ADHD and Rejection Sensitive Dysphoria

Webinar Transcript

Introduction and Executive Functioning in ADHD

Victoria Bagnall: Good evening, everyone, and welcome to our webinar. We have a full house joining us tonight. My name is Victoria Bagnall, Co-founder and Managing Director of Connections in Mind. We specialize in raising awareness about executive functions and how we can develop stronger executive processes.

Executive functions are managed by the prefrontal cortex—the area of the brain behind the forehead. They help us regulate emotions, manage time, organize belongings, and navigate daily life. Joining me tonight are Phil Anderton and Lisa Mangle from ADHD 360.

Phil Anderton: Hello, everyone. I am Phil Anderton, co-founder of ADHD 360 alongside Lisa. For over 20 years, Lisa and I have worked to improve the lives of individuals with ADHD. My background spans criminal justice as a senior police officer, the National Health Service (NHS), and the pharmaceutical industry.

Lisa Mangle: Hi, I am Lisa Mangle. My background is in the NHS, where I have worked in ADHD care for over two decades. At ADHD 360, we assess, diagnose, and support patients ranging from age four to 76. Diagnosing and treating ADHD changes lives daily for individuals who have struggled for years.

Understanding Rejection Sensitive Dysphoria (RSD)

Victoria Bagnall: Tonight’s topic emerged from our community discussions regarding Rejection Sensitive Dysphoria (RSD). RSD frequently co-occurs with ADHD and other neurodevelopmental conditions, serving as a significant symptom of emotional dysregulation.

Phil Anderton: RSD is often viewed as a newer concept, yet clinicians have managed it under the umbrella of ADHD for years. ADHD is not merely about hyperactivity, inattention, and impulsivity; it is fundamentally about executive function deficits and how those impairments manifest in an individual’s daily life.

Addressing sensitivity to rejection and criticism as an intrinsic impairment of ADHD allows us to move toward more accurate labels and targeted support. Emotional dysregulation often leads to extreme behavioral reactions, such as severe distress over seemingly minor occurrences, driven by years of underlying frustration.

The Developmental Roots of Low Self-Esteem

Phil Anderton: In a survey of 250 families in the UK and 250 in the US, parents consistently reported noticing significant declines in their child’s self-esteem starting around age six. By this age, neurodiverse children in traditional school settings often experience peer exclusion, segregation during breaks, and embarrassment without understanding why. This establishes a negative emotional baseline early in life.

Lisa Mangle: Clinical trials for ADHD medications historically focused on ages six to 17, but symptoms and emotional suffering clearly exist before age six. When a four- or five-year-old child struggles to focus or experiences severe outbursts at home, early intervention is essential to protect their early learning building blocks.

In clinic, I recently assessed a bright six-year-old boy who referred to his assigned seat as the “stupid table” and shared that he felt lonely because his behavior embarrassed his friends. When self-worth plummets so early, children internalize negative self-perceptions that persist into adulthood.

Adulthood Manifestations, Anxiety, and Misdiagnosis

Phil Anderton: As children grow into adults, executive function challenges persist. When the prefrontal cortex struggles to conduct the brain’s processes, daily performance suffers. Many adults present with chronic fear of failure, paralysis, and severe situational frustration, which is frequently misdiagnosed as primary depression or anxiety.

Lisa Mangle: Many individuals operate near their emotional limit—what I call being right below the “lose-it line.” Because their baseline stress is constantly elevated at 99%, a minor trigger can cause an immediate, explosive reaction.

For instance, a 22-year-old university student was referred after years of emotional volatility and substance abuse. Despite obtaining solid grades due to high innate intelligence, he viewed himself as a constant failure because he fell short of his full potential. Identifying his underlying ADHD provided immediate clarity and opened the door to effective treatment.

Differentiating RSD from Mood Disorders and Managing Triggers

Phil Anderton: As Dr. Russell Barkley notes, emotional responses in ADHD—including RSD—are time-limited, setting-specific, and directly tied to identifiable triggers. They represent acute reactions to specific situational provocations. In contrast, primary mood disorders or oppositional defiant conditions involve long-lasting, pervasive emotional states across settings.

Because RSD reactions are trigger-dependent, the primary strategy for management is identifying and modifying environmental triggers. Rather than expecting an individual with a neurodevelopmental deficit to abruptly change their internal response, parents, educators, and clinicians must adapt the environment and approach.

Victoria Bagnall: Empathy is an extraordinarily powerful tool in these moments. Validating an individual’s emotional reality helps them process intense feelings, de-escalate the fight-or-flight response, and return to a state where rational communication is possible.

Medical Management and Behavioral Strategies

Phil Anderton: Managing ADHD and RSD requires a comprehensive approach. Medication can stabilize core executive deficits, while cognitive behavioral strategies and executive function coaching help build long-term resilience and coping mechanisms.

Lisa Mangle: When selecting medication for patients with prominent emotional dysregulation or RSD, non-stimulant options like Guanfacine can be particularly effective. Originally formulated for hypertension, Guanfacine lowers blood pressure and heart rate, directly dampening the body’s sympathetic fight-or-flight response. It offers continuous 24-hour coverage, making it suitable for patients with co-existing conditions like Autism or severe anxiety.

Furthermore, proper medication does not “zombify” patients. When hyperactivity and impulsivity are reduced, an individual’s true personality—such as an introverted preference for quiet activities—can emerge naturally. In adults, effectively treating core ADHD resolves co-occurring anxiety and depression symptoms in up to 90% of cases.

Conclusion and Recommendations

Phil Anderton: RSD is a genuine, deeply felt manifestation of ADHD root executive impairments starting in childhood. Effective care requires early clinical assessment, environmental trigger reduction, empathetic communication, and tailored medical and therapeutic interventions.

Victoria Bagnall: Understanding executive function challenges as a natural aspect of human diversity helps strip away the shame surrounding RSD. By fostering empathy and public awareness, we can better support neurodiverse individuals across all stages of life.