6 Signs Your Child Has Rejection-Sensitive Dysphoria (And How To Support)
Updated: Sep 6, 2023
Have you noticed any of the following things in your child with ADHD?
Sudden, intense bouts of rage when their feelings are hurt
Thinking they are in "trouble" every time a teacher or adult asks to speak with them
Spending excessive amounts of time on projects or assignment to ensure there are no mistakes (so it is above feedback)
Avoiding starting assignments because of fear they will fail
Assuming no one likes them
Bending over backward to get on someone's good side (people pleasers)
If you have noticed more than a few of these attributes in your child with attention deficit hyperactivity disorder, there is a good chance they have rejection sensitive dysphoria.
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But what is rejection sensitive dysphoria?
Imagine a person with 3rd degree burns covering his entire body.
Even the slightest touch would cause unbearable pain.
Like this person with 3rd degree burns, a person with RSD has an unbearable sensitivity covering his entire emotional "body".
Even the slightest switch of tone or phrasing can cause massive emotional dysregulation in a youth with RSD leading to outbursts, avoidance and other maladaptive patterns.
It is called rejection sensitive dysphoria because "dysphoria" comes from the Greek word meaning “difficult to bear" and it was Dr. William Dodson who first defined rejection sensitive dysphoria as:
"A triggered, wordless emotional pain, that occurs after a real or perceived loss of approval, love or respect...RSD appears to be the one emotional condition found only with ADHD."
These intense emotions often stem from a perceived criticism or a perceived slight and make managing social relationships extremely challenging for individuals with RSD.
Why are people with RSD so sensitive?
RSD is the inability or lack of skills to perform emotion regulation.
Children and young adults with ADHD often lack the essential executive function skills that neurotypical individuals use to regulate their emotional dysregulation.
These skills include:
Self-awareness
Inhibition
Reframing
Socially appropriate self-soothing behaviors
When an individual with attention deficit hyperactivity disorder feels rejected (even if they are not being rejected), they experience an emotional reaction aligned with this perception which may include loss, grief, rage and self-hate.
This misperception of rejection is rooted in cognitive distortions such as emotional reasoning and personalization.
Emotional Reasoning
Emotional reasoning is the assumption that whatever one is feeling is the objective truth, without the need for evidence or facts that align with this perception.
When an overwhelming emotional response occurs, children and teens may use emotional reasoning, rather than analyzing the situation with objectivity.
For example, your child raises her hand in class and the teacher makes eye contact, but does not call on her.
Your child feels rejected and assumes that the teacher doesn't like him and begins to say he cannot succeed in the class because the "teacher doesn't like me."
In reality, the teacher was actually looking at the clock behind your child and realized he needed to skip to the next part of the lesson instead of gathering more answers, but because your child has internalized the teacher "hates" him, he withdraws further and is afraid to speak directly with the teacher.
Personalization
When your child perceives a response as a indicator of something they have done wrong, rather than something related to the other person's needs, this is called personalization:
Tommy said he didn't want to play basketball with me after school. I knew he didn't like me! And if Tommy doesn't like me, then none of the kids like me.
In reality, there could be a million reasons Tommy doesn't want to play basketball -- maybe he has a dentist appointment; maybe he is hurt, or maybe he feels like he isn't good enough.
It is because of emotional reasoning and personalization that individuals with RSD think they are faulty and begin to internalize this feeling.
This can lead to a range of maladaptive behaviors such as:
Avoiding asking people for help because they think that person doesn't like them
People pleasing because they feel they need to do so in order to be liked
Skipping social events because of a fear that they are unliked
Treating ADHD and RSD is of vital importance for young people and by understanding RSD and the associated mental health outcomes, you can provide your child with an opportunity to lead a successful and joyful life.
What is the impact of rejection sensitive dysphoria on young people?
Unless they learn coping mechanisms and emotional regulation strategies to cope with real or perceived rejection, their ADHD symptoms related to executive function challenges combined with explosive emotional reactions will likely worsen and have disastrous consequences in their adult life.
Children and teens with attention deficit hyperactivity disorder are already struggling with executive function challenges.
It is very common for students with ADHD to already be experiencing the following in school:
Many missing assignments
Teachers who think they are "lazy" and/or "unmotivated"
Isolation from their peers due to an inability to regulate emotions
Fear of asking teachers for help
Excessive time spent on assignment to avoid "being wrong" about anything
When rejection sensitive dysphoria is added to this mix, the extreme emotional sensitivity can cause mental health conditions to worsen.
If not addressed, RSD symptoms can snowball into:
Lowered self esteem
Tendency to self harm
Emotional instability
Other mental health disorders such as depression and anxiety
Social phobia
As a person with adult ADHD, I have dealt with rejection sensitive dysphoria my whole life.
Examples include:
Being so heartbroken that I discontinued BMX biking in the 6th grade, when my older brother suggested I spend time with kids my own age, rather than following around his group of BMX biker friends
Being so upset that I was benched on the basketball team during high school that I asked a journalist from the school's newspaper to do an article on how the coach was unfair
Feeling so upset at a professor's unpleasant response to my email about scheduling confusion during the start of my master's degree program for special education that I unenrolled from the program (I calmed down an eventually re-enrolled)
Many instances of personalizing rejection led to acting on negative impulses and have stunted my emotional growth.
Learning how to manage my emotional responses in situations where I felt rejected was a slow and often painful process, which is why it is so important for parents, educators and mental health professionals to continue to examine and research the impact of undiagnosed rejection sensitivity dysphoria.
Use these indicators to gauge if your child is struggling with RSD and consider the associated strategies when seeking to support them.
Sign #1: Sudden, intense bouts of rage when her feelings are hurt
You come home from work and see your child watching TV.
You know she has a test tomorrow and that she has been avoiding studying.
You gently say, "Cheryl, don't you think it would be wise to begin studying now?"
Cheryl stands up and yells, "YOU ARE ALWAYS PUTTING SO MUCH PRESSURE ON ME! I'M JUST A FAILURE IN YOUR EYES, AREN'T I??"
Take a moment to breathe. Don't react.
And definitely don't call Cheryl "overly sensitive."
Strategy #1: Count to 10 and use "I noticed" statements
When your child is this upset (I call it the Red Zone), do not try to fix her.
Instead, take 10 deep breaths and then use an "I noticed" statement.
Cheryl, I noticed you raised your voice and sounded upset. Could we go for a walk and talk?
Oftentimes, getting some fresh air has a soothing effect on anyone, but especially children with ADHD and RSD.
If Cheryl is not up for that, say something like:
I am going to check back in with you in 30 minutes. I'd like for us to speak then.
At that point, Cheryl will hopefully be calmer and you can have a productive conversation about how Cheryl can use her accommodations and strategies to prepare for the upcoming test.
Sign #2: He thinks that he's in "trouble" every time an adult asks to speak with him
You know that feeling you get when your boss emails you saying, "Can you stop by my office at the end of the day?"
If your internal response to that statement is "dread" then you may have RSD as well (remember, as a parent of a child with ADHD you are genetically predisposed to it).
Now, imagine experiencing that dread every day, when interacting with teachers, coaches, other parents...
Children and young adults with ADHD are consistently falling into "fight or flight" mode when interacting with the adults around them.
Strategy #2: Practice reframing and inquiry with them
If your child defaults to, "Am I in trouble?" anytime an adult would like to speak to him, ask him questions like:
Why else might your teacher want to talk to you?
What have you been doing well lately that might make your coach want to speak with you?
Oftentimes students with RSD want assurance that they are doing well and following directions correctly.
Teach them phrases like:
Would you tell me what this meeting is about so that I can prepare in advance?
What would you like to discuss?
And as they get older and enter the workplace, they will then be prepared to ask questions like:
Would you send an agenda for this meeting?
Sign #3: She spends excessive amounts of time on projects or assignment to ensure there are no mistakes (so it is above criticism)
I cannot tell you how many times parents have reached out for executive function coaching support because their child is spending hours and hours working on assignments after school when she or he could be riding bikes and doing other stress relieving activities.
The root of this is often the need for perfection in order to avoid reproach.
This fear is disabling and detrimental.
It causes the good to be sacrificed for the perfect and leaves not only many school assignments incomplete and not turned in, but also creates an isolating effect in which the student spends less time socializing because they are hyper focused on perfecting one assignment.
Strategy #3: Teach them how to submit drafts and request feedback
Many students do not know that it is actually better to submit a draft or a minimum viable product (MVP), to then get clear and direct feedback on how to complete an assignment or project.
By providing your child with email templates that give them the wording they do not have on how to get a teacher's input, they will realize that there is no such thing as perfect, and that it is better to submit something that they can improve on, rather than nothing at all.
Here is an example email from my collection of templates you can download:
Hello,
I’ve been working on the assignments, (assignment name), for your class and have completed a draft of it.
Would you please review it and provide me with feedback on how I can get closer to achieving my goal of earning an (choose grade you want) on this assignment?
Also, is there anything else you suggest I do to work toward my goal of earning a (desired grade) in your class?
Thank you for your guidance.
Sincerely,
(Your Name)
Sign #4: He avoids starting assignments because of fear that he will fail
The flip side of the perfectionistic tendency above is the complete avoidance of assignments, projects and tasks.
The internal monologue goes something like this:
Why should I start this when I'm doomed to fail? There is no way I could actually be successful on this so I'll just avoid the pain of experiencing failure.
Does that sound familiar?
If so, try this strategy.
Strategy #4: Redefine failure and focus on the approach
First, check in with them about what failure actually is.
Devon, would you define failure more as getting a bad grade on the assignment or not turning anything in at all?
If they are able to start to redefine failure, then you can help them focus on the steps they need to take, rather than the outcome.
Let's break this assignment down into steps. In order to complete the study guide, we can use this checklist:
Print out study guide
Grab textbook
Answer question 1
Answer question 2
Take a break
And so on...
Remember, things that seem small to you, might feel colossal and overwhelming to them.
By breaking assignments down into discrete tasks, you can help them see success is taking each step, rather than just finishing the assignment.
Sign #5: She assumes no one likes her
When I worked at Whole Foods in Columbus Circle, I memorized this quote I saw on the job board as a way to counteract my mind's tendency to fear the worst.
"Our doubts are traitors and make us lose the good we oft' might win by fearing to attempt." - Shakespeare
Indeed, the Bard had it correct.
Individuals with RSD assume the worst.
Often victims to the humans tendency of automatic negative thoughts (ANTs), they assume that people don't like them, so why even try to set up a time to get together?
Thus, they end up avoiding social interactions and feeling down when no one reaches out to them.
Strategy #5: Explicitly teach social skills
When your child has been trying to manage disproportionate emotional reactions for years, her social skills take a hit.
Social withdrawal is a consequence of this experience, but the teaching of social skills to your child should be a key part of your treatment plan.
Social skills you can explicitly teach are:
Modeling good manners
Showing appreciation
Proactively checking in with friends and family
Making plans rather than expecting others to inviting
Role playing challenging scenarios and how to respond to them
If you make this a part of your weekly experience, your child will begin to develop more resources that he can call upon when they feel rejected.
Along with the explicit instruction of social skills, teach your child questions they can ask to clarify perceived rejection like:
What did you mean by that?
Is there an alternative time for us to (hang out, play basketball, etc.)?
What would you like to do?
Remember, the key word is SKILLS in social skills. These are things that can be developed.
Sign #6: He bends over backward to get on someone's good side (people pleasers)
Man, am I guilty of this.
One of my most famous acts of people pleasing was when I had a group of my wife's colleagues staying in our house during the fires in Northern California in 2017.
Because of my difficulty in recognizing and processing emotions, I wasn't able to identify that even though I was glad we could help out a group of people, it was also challenging that 12 people were living in our two-bedroom rental.
Instead of talking to my wife or a trusted loved one about this new challenge and the feelings associated with it, I came home from a long day of working in a Counseling Enriched Classroom and proceeded to bake muffins for everyone.
I then ended up complaining to my wife about how frustrated I was with having to share our bathroom with twelve people!
People, and especially youth with RSD, feel terrible about how emotionally dysregulated they get and because of this, they try to avoid this sense of rejection by pleasing others, even at a significant cost to their own well-being.
Many times in my life, I've let someone continue to try to sell me something on the phone because I am too uncomfortable to say, "I'm sorry, I have to go."
This inability to express needs and wants often ends up in boundary erosion which creates resentment, leads to avoidance and makes relationships hard to maintain.
Individuals with RSD will go above and beyond to please someone, even at a cost to their own mental health, because they do not have the skills to process the potential rejection that they are afraid to experience.
Strategy #6: Practice processing emotions with them
First, teach your child strategies to notice her body's response to feeling rejected.
Questions you can ask her are:
When you are upset, how do you know? Do you clench your fists? Does your face get hot?
Is your stomach tight right now?
Are you fighting back tears?
I suggest using a journal to track these feelings. I like the Day One app since it syncs across my devices and can quickly be accessed.
Once your child can recognize RSD symptoms and when he is feeling triggered, the next step is to help him differentiate his feelings.
You can use the Red, Yellow, Green framework to help your child identify his emotions.
Green
I'm fine
Thinking clearly
Body feels loose and free
Yellow:
I'm feeling slighted
Rejection is growing
Body is beginning to tighten
Red:
I'm furious
I'm ready to destroy everything around me
My fists and jaw are clenched and my body is hot
Your child will begin to improve her self-awareness by using this framework and journaling about the signs that indicate she is feeling dysregulated and to what degree.
Lastly, teach your child strategies to calm the central nervous system when he starts to enter the red or yellow zones. Have him come up with a "menu" of activities that can help him self-regulate.
These may include:
Finger breathing
Counting
Going for a walk
Petting the dog
Drinking tea
Playing basketball (my favorite)
If a child or young adult learns to recognize the signs of emotional dysregulation before she or he reaches catastrophic proportions, she or he can take the appropriate steps to self-care.
When individuals self-care their blood pressure drops, their nervous system calms, and they are less likely to engage in the cycle of explosive reactions that can lead to more social rejection, peer rejection, and lowered self-esteem.
Conclusion
With understanding and attention, individuals with ADHD (who are genetically predisposed to have RSD), can manage RSD and experience better life outcomes including:
Improved school experience
Great job retention
Reduced mental health disorders
Better marital outcomes (when they are older)
More authenticity through assertive communication
If you believe your child is struggling with RSD, connect with a mental health professional who understands RSD .
While rejection sensitive dysphoria is not in the diagnostic and statistical manual and thus cannot receive a professional diagnosis, a skilled mental health provider can recognize RSD and help your child with the following things:
Regulating emotions
Assertive communication
Improving self-esteem
Increasing self-care
Even without an official diagnosis, mental health providers can also determine if ADHD symptoms and RSD are linked to other mental disorders which may include:
Mood disorders
Borderline personality disorder
Additionally, consider having your child work with an executive function coach who can help with other ADHD symptoms that include:
Procrastination
Disorganization
Avoidance of interacting with school staff
Assertive communication
Time management
If you would like to do further reading on this subject, check out the book, "Why will no one play with me?" by Caroline McGuire.
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About the author
Sean G. McCormick is the founder of Executive Function Specialists, an online coaching business that guides middle, high school, and college students in overcoming procrastination, disorganization and anxiety by teaching time management, prioritization and communication skills so they feel motivated, prepared, and empowered.
He also founded the Executive Function Coaching Academy which trains special education teachers, school psychologists and other professionals to support students with ADHD and executive function challenges.