The textbook signs of ADD — inattention, hyperactivity, and impulsivity — fail to reflect several of its most powerful characteristics; the ones that shape your perceptions, emotions, and motivation. Here, Dr. William Dodson explains how to recognize and manage ADHD’s true defining features of rejection sensitivity, emotional hyperarousal, and hyperfocus.

The DSM-V – the bible of psychiatric diagnosis – lists 18 diagnostic criteria for ADHD. Clinicians use these to identify symptoms, insurance companies use it to determine coverage, and researchers use it to determine areas of worthwhile study.

The problem: These criteria only describe how ADHD affects children ages 6-12. The signs of ADHD in teens, adults, and the elderly, on the other hand, are not as well known. This has led to misdiagnosis, misunderstanding, and failed treatment for these groups.

Most people, clinicians included, have only a vague understanding of what ADHD means. They assume it equates to hyperactivity and poor focus, mostly in children. They are wrong.

When we step back and ask, “What does everyone with ADHD have in common, that people without ADHD don’t experience?” a different set of symptoms take shape.

From this perspective, three defining features of ADHD emerge that explain every aspect of the condition:

1. An interest-based nervous system

2. Emotional hyperarousal

3. Rejection sensitivity

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

1. Interest-Based ADHD Nervous System

What is an interest-based nervous system?

Despite its name, ADHD doesn’t actually cause a deficit of attention. It actually causes inconsistent attention that is only activated under certain circumstances.

People with ADHD often say they “get in the zone” or “hit a groove.” These are all ways of describing a state of hyperfocus – intense concentration on a particular task, during which the individual feels she can accomplish anything. In fact, she may become so intently focused that the adult with ADD may lose all sense of how much time has passed.

This state is not activated by a teacher’s assignment, or a boss’s request. It is only created by a momentary sense of interest, competition, novelty, or urgency created by a do-or-die deadline.

The ADHD nervous system is interest-based, rather than importance- or priority-based.

[Free Download: 3 Defining Features of ADHD That Everyone Overlooks]

How do I recognize an interest-based ADHD nervous system?

Clinicians often ask, “Can you pay attention?” And the answer is typically, “Sometimes.”

This is the wrong question. Parents, loved ones, and teachers answering it often express frustration because they have seen you hone in on something you enjoy – like video games – for hours, so your inability to conjure that same focus for other tasks and projects is interpreted as defiance or selfishness.

Instead, practitioners should ask, “Have you ever been able to get engaged and stay engaged?” Then, “Once you’re engaged, have you ever found something you couldn’t do?”

Anyone with ADHD will answer along these lines: “I have always been able to do anything I wanted so long as I could get engaged through interest, challenge, novelty, urgency, or passion.”

“I have never been able to make use of the three things that organize and motivate everyone else: importance, rewards, and consequences.”

What can I do to manage an interest-based nervous system?

An effective ADHD management plan needs two parts:

medication to level the neurological playing field

a new set of rules that teach you how to get engaged on demand

Stimulant medications are very good at keeping the ADHD brain from getting distracted once they are engaged, but they do not help you get engaged in the first place.

Most systems for planning and organization are built for neurotypical brains that use importance and time to spark motivation. Instead, you must create your own “owner’s manual” for sparking interest by focusing on how and when you do well, and creating those circumstances at the outset.

This work is highly personal, and will change over time. It can involve strategies like “body-doubling,” or asking another person to sit with you while you do work. Or “injecting interest” by transforming an otherwise boring task through imagination. For example, an anatomy student who is bored with studying can imagine she is learning the anatomy to save her idol’s life.

2. ADHD Emotional Hyperarousal

What is emotional hyperarousal?

Most people expect ADHD to create visible hyperactivity. This only occurs in 25% of children and 5% of adults. The rest experience an internal feeling of hyperarousal. When I ask people with ADHD to elaborate on it, they say:

“I’m always tense. I can never relax.”

“I can’t just sit there and watch a TV program with the rest of the family.”

“I can’t turn my brain and body off to go to sleep at night.”

People with ADHD have passionate thoughts and emotions that are more intense than those of the average person. Their highs are higher and their lows are lower. This means you may experience both happiness and criticism more powerfully than your peers and loved ones do.

Children with ADHD know they are “different,” which is rarely experienced as a good thing. They may develop low self-esteem because they realize they fail to get engaged and finish what they start, and because children make no distinction between what you do and who you are. Shame can become a dominant emotion into adulthood as harsh internal dialogues, or criticism from others, becomes ingrained.

How do I recognize emotional hyperarousal?

Clinicians are trained to recognize mood disorders, not the increased intensity of moods that comes with ADHD. Many people with ADHD are first misdiagnosed with a mood disorder. On average, an adult will see 2.3 clinicians and go through 6.6 antidepressant trials before being diagnosed with attention deficit disorder.

Mood disorders are characterized by moods that have taken on a life of their own, separate from the events of the person’s life, and often last for more than two weeks. Moods created by ADHD are almost always triggered by events and perceptions, and resolve very quickly. They are normal moods in every way except for their intensity.

Clinicians should ask, “When you are upset, do you often ‘get over it’ quickly?” “Do you feel like you can’t rid your brain of a certain thought or idea when you want to?”

What can I do to manage emotional hyperarousal?

To counteract feelings of shame and low self-esteem, people with ADHD need support from other individuals who believe they are a good or worthwhile person. This can be a parent, older sibling, teacher, coach, or even a kind neighbor. Anyone, as long as they think you are good, likeable, and capable – especially when things go wrong. This “cheerleader” must be sincere because people with ADHD are great lie detectors.

A cheerleader’s main message is, “I know you, you’re a good person. If anybody could have overcome these problems by hard work and just sheer ability, it would have been you. So what that tells me is that there’s something we don’t see that’s getting in your way and I want you to know I will be there with you all the way until we figure out what it is and we master that problem.”

The true key to fighting low self-esteem and shame is helping a person with ADHD figure out how to succeed with his unique nervous system. Then, the person with ADHD is not left alone with feelings of shame or blamed for falling short.

3. Rejection Sensitivity

What is rejection sensitivity?

Rejection sensitive dysphoria (RSD) is an intense vulnerability to the perception – not necessarily the reality – of being rejected, teased, or criticized by important people in your life. RSD causes extreme emotional pain that may also be triggered by a sense of failure, or falling short – failing to meet either your own high standards or others’ expectations.

It is a primitive reaction that people with ADHD often struggle to describe. They say, “I can’t find the words to tell you what it feels like, but I can hardly stand it.” Often, people experience RSD as physical pain, like they’ve been stabbed or struck right in the center of their chest.

Often, this intense emotional reaction is hidden from other people. People experiencing it don’t want to talk about it because of the shame they feel over their lack of control, or because they don’t want people to know about this intense vulnerability.

How do I recognize rejection sensitivity?

The question that can help identify RSD is, “For your entire life, have you always been much more sensitive than other people you know to rejection, teasing, criticism, or your own perception that you have failed?”

When a person internalizes the emotional response of RSD, it can look like sudden development of a mood disorder. He or she may be saddled with a reputation as a “head case” who needs to be “talked off the ledge.” When the emotional response of RSD is externalized, it can look like a flash of rage. Half of people who are mandated by courts to receive anger-management training had previously unrecognized ADHD.

Some people avoid rejection by becoming people pleasers. Others just opt out altogether, and choose not to try because making any effort is so anxiety-provoking.

What can I do to manage rejection sensitivity?

98-99% of adolescents and adults with ADHD acknowledge experiencing RSD. For 30%, RSD is the most impairing aspect of their ADHD, in part because it does not respond to therapy.

Alpha-agonist medications, like guanfacine and clonidine, can help treat it. Only about one in three people experience relief from either medication, but 60% experience robust benefits when both are tried. When successfully treated, people with RSD report feeling “at peace,” or like they have “emotional armor.” They still see the same things happening that would have previously wounded them, but now it bounces off without injury. They also report that, rather than three or four simultaneous thoughts, they now have just one thought at a time.

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William Dodson, M.D., is a member of ADDitude’s ADHD Medical Review Panel.

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Updated on July 31, 2020