What Is ADHD Masking, And Why Is Diagnosis Challenging?

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:

1. Predominantly inattentive presentation (ADHD-PI) 
2. Predominantly hyperactive or impulsive presentation (ADHD-HI) 
3. 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.