The ADHD Brain

3 Defining Features of ADHD That Everyone Overlooks

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.

How Symptoms of ADD Change The Way You Feel and Think

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 their 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.

More Recommended Reading

  1. Self-Test: Could You Have Adult ADHD / ADD?
  2. Exaggerated Emotions: How and Why ADHD Triggers Intense Feelings
  3. Free Download: Inattentive ADHD — Explained

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

41 Comments & Reviews

  1. I’ve never felt so much like someone understands my child (and me)! Thank you for putting these features together with detailed explanations and suggestions for treatment strategies. Now, how can we work to help others see ADHD this way?

  2. Ven la Faxine xr prescribed for a major depression has performed admirably for RSD the hyper in my Hypersensitivity although Pthe dose is only 75 mg and unchaned for 5 years the results are excellent..

      1. Do you have any tips on how we can better advocate for ouselves with our clinicians (especially if they are not as well versed about RSD?)

      2. I dont have any. This was the psychiatrists answer to my major depression and it took several months to have total effect. Around that time i read mindfulness for dummies which had a major impact on my interpretation of those around me. Also my working memory started a long term trend upward that is now outstanding by comparison to what it was 5 years. Ago. Now I can walk out of my appartment and seldom return for forgotten items. At my worst i would return three times for hats, gloves, sunglasses, keys, and assorted other items necessary for the outing i was attempting to go on. I rarely leave a tap running or burner on . At least 8 hours and preferrably 9 have become a priority, Convenience food has taken a back seat to a healthy diet heavy in Vegetables and fruits (nad choclate) Pop drinks and alchohol are infrequent indulgencies. Next on my list I hope to add a decent amount of exercise.
        Sweets still play too large a part but i am human (i think).
        As to advising your clinician, i am of no help. Mine confirmed the diagnosis and prescribed concerta but I have chosen not to pursue a stimulant nor do i consume caffeine by the the two liters a day i used to.
        When a medication works as well as mine did, i thank my lucky stars and God, and read as much as I can and attend any group programs i can find.

  3. Hello!

    Dr. Dodson, could you please further clarify the question that your premise is based on? “What does everyone with ADHD have in common, that people with ADHD don’t experience?” I’m having trouble understanding the nuance. Thanks!

    1. I don’t know for sure and I can’t speak on behalf of the person who wrote the article, but I got the impression that the second “with” might have been supposed to be “without”, since then the sentence would basically be “what do people with ADHD experience that people without ADHD don’t?”, which makes more sense to me.

    1. It is interesting because I do not actually have that feature in my experience of ADHD. I believe, in part, that my mothers emphatic assertion that I be on time and respect other poems time helped to curb some of those tendencies.

      1. It is interesting that this condition is determined not by the severity of the underlying clinical brain injury but by the inadequacy of our adaptation. If this were any other limb or organ, the condition would be the same regardless of our success at adapting to the malady.

  4. This article is extraordinary! I always thought I was “thin-skinned” and take things too personally. Having never heard of ADD growing up, it has been so helpful as an adult (77 yrs. old now) to understand what makes me literally tick. And now to have a name for my hyper-focus and my sensitivity is healing beyond words. These last 10 years have been like peeling layers off an onion. And now I have a great-grand-daughter with ADD who I can support and encourage as she comes to terms with who she is — an amazing gifted girl with an ability to shoot for the moon if she wants to.

    1. Amen to that from a 73 yr old . I suspect though that you may find some of your other offspring may also be undiagnosed. My son, my grandson , and my great grandDaughter are all ADHD. Grandson is my Daughters son. He and his spouse and Dtr are all ADHD

  5. I have to say that I disagree with the assertion that hypersensitivity can only be managed via medication. As a therapist and a person who experiences ADHD, I have found that somatic psychotherapy and mindfulness have been highly effective in helping with hypersensitivity, especially as it relates to rejection and relational challenges.

  6. I think it’s important to note that “interest” can be a VERY situational thing for people with ADHD.

    Before I was diagnosed, I would get upset because many well-meaning people insisted that the reason I was struggling with my dissertation was that I must not be that interested in the topic. But I was! I really was!

    The problem was a) of course, a dissertation is still a huge project that’s going to be inherently hard for anyone with executive dysfunction to manage and b) not every single task – or even every part of every task – is as interesting as the next. My interest in the topic did not make it any easier to get engaged with individual tasks that were not as interesting as, say, reading an article on the topic or analyzing my data. “I get to do the interesting part next” doesn’t work as a reward in my brain. It only cares about what I’m doing now and why it should care about that one task I’m trying to do now.

    Or there’s the fact that I struggle to stay awake during talks, even if I’m very interested in the topic – my brain just can’t sustain focus on any topic via *that particular medium* for an extended period of time. It’s not the topic, or even that the speaker isn’t engaging or isn’t explaining things well! I just can’t sustain focus on something talking about *anything* for more than 10-15 minutes. I have to play a game or something on my phone so I can switch my focus back and forth just so I can stay awake during a talk that I am really enjoying! I also love audiobooks – but only while I’m driving, so I have other things to focus on. The same audiobook would put me right to sleep if I just sat in my living room listening to it, even though the story isn’t boring.

    I have several other examples, but this is long enough. I’ve just been frustrated lately by seeing several articles with this focus on interest that make it sound like if a person with ADHD has trouble focusing on something, they must think it’s boring. I know that’s not what anyone’s trying to say, but without further clarification that can be the message conveyed.

    1. I concur that being an academic with ADHD is very challenging. When I was struggling through graduate school, I noticed a pattern in my struggle to complete papers; the problem as that as I complete the paper, my understanding of the topic would shift, and in turn, I would adapt my thesis/framing of the topic to this new understanding. Unfortunately, this instinctive tactic does not lend itself to meeting deadlines, nor did I ever feel as if I had a real direction for the paper, until the very end, at which time I was already thoroughly burned out and in no shape to write up the final analysis under the pressure of a looming deadline. When you study the humanities, (French literature, in my case), there are additional challenges like the exactitude required to write well in a foreign language, the ability to synthesize the methodology of your profession, which seemingly is never fully addressed in a direct manner. If I were to do it again, with the understanding that I have ADHD combined type, I believe that it would have helped tremendously to glimpse ahead, and understand that for me, I needed more time, maybe a few years more, to everything to gel. After a long struggle, it is all too clear (one thinks) that they have failed; but, when it does come together finally, we are the real deal, experts. The path to growth is not at all linear, and may require more time for us than for others. For those with ADHD, it is important to pace yourself according to your own needs, and make a strong commitment to keep moving forward at a pace that is reasonable for you.

    2. I describe that (falling asleep in lectures unless also doing something else is a great example) as “having an 8-track brain”.
      If only one track is being engaged, the rest of my brain keeps looking for something to occupy some of the other tracks, and that gets VERY distracting, but if I give one or more of the other tracks something to do I’m able to pay much closer attention to the more important whatever-it-is occupying the first track.
      What works best for me in academic settings is using really great pens in a variety of colors, and filling the margins of my notes with whatever song lyrics are stuck in my head, or complex swirling doodles inspired by the ink flow of an awesome pen*, making interesting patterns around key points in my notes themselves (which has the added benefit of enhancing my visual recall of the notes when test time comes around).
      Back in the day when we still wrote and mailed letters I’d sometimes start a letter to a friend a little further back in my notebook and keep adding to it during that same class for a few weeks at a time. Given that my ADHD seems to include an allergy to the post office, waiting until I had several pages made it seem worth the effort of getting it in the mail eventually.
      I heartily recommend using art supplies like sketchbooks and fancy fine tip markers instead of basic notebooks and pens/pencils, as the visual stimulation and tactile pleasures (for me at least) keep a few of the other tracks occupied enough to free up my auditory focus, and ability to stay awake. I end up hearing and retaining the lecture content so much better!
      Similarly, highlighting passages in textbooks with the same highlighter defeated the purpose for me, it all just blended together. It worked much better for me to underline in colored pencils and switch the colors regularly.
      *My all-time favorite pen is the Pilot Varsity disposable fountain pen with purple ink!

    3. I had to chuckle at the dissertation-writing reflections. As a nursing student I developed a pattern: find a spot in the newspaper-reading room of our local library (because I love the sound of rustling newsprint!) Then I would lay my head on my pile of books and nap, because it was useless to do anything while tired. Twenty minutes, or so, later I would begin- but not with the assigned texts. I started by flipping through my anatomy book or medical dictionary until something caught my attention. I especially loved the weird stuff, bizarre syndromes, etc. Once I reached “the zone” I would turn to the necessary task. I found that the same attention, once aroused, would transfer to that task. I finished pre-requisites and nursing courses with a 4.00.

  7. On RSD (Which I did not know about until today, despite having been diagnosed with ADHD at the age of six eighteen years ago): “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./”
    So what exactly is a person supposed to do when they’ve ‘opted out’ and what’s left of the part of them that cares about this would like to stop doing that?

    1. Here’s what’s helped me:
      1.) a therapist with a thorough understanding of adult adhd. My therapist helped me establish new thought patterns and behavior patterns. She taught me to combat the negative thoughts about myself or the activity (whatever activity I was avoiding in my life, including interacting with new people) that caused me to just not even try and that helped me reframe my mind.

      2.) I’ve become almost obsessively mindful of my behavior and thoughts. By habit, I ask myself what I’m feeling, why I’m feeling that way, and if my thoughts are logical and if not, I think about the reality of the situation and I turn to the strategies I learned about in therapy, to help me reframe my mind.

      For me, it’s all about analyzing my thoughts, mindfulness, and extensive education on how adhd affects people who have it. It’s also about knowing myself and my reality/perspective and how that differs from the realities/perspectives of others. Feeling like I have a solid view of myself and the entire situation helps me reframe my mind.

  8. So, I haven’t been diagnosed with ADHD, are we absolutely sure that emotional hyperarousal and rsd as described here, do not occur in neurotypical people? I do relate to the first one – interest based nervous system, but not entirely. I do find that I can do SOME tasks based on the fear of consequences, usually related to my job, because I don’t want my boss mad at me, and I don’t want to get fired.

    So I ask, where would you categorize someone who fully experiences 2 and 3, but not necessarily 1?

  9. This is the first time I have seen ADHD described in this manner. Thank you! I have always described my child’s ADHD as easy (mostly) when it comes to being hyper. It’s the fits of rage (emotional arousal) that is so difficult to deal with. I agree the Intuniv XR works…but in our experience at some point it is no longer effective and has to be stopped for a long period of time before use again. Thanks again for so eloquently describing this condition!

  10. Dear Doctor Dodson,
    Thank you.
    One thing that the adult adhd afflicted have likely tried, pre formal diagnosis, is a self medication regime based around street stimulants and depressants. Which of course, sans formal treatment, contribute to the shame spiral. But most importantly they also cloud the ability to successfully diagnose. I spent a long time fighting with the precepts of Alcoholics Anonymous. But that too was bashing the star shape into the round hole- there were many behaviours which fit, but not an alcoholic is not an alcoholic. Although some valuable management skills can be picked up the biggest blockage was in RSA. That was and is the key defining thing for this adult ADHD afflict.

    Now I might have some chance of avoiding the devastating lows that come with the pain in the chest and the destruction of the bridges in the process. Truly being able to name a thing aids in gaining power over it.
    Thank you. Thank you.

  11. I strongly disagree with the statement that only medication can manage rejection sensitivity. While I have and take medication for ADD, I have found Dialectical Behavioral Therapy (DBT) extremely helpful. It teaches skills such as mindfulness, building tolerance to negative experiences, coping, and communication. Before DBT, I seriously suffered from rejection sensitivity. Now I am learning to live with my emotions.

    More about DBT:

  12. Thanks for this interesting article, I am 53 years old and have been diagnosed as ADHD since primary school. I have never been advised by doctors or psychologists of these “other” symptoms of ADHD, I in fact took these to be normal!
    Especially “RSD”! Who knew?
    Thanks again.

  13. Some wheat in the chaff. Mostly this article is junk science though. (Sorry)

    Rejection sensitivity isn’t an ADHD trait. Its a non-ADHD trait that may well be activated by ADHD. The same happens with high functioning autism and other MH which can leave feelings of shame, confusion and self-criticism over “why can’t I get round this?”

    Its true that DSM does mislead, in that symptoms tend to differ adult/child. Its also true that interest plays a part and a state of intense focus exists. But ADHD isn’t interest based. That’s pure junk. It might be how it *seems*, but that’s all. Rather, the ability to regulate stimulation (engage/disengage/switch, i.e. wilfully set and choose what to attend to and what not) is the underlying problem. “Interesting stuff” is not the underlying characteristic – it just increases the likelihood that the brain will be able to reach a stimulation threshold to engage.

    It’s also a self fulfilling definition. We tend to *define* “interesting” in the first place, by observation, being what the brain seizes on and pays attention to. Then, naturally things that are “interesting” are those that get locked onto. Circular logic. Not actually helpful or, really, even accurate.

  14. Wow….what can i say… everything i read is myself to a T, my life, my childhood, my schooling is all making a lot more sense to me. My brother, after many many years of ADHD specialist appointments finally was diagnosed with Adult ADHA. Because of growing up with him, i have quite an understanding of adhd but never quite like this. My brother has always told me that he thinks i am ADHD also as we are very very similar in the way our mind works. I am now 39 years old and the older i get the more stranger i get and the more i am not coping with life in general. I have yet to be diagnosed ADHD but everything i just read here all makes so much sense to me….its exactally how my mind works…i am feeling a feeling of relief as if someone understands me…..i am currently having a very hard time in life due to my emotional outbursts which is putting pressure on my relationship almost ending it but this is amazing, even reading it to my partner he also was in amazement with how accurate it is to me…..i have now booked myself in to see a specialist and hopefully i can learn and understand finally why my life had been harder than most to function….and hopefully with this new knowledge and understanding i can now move forward in a positive way with the right tools that work for my ADHD mind…..Thankyou Thankyou Thankyou…
    Please email me any more information that may help me in any way.

  15. This article by a different author directly contradicts the claim here regarding Guanfacine and Clonidine, that 1/3 of people respond well to one treatment or the other, but that 60% respond to both treatments combined. Which assertion is correct and what are the sources for this information?

    “Guanfacine and clonidine appear to work equally well for different patient populations. Individuals respond differently to different medications. If you don’t experience benefits from taking one medication, work with your physician to stop taking it, and try the other option. Most patients experience benefit from one or the other.”

  16. Hi, I am a clinical psychologist with a degree in Biochemistry as well. This article explains some interesting concepts about ADHD. However, I take issue with one statement:
    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

    The point that medication is NEEDED to level the neurological playing field shows an overly simplistic (and overly medicalized) view of ADHD. The neurological playing field can be leveled through means other than medication and it is important that individuals with ADHD undertand that.

  17. Dear Dr. Dodson,

    I am a first time visitor. I find your discussion of an interest based nervous system *deeply* troubling, enough to make sign up just so I could post this comment. What you describe is the subject of an entire industry of peak performance study, starting with the national bestseller “Flow”, by Mihaly Csikszentmihalyi, first published 30 years ago, in 1990. NONE of those writers, researchers, psychologists, journalists, and educators refer to being ‘in the zone’ as *pathological* or in need of medication. Indeed, it is a very good thing, and people want to know how to call upon it at will, and sustain it.

    I hope that you will review the work in this field, and rewrite or delete this post in light thereof.

  18. RSD is so hard. It’s hard to watch what it does to your child, and it’s hard to successfully manage it. I am so glad that it’s better understood now; how many children and adults had to go through life feeling this way without knowing what it was, or be called a drama queen or overly sensitive during that time? It’s heartbreaking. My child has this in addition to ADHD and watching her hide under a table and cry because she thinks we don’t love her anymore is the most awful feeling in the world.

  19. You state that people with ADHD are great lie detectors. Why is that? What is the evidence for that? Are there any articles about that? Because searching for it only comes up with information about kids with ADHD lying.

  20. “The problem: These criteria only describe how ADHD affects children ages 6-12.”

    I’m concerned about the lack of sources in this article overall, particularly when it comes to this comment at the beginning of the article. The DSM-V specifically calls out differences in the number of symptoms to look for in children under 16 vs older teens and adults, and I can’t find any other literature that supports this comment.

    I have a hard time trusting the entire article when the central argument of the introduction doesn’t seem to be substantiated by anything other than the author’s personal opinion.

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