If you need help with this, consult a trusted resource such as an admired friend, a family member, or a professional.

[Download This Free Resource: Common Executive Function Challenges and Solutions]

3. Say as little as possible in the heat of the moment. Your child will remember your words, especially when you would rather they wouldn’t. What’s more, siblings will remember what you said and repeat it later. You cannot control what your child says in the moment, but you can control the message that you communicate in those tough moments. It may be easier to repeat one or two standard phrases of support, validation, and personal limits. Going “off script” in these heated moments can be less than ideal.

4. Identify the emotion(s) underneath the anger or rage. When your dysregulated child is angry, they may say things that are both distressing and distracting. Don’t allow yourself to be distracted by the outward anger, which is very often the “secondary” emotion — the manifestation of an even stronger driving emotion under the surface.

Could your child be upset because of an unexpected change in plans? Are they feeling embarrassed or like they seem babyish or uncool? Do they feel as if others are not listening or “ganging up” on them? Trying to understand the root cause of this emotion can help create some understanding, and help to keep you calm even when your child is hurling harsh words, threats, or accusations at you.

5. Wait for everyone to calm down before you have a conversation. There is no exact moment of “calm enough” — you will need to gauge your own level of arousal, the intensity of your child’s cry or tone of voice, their body language, etc. Try your best, and if you realize that one or both of you are still too upset, ask for a little more time. But make sure to come back to the conversation together to help create understanding, repair any damage in the relationship, and make a plan for the next time this emotion or situation presents itself.

6. Be kind — not only to your child, but to yourself. You have an amygdala, too! Kids can say scary, unsettling, mean, and challenging things sometimes. It is natural to feel hurt, scared, or incredibly angry. Forgiveness is a powerful tool — for both you and your child.

And if all else fails, can we get our hands on some inflatable hugs?!

[Read This Next: How ADHD Ignites Rejection Sensitive Dysphoria]

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ADHD is an inaccurate — and potentially corrosive — name. The term “deficit disorder” places ADHD in the realm of pathology, or disease. Individuals with ADHD do not have a disease, nor do they have a deficit of attention; in fact, what they have is an abundance of attention. The challenge is controlling it.

Therefore, we argue that a more accurate descriptive term is “variable attention stimulus trait” (VAST), a name that allows us to “de-medicalize” ADHD and focus instead on the huge benefits of having an ADHD brain.

VAST symptoms can, of course, negatively impact a person’s life, work, and relationships. Rejection sensitive dysphoria, a phrase coined by Dr. William Dodson, refers to the extreme emotional sensitivity and feelings of guilt, shame, and rejection often experienced by those living with VAST.

But with VAST there are always pairs; you can hyperfocus and then you can’t focus. You are distractible, but you’re also curious. So if individuals with VAST tend to succumb to perceived rejection, they can just as easily thrive with perceived recognition, an experience we call “recognition responsive euphoria.”

[Self-Test: Could You Have Rejection Sensitive Dysphoria?]

The Flip Side of Rejection Sensitive Dysphoria

Individuals with VAST are accustomed to receiving negative feedback in their personal, academic, and professional lives. Real or imagined criticism gets caught in the Default Mode Network — one of the primary networks in the brain that is active when a person is not focused — and creates the negative feelings that spiral into rejection sensitive dysphoria.

However, the Default Mode Network can have the opposite effect when positive recognition is perceived by someone with VAST. This positivity and encouragement super-charges the VAST brain with the same intensity with which negative feedback defeats it.

Those with VAST are often embarrassed to ask for encouragement, so supporters have to remember to offer accolades for goals met, effort expended, and movement in the right direction. Do not wait to praise perfection because perfection may never happen without praise along the way. Individuals with VAST thrive when surrounded by positive people and when they can step away from projects and people that are a chronic disappointment. These choices, sometimes paired with medication, create recognition responsive euphoria and lead people with VAST to success and happiness.

Just as a little negativity can tumble into anxiety and panic, a drop of praise can build into a tsunami of hope and motivation. Remember, key traits of VAST are resilience and an amazing ability to never give up.

This content came from the ADDitude webinar by Dr. Hallowell and Dr. Ratey titled “The Flip Side of Rejection Sensitive Dysphoria: How to Tap into ADHD Energy and Motivation,” which is available for free replay here.

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What Is Rejection Sensitive Dysphoria?

No one likes rejection or feeling like a failure. But for people with attention deficit disorder (ADHD or ADD), these feelings can be debilitating — and may manifest as either crippling sadness or uncontrollable rage.

There’s a name for this phenomenon: Rejection Sensitive Dysphoria, or RSD. In people with ADHD, RSD can lead to an all-encompassing need to please others, or it can result in someone with ADHD giving up on anything that is perceived to have a risk of failure.

RSD is treatable — but first, you need to understand it. Use this quick-reference guide to get the facts about rejection sensitive dysphoria: why it happens, what it looks like, and what you can do to get the help you need.

NOTE: This resource is for personal use only.

“Recognition Responsive Euphoria” or RRE

The ADHD brain is turned up to 11; our neurotransmitters burn bright. On an emotional level, this means we feel the stabbing pain of rejection, frustration, and failure more acutely than do others. On the flip side, we also experience a meaningful and powerful zing of energy and esteem with every word of encouragement, praise, or approval we receive. The smallest gesture can power euphoria — and great accomplishments — for us.

The steep valleys of this emotional rollercoaster are well documented. Dr. William Dodson calls this common ADHD condition Rejection Sensitive Dysphoria, or RSD. To date, however, the soaring peaks of positivity and euphoria have been largely overlooked. This sister syndrome, which I’ve observed in my 69 years of living with ADHD and my 38 years of treating the condition in children and adults, is sweet and wonderful. It’s to be cultured and captured at every turn. It is our great friend, ally, and tool for growth and productivity. I call it “Recognition Responsive Euphoria,” or RRE.

If you have ADHD, and you find that you are low on motivation, energy, and are not working up to your potential, then join Dr. Hallowell and Dr. Ratey and learn how to tap into and get or give Recognition Responsive Euphoria. In this webinar, they will explain all we need to know about RRE, and all we need our teachers, mentors, partners, managers, partners, supervisors, spouses, and others to understand about it and its power to inspire our best work.

Listen and learn from Edward (Ned) Hallowell, M.D, and John J. Ratey, M.D., about:

• why criticism and correction leads to feelings of frustration, rejection, and failure
• how receiving encouragement and recognition changes these feelings into positivity
• how to find the right person or people who can give encouragement and recognition
• how to work up to your potential by tapping into the power of praise and RRE
• how to encourage others to provide this to you without feeling childish or embarrassed
• how to give the gifts of RRE to others

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Read More on Rejection Sensitivity Dysphoria

• [Self-Test] Could You Have Rejection Sensitive Dysphoria?
• [Download] Understanding Rejection Sensitive Dysphoria
• How ADHD Ignites Rejection Sensitive Dysphoria

Meet the Expert Speakers

Edward (Ned) Hallowell, M.D., is a child and adult psychiatrist,  leading authority in the field of ADHD, the host of “Dr. Hallowell’s Wonderful World of Different” –  a weekly podcast for thriving in this CrazyBusy world, NY Times best-selling author, world-renowned speaker and the founder of The Hallowell Centers in Boston MetroWest, NYC, San Francisco and Seattle. Learn more at www.drhallowell.com. Dr. Hallowell does not have any financial affiliations.| See expert’s full bio »

John J. Ratey, M.D., is an associate clinical professor of psychiatry at Harvard Medical School and an internationally recognized expert in neuropsychiatry. He has published more than 60 peer-reviewed articles and 11 books, including the groundbreaking Driven to Distraction series with Ned Hallowell, M.D. With the publication of Spark: The Revolutionary New Science of Exercise and the Brain, Dr. Ratey has established himself as one of the world’s foremost authorities on the brain-fitness connection. Dr. Ratey is a consultant to GoNoodle and HS Performance of Beijing.| See expert’s full bio »

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A: Unfortunately, meltdowns — whatever their root cause — usually have to run their course. That said, as a psychiatrist, I would first evaluate whether these temper tantrums are, indeed, temper tantrums. Do they have a secondary gain? Are they manipulative? Are they done by the child to get his way? As soon as he gets his way, does the temper tantrum go away? (Once the tantrum has achieved its goal?) Is there a noticeable trigger for the meltdown? If you answered yes to these questions, the tantrums might be a sign of rejection sensitive dysphoria (RSD), a common symptom of attention deficit disorder (ADHD or ADD) wherein a patient feels extremely strong emotions and reacts equally extremely to real or perceived criticism or rejection.

Children with bipolar disorder, on the other hand, have what are known as “affective storms,” which are uncontrolled rages that follow a minor (or no) provocation. If you’ve ever seen one, you’ll never forget it. These are way, way beyond temper tantrums.

If I were fairly sure that the temper tantrums were not manipulative — a child trying to get his way on pretty much any conflict with the parent — I would hope the child is in that lucky 60% of people who respond to medication for bipolar disorder. If he is in the 40% that do not respond, I would try behavioral management, which would give the child ways to correct his distortion and respond in a healthier fashion.

The following information is from William Dodson, M.D.’s webinar titled “All the Feels: An ADHD Guide to Emotional Dysregulation and Rejection Sensitive Dysphoria.” That webinar is available for free replay here.

A: Bipolar disorder and attention deficit hyperactivity hyperactivity disorder (ADHD or ADD) share 14 features in common, so even a well-trained clinician could easily misdiagnose ADHD as bipolar, vice versa, or miss that both disorders are present. Two studies, the STAR*D program and the STEP-BD program, both found a tremendous overlap between the disorders; if you have bipolar disorder, you have a 40% chance of having ADHD as well. So, the question is: Could it be ADHD, bipolar disorder, or both?

Unlike ADHD, bipolar is a classic mood disorder that has a life of its own separate from the events of a person’s life, outside of the person’s conscious will and control. Bipolar moods aren’t necessarily triggered by something; they just come and they stay. Usually, the onset is very gradual over a period of weeks to months. To meet the bipolar definition, the mood must be continuously present for at least two weeks and then its offset or resolution must be gradual over a period of weeks to months.

With adult ADHD, you see a very different pattern; the moods of an individual with ADHD are clearly triggered. The ADHD symptom of rejection sensitive dysphoria, for example, is triggered by the perception that a person has been rejected, teased, or criticized. An observer might not be able to point out the trigger, but the individual with ADHD can say, “When my mood shifts, I can always see a trigger. My mood matches my perception of the trigger.” In technical terms, ADHD moods are “congruent.”

Mood changes are instantaneous and intense in individuals with ADHD, much more so than in a neuro-typical person.

ADHD moods rarely persist for more than a few hours. It is extremely rare for them to last two weeks. Typically, the mood can be altered by the person with ADHD finding a new interest or occupation that captures their interest and distracts them from the intense emotion. Distinguishing between these mood presentations is how I separate out mood disorders of all types from ADHD.

[Self-Test: Could You Have Rejection Sensitive Dysphoria?]

The above information is from William Dodson, M.D.’s webinar titled “All the Feels: An ADHD Guide to Emotional Dysregulation and Rejection Sensitive Dysphoria (RSD).” That webinar is available for free replay here. William Dodson, M.D., is a member of ADDitude’s ADHD Medical Review Panel.

The Clinicians’ Guide to Differential Diagnosis of ADHD from Medscape and ADDitude

• How can I better understand ADHD, its causes, and its manifestations?
• What do I need to understand about ADHD that is not fully represented in the DSM?
• How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
• How can I best consider psychiatric comorbidities when evaluating a patient for ADHD?
  • What comorbidities are associated with ADHD?
  • How can diagnosticians differentiate symptoms of anxiety, depression, and ADHD?
  • What are the key distinctions between ADHD and depression?
  • How is ADHD distinct from oppositional defiant disorder and disruptive mood dysregulation disorder?
  • How are the symptoms of ADHD and bipolar disorder often conflated?
  • What are the shared and distinct characteristics of obsessive compulsive disorder (OCD) and ADHD?
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• How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
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• What diagnostic criteria and tests are recommended for performing a differential diagnosis of ADHD?

“Stop being so sensitive,” everyone told me when I was younger. “If you stop crying, they’ll stop teasing you.”

I was the kid who couldn’t handle red marks on my homework, who melted down at any sign of criticism. I’d dissolve into tears. I’d sometimes stomp away. I’d curl up into myself and feel worthless, miserable, and guilty. The shame was overwhelming. It led to self-harm in my teens and early 20s. I could not cope with the normal slings and arrows of daily life. Everything bad was my fault.

My psychiatrists thought I was depressed and put me on an SSRI. It didn’t help much, because I wasn’t depressed. Like so many women, I went through many diagnoses before my doctors finally hit on ADHD. I wasn’t manifesting depression or isolated anxiety issues. I was dealing with rejection sensitive dysphoria (RSD).

RSD is a condition that the psychiatric community at large, and the ADHD community, is just beginning to understand. ADHD expert William Dodson, M.D., calls it “an extreme emotional sensitivity and emotional pain triggered by the perception — not necessarily the reality — that a person has been rejected, teased, or criticized by important people in his or her life. RSD can also be triggered by failing to meet [your own] or others’ high expectations.”

As women, we know about high expectations, the failure to meet them, and the emotional backlash when we fall short. Add an actual, diagnosable psychiatric condition to that response, and you have a recipe for some serious psychological damage. It started with teasing from my peers in childhood over my reactions to not getting an A on every single paper; along with forgetting my homework or losing a book or doing any number of things girls with attention deficit disorder (ADHD or ADD) do regularly — missing social cues, flubbing personal interactions, blurting things out. I berated myself, and it didn’t help that others berated me too. I played those criticisms as a soundtrack of self-loathing.

[Self-Test: Could You Have Rejection Sensitive Dysphoria?]

Rejection Sensitive Dysphoria: Extreme Sensitivity to Criticism

It’s no surprise that a childhood like that, combined with RSD, left me with a hair-trigger response to criticism. I’m in my 30s now, and RSD is still the devil on my shoulder, the voice in my head, the soundtrack to my life. It affects every relationship in my life, from my parenting to my marriage to my friendships. I once took a much-anticipated trip to meet work friends in another state. I had fun for four hours before a comment had me convinced that these women hated me, that they thought I was an idiot.

I spent the rest of the trip in near tears. It took me months to recover. I’ve since realized that all of this was in my head, and my friends were, as they professed to be, my friends. They liked me.

I often feel like a terrible parent. The normal things that parents do — lose their temper, say — seem life-altering to me. I feel that I’m destroying my children’s lives. I may cry in apology in front of them. RSD means having to say you’re sorry more than anyone on the planet.

[Free Resource: Understanding Rejection Sensitive Dysphoria]

Rejection Sensitivity: Impact on Marriage and Parenting

RSD has a big impact on my marriage. I would encourage anyone who thinks he or she may be suffering from RSD to enter marriage counseling. It will help your spouse understand that when he or she asks you to take out the garbage, it may lead to an hour-long argument, complete with tears. Of course, you should have taken out the garbage long ago and why haven’t you done it sooner and what’s wrong with you, anyway? The person only said “Could you please take out the trash?” He’s baffled and upset that you’re flying into accusations.

RSD can imitate a mood disorder, including rapidly cycling bipolar disorder complete with suicidal ideation. Guanfacine or clonidine helps some patients, says Dodson. MAOIs can also be effective, but they come with a list of don’ts, including ADHD meds. Talk with your doctor.

Many people with ADHD experience some form of RSD. In women, it usually turns inward. So you’re not the only one feeling that guilt, shame, and rejection. I understand. I am right there fighting them with you.

RSD: Next Steps

• Read: How ADHD Ignites Rejection Sensitive Dysphoria
• Watch: All The Feels: An ADHD Guide to Emotional Dysregulation 
• Download: What Is Rejection Sensitive Dysphoria

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