ADHD Masking: Uncovering the Hidden Challenges

Introduction

Masking, especially regarding autism and ADHD, involves hiding symptoms to fit societal norms or avoid stigma. While often associated with autism, masking is also common in ADHD, though it presents differently. ADHD masking includes managing hyperactivity, refraining from impulsive comments, and adapting to neurotypical environments. This constant effort to appear "normal" can cause significant mental and physical stress. This blog will explore ADHD masking, its psychological effects, health impacts, and ways to support unmasking and healthy coping strategies.

What is ADHD Masking?

Masking, also known as camouflaging or impression management, refers to behaviors used by individuals with ADHD to conceal their symptoms to appear more "neurotypical" (Lovering, 2022; Williams, 2023). For those with ADHD, this often involves consciously or subconsciously suppressing actions such as fidgeting, hyperactivity, or impulsiveness to avoid attracting negative attention or judgment. While masking serves as a coping strategy, it can significantly impact mental well-being.

Masking behaviors manifest in various forms. Common examples include sitting excessively still during meetings, refraining from interrupting others, arriving very early to appointments to manage time effectively, and imitating socially acceptable behaviors (Cuncic, 2024; Lovering, 2022). Additionally, masking may involve strict routines, such as recording everything to compensate for memory issues, or meticulously organizing tasks to avoid appearing disorganized. In social situations, individuals may suppress their natural tendencies, like fidgeting or displaying emotions, to prevent being perceived as disruptive or inattentive.

Although masking might temporarily assist individuals in blending in, it necessitates hiding significant aspects of themselves, leading to emotional exhaustion, identity issues, and a sense of inauthenticity. Over time, the constant effort to appear neurotypical can damage self-esteem, making it challenging for individuals to fully accept their neurodivergence. The ongoing pressure frequently results in mental fatigue, causing individuals to feel isolated and misunderstood, even in environments that are ostensibly safe.

ADHD vs. Autism Masking

A study conducted by van der Putten et al. (2024) examined the prevalence of camouflaging, a behavior typically associated with autism—among individuals with ADHD. The research found that while adults with ADHD do engage in camouflaging behaviors, they do so to a lesser extent compared to autistic individuals. Specifically, adults with ADHD exhibited higher levels of assimilation behaviors—attempting to fit in with others—than neurotypical adults, but lower than autistic individuals. Notably, autism traits were stronger predictors of camouflaging behaviors than ADHD traits, indicating that current measures may not fully capture ADHD-specific masking behaviors.

The study also elucidated the differing motivations behind camouflaging for autistic individuals versus those with ADHD. Autistic individuals often camouflage to avoid sensory overload or due to social communication challenges, whereas individuals with ADHD primarily camouflage to meet expectations regarding productivity and focus. This distinction is essential as it highlights that the reasons for masking are often context-specific and rooted in the unique challenges faced by each neurotype.

Additionally, the study revealed that adults with ADHD who scored higher on camouflaging reported increased levels of stress and burnout. The effort required to maintain an image of competence across various settings can be mentally taxing and contribute to emotional fatigue. These findings underscore the necessity of creating supportive environments that acknowledge and accommodate neurodivergent behaviors, thereby reducing the need for individuals to consistently mask.

The researchers advocate for the development of more nuanced tools to better differentiate between camouflaging behaviors observed in ADHD and autism. Such tools would enhance clinicians' understanding of the specific struggles experienced by individuals with ADHD, thus improving diagnostic accuracy and tailoring support strategies more effectively. Differentiation is paramount to providing adequate mental health interventions that address the distinct experiences of individuals who mask due to ADHD, rather than relying solely on frameworks established predominantly for autism (van der Putten et al., 2024).

Why Masking Happens

Masking often originates from a desire to evade the stigma and negative judgments associated with ADHD traits. Individuals with ADHD may feel compelled to align with their neurotypical peers, especially in environments such as school or the workplace. The societal expectation to conform can result in individuals with ADHD mask as a means of meeting these expectations or avoiding embarrassment (Lovering, 2022; Williams, 2023). This pressure is particularly pronounced in environments that value productivity, focus, and social norms that do not readily accommodate neurodivergent behaviors.

For children, masking can commence early, frequently in response to feedback from teachers, parents, or peers. This early pressure to appear "normal" can establish a lifelong habit of concealing symptoms. Children quickly learn that behaviors such as fidgeting, speaking out of turn, or struggling to concentrate can lead to adverse consequences, such as punishment or social exclusion. As these children mature into adulthood, masking becomes an ingrained survival strategy, utilized in academic, social, and professional settings to blend in.

The misdiagnosis of ADHD as anxiety or depression is also a considerable factor in masking. According to Hallowell (2022), numerous individuals who mask their ADHD symptoms are misdiagnosed with anxiety or depression since these conditions frequently share overlapping symptoms. This can lead to inappropriate treatments that address only part of the problem. For instance, individuals may receive medications such as SSRIs for anxiety or depression without receiving the stimulant medications or behavioral interventions necessary for ADHD. This misdiagnosis prolongs suffering and reinforces the need for masking, as individuals may continue to struggle without understanding the root cause of their symptoms.

The fear of social rejection also significantly contributes to why individuals mask their ADHD symptoms. Those with ADHD often experience recurrent negative feedback regarding their behaviors being inappropriate, annoying, or disruptive. Over time, this can instill a deep-seated fear of judgment or ostracism, further reinforcing the masking cycle. Masking becomes a method to avoid criticism, maintain relationships, and preserve self-worth, even if it comes at the expense of authenticity and mental well-being.

In professional settings, masking is particularly prevalent, as the demands for productivity and maintaining a certain image are high. Individuals with ADHD may exert extensive efforts to appear organized, punctual, and focused, even if it entails working far beyond their limits to compensate for challenges. This can lead to burnout, as the effort required to sustain the mask often depletes energy needed for genuine self-care and rest.

The social and professional costs of not masking can feel exceedingly high, making it challenging for individuals to break the cycle. However, understanding the root causes of masking and recognizing it as a response to external pressures, rather than a personal failing, is an essential step toward reducing its prevalence and promoting healthier coping strategies.

The Physical Health Costs of Masking

Masking not only has significant psychological impacts but also carries considerable physical health costs. The continuous effort to suppress natural ADHD behaviors—such as fidgeting, hyperactivity, or emotional expressions—can induce chronic physical stress. This stress response can manifest in physical symptoms such as muscle tension, headaches, gastrointestinal issues, and fatigue. For individuals who mask extensively, the body often remains in a state of heightened alertness, which can compromise immune function over time, increasing susceptibility to illnesses (Saline, 2024).

Sleep disturbances are another common physical consequence of masking. The mental exhaustion from sustained masking throughout the day often makes it difficult for individuals to relax and fall asleep. This lack of quality rest further exacerbates issues related to focus, emotional regulation, and overall physical health. Moreover, prolonged masking can contribute to stress-related conditions, including hypertension, increased heart rate, and cardiovascular issues.

The physical health toll of masking highlights the need for awareness and early intervention. Addressing masking behaviors and encouraging authentic self-expression can help alleviate these physical symptoms, improving both mental and physical health outcomes for individuals with ADHD.

Furthermore, masking behaviors may delay a proper diagnosis of ADHD. Without an accurate diagnosis, individuals are often deprived of appropriate treatment, leading to continued challenges in daily functioning and increased feelings of inadequacy (Cuncic, 2024; Williams, 2023).

The Mental Health Costs of Masking

The mental health consequences of masking are substantial and can have long-lasting impacts on an individual's well-being. When individuals with ADHD mask their symptoms, they often suppress their natural tendencies to meet external expectations, leading to significant psychological stress. This continuous suppression can contribute to anxiety, depression, and chronic low self-esteem. Moreover, individuals may feel disconnected from their authentic selves, resulting in a persistent sense of inauthenticity and emotional exhaustion (Cuncic, 2024; Saline, 2024).

One of the most detrimental effects of masking is the development of anxiety. The constant vigilance required to monitor and adjust one's behavior can place individuals in a heightened state of anxiety, as they continuously worry about revealing their true selves. Over time, this heightened anxiety can become overwhelming, leading to panic attacks, social withdrawal, and difficulty relaxing, even in typically safe environments.

Depression is another common mental health consequence of prolonged masking. The effort to maintain a mask often leaves individuals feeling isolated and misunderstood, leading to a deep sense of hopelessness. When people are unable to express their true selves or have their needs understood by others, building meaningful connections becomes challenging. This isolation can exacerbate depressive symptoms, particularly when individuals feel compelled to maintain their mask around friends, family, and colleagues (Cuncic, 2024).

Long-term masking can also result in burnout. Burnout occurs when the mental and emotional resources required to sustain the mask are depleted. Individuals may find themselves completely exhausted, with no energy left for genuine self-care or personal growth. Burnout can manifest in various ways, including chronic fatigue, irritability, and a decreased ability to manage daily tasks. The emotional toll of constantly hiding one's struggles can also lead to feelings of worthlessness and a diminished sense of purpose.

Addressing the mental health costs of masking requires fostering environments that support authenticity and neurodiversity. Encouraging open dialogue about ADHD, reducing stigma, and providing access to mental health resources can help individuals feel more comfortable unmasking. Seeking support through therapy, ADHD coaching, and medication can also be instrumental in helping individuals reconnect with their authentic selves and manage the challenges of ADHD in a healthier manner (Saline, 2024; Williams, 2023).

Unmasking: Moving Toward Authenticity

Many adults with ADHD are choosing to embrace their true selves by unmasking, which involves reducing masking behaviors and being open about their neurodivergence. This can improve mental health and relationships but requires supportive environments, setting boundaries, communicating openly, and finding communities that value diversity. Professional support such as therapy, ADHD coaching, and medication can aid in this process.

Unmasking starts with self-awareness, recognizing the need to mask and its emotional toll. Self-reflection helps individuals explore their true selves. Building a supportive network of friends, family, and colleagues is crucial; educating them about ADHD traits and expressing the desire to live authentically can help.

Developing coping strategies that don't involve masking, like practicing self-compassion, stress management techniques, and mindfulness practices, reduces anxiety. Unmasking may lead to reevaluating life choices and making changes, such as changing jobs or seeking new friendships, to better align with personal needs.

Despite the challenges, many report positive outcomes from unmasking, including improved self-esteem, deeper relationships, and greater fulfillment. Living authentically enhances mental and emotional well-being and fosters genuine connections.

Ultimately, unmasking is about embracing one's neurodivergence and living without trying to fit into neurotypical expectations. It requires patience, resilience, and support, but offers rewards of self-acceptance, emotional freedom, and stronger connections.

The Adult ADHD Masking Measure (AAMM)

Behavioral Health Consulting Solutions (BHCS) has introduced the Adult ADHD Masking Measure (AAMM), a self-assessment tool designed to identify masking behaviors in adults with ADHD. The AAMM aims to provide clinicians with valuable insights into the frequency at which individuals conceal or suppress ADHD symptoms, offering a comprehensive understanding of these coping mechanisms (Behavioral Health Consulting Solutions, 2024).

The AAMM comprises 28 items assessing the prevalence of various masking behaviors, such as concealing difficulties to appear more competent, imitating others in social situations, or repressing physical symptoms like fidgeting (Adult ADHD Masking Measure, 2024). Each statement is rated on a scale from 0 (Never) to 4 (Very Often), enabling clinicians and individuals to evaluate the extent of masking. Sample statements include, “I pretend to be ‘fine’ when I am not” and “I suppress strong emotions until I experience physical symptoms.” The AAMM provides a scoring range from 0 to 112, with higher scores indicating more frequent masking behaviors.

Currently undergoing validation, the AAMM is intended to be used as a supplementary assessment alongside other diagnostic measures. Scores can offer preliminary insights into the degree of masking but do not replace professional evaluations (Adult ADHD Masking Measure, 2024). It is imperative for clinicians to interpret the results within the context of each individual's unique circumstances.

BHCS encourages mental health professionals to utilize the AAMM to gain a deeper understanding of the hidden challenges their clients may face, particularly those who might not exhibit typical ADHD profiles due to effective masking. The AAMM represents a significant advancement toward improving the diagnostic process and ensuring individuals with ADHD receive appropriate support and recognition for their struggles.

Download the AAMM here: https://www.bhcsmt.com/aamm 

Conclusion

ADHD masking is a behavior with implications for mental health, diagnosis, and overall well-being. Masking might assist individuals in social situations by allowing them to blend in or avoid judgment, but it can lead to emotional and psychological outcomes such as anxiety, depression, and chronic stress. These outcomes can be compounded by the internal conflict between presenting as neurotypical and managing ADHD challenges. By understanding ADHD masking, both individuals and healthcare professionals can work toward support systems that encourage authenticity, reduce the need for masking, and promote overall well-being.

References

1. ADDitude Editors. (2023, March 20). Be yourself, be authentic: Unmasking ADHD in adulthood. ADDitude Magazine. https://www.additudemag.com

2. Adult ADHD Masking Measure. (2024). Adult ADHD masking measure. Behavioral Health Consulting Solutions. http://www.bhcsmt.com

3. Behavioral Health Consulting Solutions. (2024). ADHD masking self-assessment tool. Behavioral Health Consulting Solutions.

4. Cuncic, A. (2024, May 10). ADHD masking: Examples, impact, and coping. Verywell Mind. https://www.verywellmind.com

5. Hallowell, E. (2022, March 31). When anxiety and depression symptoms are really ADHD. ADDitude Magazine. https://www.additudemag.com

6. Lovering, N. (2022, May 10). ADHD masking: What it is and more. Psych Central. https://www.psychcentral.com

7. Saline, S. (2024, June 19). ADHD masking: Pretending to be neurotypical is unhealthy. ADDitude Magazine. https://www.additudemag.com

8. van der Putten, W. J., Mol, A. J. J., Groenman, A. P., Radhoe, T. A., Torenvliet, C., van Rentergem, J. A. A., & Geurts, H. M. (2024). Is camouflaging unique for autism? A comparison of camouflaging between adults with autism and ADHD. Autism Research, 17(4), 812–823. https://doi.org/10.1002/aur.3099

9. Williams, F. (2023, June 19). ADHD and masking: Why it happens, symptoms, and how to cope. Medical News Today. https://www.medicalnewstoday.com/articles/adhd-masking