ADHD: Rejection Sensitive Dysphoria

The world of ADHD has added a new symptom that is not yet in the Diagnostic and Statistical Manual. That new symptom is called “rejection sensitive dysphoria.” It was coined by Dr. William Dodson, a well-respected psychiatrist specializing in ADHD treatment. RSD is basically being overly sensitive to criticism and responding with anger to that criticism or slights - real or imagined.

At first, I was not particularly pleased with yet another undocumented symptom being added to the already extremely complex process of diagnosing ADHD. The diagnostic and statistical manual description already has a large number of symptoms of ADHD and adding more seemed to be unnecessary and overcomplicated. But as I thought more about this new addition to the symptom list, it began to make more sense to me. As I have said in my podcasts and other writings, the average ADHD child gets approximately 70 critical comments per day - so that by the time they're 12 years old, they have gotten 20,000 more critical comments than a non-ADHD child. It's obvious that this level of criticism would lead to over-sensitivity and over-reaction to any criticism. The ADHD child gets nearly constant criticism from parents, from teachers, from coaches and sometimes even from the other parents in the neighborhood. So, it seems likely they would become very sensitive to criticism. 

As the parent of a couple of ADHD children - now adults - it explained some of the behaviors I observed in my own children. The hyperactive ADHD child would blow up, be angry, yell and scream, and maybe even jump up and down. And this is even when he was a teenager. My inattentive child just tended to withdraw more and pretend everything was OK. But then as she got older, she became rebellious and acted out. Fortunately, this period of tension and frustration did not last a long time and there were no permanent consequences, but sometimes her rebellion was difficult to tolerate.

Again, at this stage of raising children we at least knew about ADHD, but it was not anything that either my wife or I spent a whole bunch of time researching. We had three children, two of whom were ADHDers and they were all adolescents. Adolescence is a time of incredible activity for the whole family. Between band practice, athletics and other extracurricular activities, managing the time commitment was extremely difficult. Also, ADHD research was just emerging and there was much we didn't know. Our inattentive ADHD was a girl and there was even less research on females with ADHD than there is on males. Also, at that time, hyperactivity was the only real recognized symptom of ADHD. Other variants of ADHD were in the DSM (that Diagnostic and Statistical Manual), but were rarely diagnosed and frankly, most prescription-writing clinicians were not familiar with treating these patients.

ADHDers typically have difficulties with emotional regulation. This is even more common if they are hyperactive. This is a further complexity with the whole rejection sensitive dysphoria diagnosis. Of all the ADHD symptoms, probably the one that scares ADHD parents the most is the temper tantrum -  or unregulated behavior. I know as a parent who also happens to be a psychologist, I had concerns that there might be more going on than just ADHD. The possibility of bipolar disorder was a concern, or even some of the more active character behavior disorders. The other thing about temper tantrums is that they sometimes seem to appear from no particular trigger. This makes it even more concerning that this is a sign of a more significant psychiatric diagnosis than just ADHD. But it really is possible to be that angry and that explosive and that sensitive to criticism, without a major psychiatric diagnosis.

Knowing that your ADHD child can be extremely sensitive to criticism and knowing that his or her behavior is not unusual can be helpful. It suggests that your treatment approach is not wrong and that you don't need to be necessarily contact your child's doctor to increase or change ADHD medications.

There is only one real control in managing this behavior that you have - that is to restrict yourself and be very careful with critical comments. I've written about this and spoken about how you can change it into a resilience-building exercise.  When an opportunity to criticize comes, just say “OK, this didn't work out very well. Let's see if we can do it differently next time.” This totally avoids the whole “Why in the world did you do that?” conversation. This serves two purposes: it avoids an angry outburst from your ADHDer and it teaches them to be resilient problem-solvers. Eventually, you might see improvement in your child’s behavior and have a calmer family life for everyone.

Thanks for reading and let's make the world safe for ADHD!

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DrG