What Is ADHD Masking, And Why Is Diagnosis Challenging?
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In the popular children’s book A Bad Case of Stripes, protagonist Camilla Cream refuses to acknowledge her love of lima beans as she strives to fit in with her classmates. As a result, the young girl soon has stripes covering her skin, which morph into various patterns, before she eventually starts growing odd appendages and becoming “one” with her bedroom. The classic picture book uses a funny story to showcase a powerful message: there are sometimes consequences to trying to be just like everyone else.
For people with ADHD, ADHD masking is one strategy sometimes employed to try to fit in. While masking may prevent symptoms from disrupting your life in some ways, it can also lead to several negative consequences. By unmasking your ADHD and seeking support from others, you can learn how to better manage your ADHD and prevent embarrassment if symptoms disrupt your life.
Understanding ADHD
Attention-deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders and forms of neurodivergence with which children are diagnosed. However, ADHD is not limited to childhood. People of any age can live with ADHD or be neurodiverse. Children diagnosed with ADHD may continue to show symptoms as they age, and it may take until adulthood for someone to receive their initial diagnosis.
Scientists are still looking into the causes of ADHD, but research shows that genetics can play a significant role in the condition. Other contributing factors can include low birth weight, stress during pregnancy, and exposure to toxins such as alcohol or smoking during pregnancy.
Characteristics of ADHD
An individual may be diagnosed with one of three types of ADHD based on how their symptoms present:
- Predominantly inattentive presentation (ADHD-PI)
- Predominantly hyperactive or impulsive presentation (ADHD-HI)
- Combined presentation
Each subtype of ADHD involves a unique set of symptoms. People with inattentive ADHD often struggle with staying focused and organized, finding it challenging to stay on task. Hyperactive or impulsive ADHD can cause someone to have difficulty staying still and a propensity to make impulsive decisions. An individual who exhibits both types of ADHD is characterized as having a combined presentation.
The prevalence of ADHD
For decades, diagnoses of ADHD have been on the rise. While there is still some debate about why many people are being diagnosed with the condition, studies show that young girls and adults with ADHD are often overlooked in the diagnostic process. In an article about taking a lifespan approach providing guidance in the identification of ADHD in women and girls, experts pointed out that even now, physicians may experience a lack of recognition or referral bias when it comes to diagnosing ADHD in these groups.
Potential challenges
The struggles that people with ADHD may face, whether living with undiagnosed ADHD or an official diagnosis, extend far beyond trouble focusing or sitting still. The condition has also been linked to poor school performance, substance use, unstable relationships, and poor self-image. These challenges can contribute to or accompany the development of other mental illnesses, such as mood disorders and anxiety disorders.
ADHD masking
Social norms are often established based on the behavior of neurotypical people (people without neurodevelopmental differences). To fit in, people with conditions like ADHD may choose to mask their symptoms and natural behaviors. While hiding symptoms may provide social relief in the moment, it can also lead to long-term consequences for those who mask.
What is ADHD masking?
ADHD masking, or impression management, occurs when someone goes out of their way to hide their ADHD symptoms. In some cases, masking is done consciously. However, it may also become an ingrained habit or subconscious behavior. Masking is typically done to portray a specific version of yourself. People with ADHD may mask their symptoms to fit in at work or with their friends out of concern that others may think less of them.
ADHD masking: how does it appear, and what are the consequences?
ADHD masking can show up via several behaviors. The type of masking in which you engage may depend on the type of ADHD you have, but some common ways people mask include:
- Focusing intensely to keep up when talking to others
- The urge to write everything down
- Struggling to focus because of excessive energy
- Suppressing strong emotions
- Choosing to organize a task instead of getting started
- Fighting the urge to fidget or stim
- Mimicking other people to try to be more “socially acceptable”
While masking can make it easier to believe you fit in with your peers, it can also lead to negative consequences, including physical and emotional exhaustion, imposter syndrome, identity issues, anxiety or depression, and suicidal ideation.
Masking and diagnosis challenges
Consistently masking your ADHD may delay or prevent a diagnosis of the condition. A mental health professional often uses the history of your behavior to understand whether you have the condition. If your past behavior doesn’t indicate any symptoms of ADHD, it can be challenging to diagnose and treat the condition.
Patricia Quinn, author of A Review of Attention-Deficit/Hyperactivity Disorder in Women and Girls: Uncovering This Hidden Diagnosis, published an article about these issues in The Primary Care Companion for CNS Disorders. She shared that girls with ADHD may often develop better masking strategies to disguise their symptoms but still experience consequences such as behavioral issues and academic struggles.
How to identify ADHD masking
It can be challenging to identify ADHD masking if the behaviors have become a part of your routine. However, you can use a few strategies to notice when masking. Pay attention to how you act around different groups of people. If you constantly modify your behavior in certain situations, you may be masking to cover up your natural behaviors or personality.
You may also work with a therapist to discern which masking behaviors are helpful or harmful. For example, writing everything down can be exhausting, making it harder to keep track of information. However, keeping a calendar full of important dates and a note containing helpful reminders can help you manage your commitments.
Is unmasking safe?
Although there are several ways that ADHD masking can impact your mental health, there can also be consequences to unmasking your condition and allowing your symptoms to show. An individual who unmasks may find it more challenging to find a job that can accommodate them or may experience verbal or physical assaults. It can be understandable why someone would wish to seek support in determining how to be their authentic selves while protecting their physical and emotional safety.
Manage your symptoms without masking
If you fear how people will react to your true self and your ADHD behaviors, you may be hesitant to stop masking. Your fear may be legitimate, but there are ways to learn to manage your behaviors without covering up or hiding them completely. Healthy coping strategies are often crucial to helping you successfully navigate life with ADHD. You may learn these skills in therapy with a trained therapist with experience working with neurodivergent clients.
Support options for proper masked ADHD diagnosis
In some cases, ADHD may make it challenging to participate in in-person therapy. You may lose track of time and struggle to drive to your therapist on time or struggle to sit through an entire session. Online therapy, offered through platforms like BetterHelp, provides one way to mitigate these challenges. Mental health experts will help you assess if you are masking or not. They will also provide strategies that will help you cope with the challenge.
If you forget about a therapy session, you can log in when your therapist reaches out with a reminder. In addition, you can attend the session from anywhere you believe is most conducive, allowing you to choose a location free of distractions or even move around while you chat with your therapist.
Online therapy as a treatment for attention-deficit hyperactivity disorder
In 2022, researchers published a meta-study that examined six randomized controlled trials that examined the impact of online interventions on people with ADHD. They found that online therapy was effective in improving the attention deficit and social function of individuals with ADHD, whether children or adults.
Takeaway
A therapist can help you identify masking behaviors and turn them into healthy coping strategies. Consider contacting a professional online or in your area to get started.
How is the diagnosis of attention-deficit/hyperactivity disorder properly done?
Only a qualified healthcare provider can make a proper diagnosis of a mental health condition like attention-deficit/hyperactivity disorder (ADHD), whether it’s childhood ADHD or adult-onset ADHD. The provider—typically a therapist, psychologist, or primary care doctor—will usually evaluate the person's symptoms against criteria for ADHD as outlined in the Diagnostic and Statistical Manual of Mental Disorders. If they propose a diagnosis of ADHD, they may then recommend a treatment plan appropriate for the individual.
How to manage ADHD masking?
Masking ADHD symptoms to a certain degree as a coping mechanism can sometimes be helpful, but too much of it can take a toll and lead to burnout. According to the Attention Deficit Disorder Association, managing ADHD masking symptoms appropriately can involve approaches like:
Identifying situations when you're likely to mask
Developing healthier ways to cope, typically with the help of a coach or therapist
Finding friends or family members you're comfortable with and intentionally engaging in the unmasking process around them
Joining online communities of those with ADHD to enrich your support system
Seeking professional treatment and support from a mental health care provider
What is the treatment for inattentive ADHD?
According to the American Psychiatric Association, treatment for ADHD often involves some combination of medication and therapy. This is generally true for those with primarily hyperactive, primarily inattentive, or a combined type of ADHD, though each person is different and should receive individualized care for their unique situation. Coaching may also be recommended to help a person live a more fulfilling life by learning to stay organized, complete tasks more efficiently, improve focus, develop time management skills, and develop coping strategies for other symptoms that may impact their daily life.
What does masking ADHD symptoms at school look like?
Symptoms of ADHD masking at school can take many different forms. One common example is that a student may avoid talking or speaking up in class. They may also show perfectionist tendencies, signs of social anxiety, and low self-esteem. They may sometimes experience outbursts of intense emotions after long periods of masking as well.
What does masked ADHD look like in girls?
Masking ADHD symptoms can be especially common in those who identify as women or girls. In fact, according to an expert consensus statement taking a lifespan approach published in 2020 in BMC Psychiatry, this may be a key reason why women and girls are diagnosed with ADHD at lower rates despite experiencing symptoms at similar rates as people of other genders.
ADHD masking and related compensatory behaviors in women and girls can take many different forms. One example is staying quiet in social interactions to avoid interrupting. Another is putting so much energy into appearing like they're not having any problems at school or work when they may actually be struggling with tasks and experiencing low self-worth as a result.
How do you know if you're masking ADHD?
ADHD masking is when you hide parts of the real you or your natural behavior in order to try and fit in or achieve what is expected of you at school or work. Some masking behaviors can actually be beneficial, such as setting multiple alarms to ensure you leave the house on time or taking an extra beat to consider before interrupting someone. However, some can be harmful, such as not asking for the help you may need or consistently hiding who you really are in interpersonal relationships (sometimes referred to as “social camouflaging”).
How does a high IQ mask ADHD?
According to the medical reviewers and researchers who published a 2017 qualitative study on the topic, “high IQ may “mask” the diagnosis of ADHD by compensating for deficits in executive functions.” In other words, those with a particularly high IQ may be less likely to receive an accurate diagnosis of ADHD because of their often-effective masking behaviors.
How can I tell if I'm masking?
Meeting with a therapist and joining an online community of others with ADHD or autism are two approaches that may help you learn to recognize when you’re masking, because it can look different for each person. For some, it could take the form of staying quiet in social situations for an extended period to avoid the impulse to interrupt. For others, it may look like pretending that you're doing well and not struggling with tasks or responsibilities while actually struggling on the inside.
According to a study published by the European Archives of Psychiatry and Clinical Neuroscience, trouble with emotional regulation is also a common symptom of ADHD, so people hiding their natural emotional responses in social settings could be another sign of masking.
Do I have ADHD or am I just lazy?
Only a licensed healthcare professional can diagnose a person with ADHD, so seeking an evaluation from a provider is usually the recommended first step if you believe you may have ADHD. While people with ADHD can sometimes appear to others as lazy, this is usually not the case. First, while those with ADHD may miss deadlines or have trouble paying attention, it's usually not for lack of trying—as may be the case with laziness—but due to symptoms. In addition, people with ADHD are more likely to have depression as well, which can cause a lack of motivation that is, again, a clinical symptom and not a sign of laziness.
Are people with ADHD shy?
Just as in the general population, some people with ADHD are shy while others are not. That said, it's also possible for a person with ADHD to come off as shy when they're really just masking and afraid to be themselves in a social situation.
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