Rejection Sensitive Dysphoria and ADHD: What Parents Need to Know

Being rejected never feels good, and unfortunately, childhood is rife with rejections. Best friends can become enemies by the end of recess, and being picked last for a team sport sucks.

But, as a mom of a kid with ADHD, I know that it can feel doubly bad, even painful, if you have Rejection Sensitive Dysphoria (RSD). RSD is prevalent in people with ADHD and is defined as an intense emotional reaction to perceived or actual rejection, criticism or teasing.

If you’re a parent with ADHD, perhaps you remember being tossed out of a friend group as a kid, then feeling too sick to go to school the next day. Or maybe you were a perfectionist who felt physically crushed the first time you didn’t score a high mark on a test. These are just a couple of RSD hallmarks. If you’re noticing these intense feelings in your child, there are ways to help them through it.

Firstly, let's define RSD. The word ‘dysphoria’ is defined as a state of being very unhappy, uneasy or dissatisfied. In this case, it’s not a matter of being thin-skinned but an experience of profound emotional dysregulation after rejection, whether real or perceived. For example, we’re not talking about the kid who feels a little upset after being left out of a game at recess and rolls with the punches, dusting themselves off. It’s likely the child who is really struggling to move on, even if they only think they might have been purposely left out.

The connection between RSD and ADHD

RSD is not in the Diagnostic and Statistical Manual of Mental Disorders (DSM), a widely used guidebook for mental health professionals to diagnose and classify mental disorders, for ADHD. So it's not a formal diagnosis, although emotional dysregulation is one of the fundamental features used to diagnose ADHD.

Dr. William Dodson, MD, an American clinician and psychiatrist, who has spent his career working with adult patients with ADHD, is quoted in Additude Mag as saying that one-third of his adult patients report that RSD was the most impairing aspect of their personal experience of ADHD. And they’ve struggled to cope with the pain that comes with it.  He says RSD can be distinguished from mood disorders because it is an intense, yet short-lived, emotional pain triggered by a real or perceived criticism.

Shlomo Radcliffe, Registered Psychotherapist and Practice Director at Radcliffe Psychotherapy Clinic in Toronto, says that although there is some murkiness in the field over whether this is a real disorder, most of his clients who have ADHD relate to the description. RSD seems to be a cluster of symptoms or reactions that can be linked to ADHD and autism.

Characteristics of ADHD include executive function deficits, which essentially mean difficulties with cognitive processes that help you to plan and finish tasks. For example, struggling with time management, focus, working memory and impulse control. Therefore, a child dealing with these aspects of ADHD may be frequently redirected, corrected or have their mistakes or behaviour pointed out to them by peers and authority figures. And so they often experience higher levels of real and perceived rejection.

What does RSD feel like?

Radcliffe’s clients describe RSD in a variety of ways, and say that it can include pain, crying or the sensation of being punched. If they have an experience where someone makes a critical comment, they feel like their day is over.

“When this intense emotional energy comes in for them, it’s hard to think about anything else. They feel really low, really down and hurt,” he says. He points out that his clients with ADHD tend to describe these experiences and feelings more than his clients without ADHD. He notes that there seems to be an association that these clients are feeling symptoms of rejection sensitivity more acutely than others.

What are the signs of RSD in children?

• Believing no one likes them, even when others do

• Taking small comments or feedback very personally

• Avoiding school or social situations, withdrawing, or acting out to cope with fear of rejection

• Worrying excessively about how others perceive them

• Physical symptoms like stomachaches or headaches related to anxiety

• Difficulty handling peer conflict or feeling excluded

• Perfectionism or emotional meltdowns in response to small setbacks

Michelle Lavergne, MSW RSW, from The Well Parents Centre, has extensive experience working with school boards and high school students in the Greater Toronto Area and has seen how RSD can manifest and show up in children at school.

“Often teachers will say ‘everybody likes this child, I can’t understand why they are having a hard time’, and I validate that, but I also explain that it’s about the child’s own internal experience,” she says. She explains that the heightened sensitivity or overreaction can affect relationships.  These students can have peer issues, difficulty going to class because they think they don’t have a friend in the class or anyone who likes them. They can also worry about what teachers think of them. A throw-away remark from a teacher can sometimes feel like a gut-punch to these kids.

Lavergne highlights the twin aspects of rejection plus pain as being tricky to navigate and treat. She says that Cognitive Behavioural Therapy (CBT) explains how our thoughts can become negative, which affects our body and can make us feel like we need to fight, run away, or freeze.

So, if a child is worried that they’ll be rejected at school, their muscles might tense up, they might feel queasy, which can lead to gastrointestinal issues, headaches, etc. “There might be real physical discomfort showing up around this,” she says.

Since kids might feel ashamed or blame themselves when they fail or feel rejected, they sometimes pull away from others to protect themselves. This can make their world feel smaller. At school, this can show up as acting out or keeping their feelings inside.

Lavergne has noted that for girls, this can look like drama in girl groups or perfectionism. “For high-achieving students-whose parents haven’t reported behavioural issues, the first time they get a 70 on a test, they have a complete meltdown, and parents are unable to soothe them,” she says.

Diagnosing RSD

RSD isn’t an official diagnosis in the standard list of mental health conditions, but it’s often linked to ADHD. It’s important for caregivers to pay attention to their child’s emotional development and, if possible, seek a full evaluation from a qualified professional.

Radcliffe explains that he sees RSD less in young kids and more in older kids, teens and adults. “The way I think about RSD is that there are questions around whether or not this is a neurobiological predisposition, as people with ADHD are more likely to feel rejection, or if it’s based on experience,” he says.

He explains that some research highlights that kids with ADHD are significantly more likely to receive negative feedback, compared to kids without ADHD. Therefore, when you have many years of those experiences, you learn to anticipate them and perhaps become more sensitive to them.

“It’s going to hurt more because every time you’re criticized, you’re not just criticized in the here and now, it’s the ‘here is the whole I-messed-up-there’s-something-wrong-with-me’ thing again,” he says. The more frequent these experiences, the bigger the punch it packs. Therefore, with this theory, kids who are younger may not have had those experiences to the same intensity that teenagers or adults might, so they may not experience it as intensely.

How can caregivers support their child with RSD?

Radcliffe emphasizes self-compassion. He says parents should help their children understand how their challenges and behaviours are connected to ADHD, which may help reduce feelings of rejection.

Since there hasn’t been a sufficient clinical study on RSD, Radcliffe questions Dr. Dodson’s assertion that it can only be treated with medication. “I’ve definitely been able to help my clients navigate issues around sensitivity and the emotional impacts,” he says.

Most therapists and social workers would agree that core parenting skills apply here. Validating your child’s experience is vital. If there is an ADHD component, then helping your child see what’s happening through that lens is key.

Compassionate coaching

Helping your child with their self-talk is another vital point, along with modelling healthy responses to criticism and disappointment yourself. “Basically, the parent role is acting as that compassionate coach, and the idea is that, with this coaching, the child can then internalize their own compassionate coach. It’s almost like they can hear their parents’ voice when they are facing those challenging situations,” Radcliffe says.

Kids with ADHD do require more correction, and you can’t always control how that will be received by the child or walk on eggshells whilst avoiding saying things that could potentially cause harm. “We do want to avoid shaming. There’s a difference between correction and shaming,” Radcliffe continues. “We want to avoid labelling and criticism as much as possible, but correction is going to be needed, and it can still be uncomfortable.”

Overall, the goal is to guide your child in coping with the difficult emotional experiences that will inevitably occur rather than helping them avoid pain or discomfort. Many of the corrections come up in the school setting. Parents can’t control how teachers and peers respond to and relate to their children.

Radcliffe offers, “If you’re aware of something, you can try to intervene, but it’s about helping them build their coping skills, and to the extent that you can make corrections, do so in a way that is compassionate and corrective, rather than shaming and stigmatizing.”

What does compassionate coaching look like?

As a parent of a child with ADHD, I have to revisit our emotional toolkit occasionally to see what’s still serving my child. Emotional dysregulation happens frequently, whether it’s part of feeling rejected or criticized, or for other reasons. So, for the moment, the giant Lego bin remains in his room because he knows that when he’s having big feelings, building still helps to calm his mind. As is always the case, think about your child and what strategies and techniques help them, and come up with a plan together, knowing it will change and look different as your child develops.

Along with teaching emotional regulation skills and perhaps encouraging slow and steady exposure to uncomfortable situations, Lavergne encourages parents to see out psychoeducation for themselves, if possible. Perhaps begin with a conversation with your paediatrician or family doctor to find out what is available to parents to help manage and support their young person.

How to move forward

RSD and the challenges that come along with it don’t disappear with some validation and a lot of good luck. If your child is dealing with this, it is a part of who they are and their experience. The validation and compassion pieces are key.

But Lavergne offers hope to parents. “Things change as children get older. The 16 to 24 age range is a vulnerable time for the brain, but in my experience, post age 24, as they are moving towards adulthood, the brain is coming back online and they aren’t as vulnerable to the emotional dysregulation,” she says. The more that young people find places where they are capable and confident, the more their inner resources are built.

With parenting, there is always a dual focus: the here and now and the long game. All roads tend to lead back to the basics. Show your child that you are there for them during these intense feelings of rejection, that they have it in them to get through it and seek professional help, if necessary.

The silver lining, as Lavergne points out, is that the flip side for children with RSD, or kids that may be more sensitive in general, is that they frequently become the helpers of the world—the nurses, the social workers and psychiatrists. So, one day your kiddo might end up paying things forward and, as an adult, could help a different generation of children understand themselves better.

Experts

• Shlomo Radcliffe is a Registered Psychotherapist and Practice Director at Radcliffe Psychotherapy Clinic
• Michelle Lavergne, MSW RSW, The Well Parents Centre