Behind the Mask: Masking Behaviors and How they Complicate ADHD & Autism Diagnoses
Diagnosing attention deficit hyperactivity disorder or autism spectrum disorder is complex. This complexity can be attributed to masking behaviors, how little is known about neurodivergency, and existing trends of underdiagnosis for certain groups. But, before investigating masking conditions, let’s first take a moment to understand what autism is.
Autism spectrum disorders can involve a variety of symptoms, making them difficult to sum up in brief. Generally speaking, though, ASD is a neurological and developmental condition. This is because, although experiences differ from person to person, certain manifestations of the condition involve differences in social interaction, communication, learning processes, as well as general behavior. While this can vary as a result of factors like gender and socioeconomic status, diagnoses typically come at an early age following the presentation of symptoms, which is why this can be labeled as a developmental condition.
Associate professor of psychological sciences Peter Vishton stated similar ideas, describing autism as “a constellation of symptoms” that “manifests itself really differently across lots of kids.”
Vishton provided several common examples of autism symptoms in children, such as sensitivity to external stimuli and difficulty processing social signals.
“Autistic kids tend to not be nearly as good at filtering stuff out, such that they will be very distracted by things and sensitive to loud noises and bright lights and things like that,” Vishton said.
A larger argument surrounding autism, ADHD, and similar conditions centers around the idea that these differences between individuals lead to underdiagnoses for certain groups and overdiagnoses for others. Therefore, it is critical to the study and treatment of autism that symptom variances are further understood and spotted.
The way autism presents itself in different people can vary greatly. One of the most significant divides exists between men and women.
According to an academic article in Molecular Autism on sex and gender differences across the autism spectrum, “affected females are hypothesized to have a higher average burden of ASD risk factors.” This key finding illustrates how much the general experience of someone with autism can differ based on gender.
Let’s take a look at the definition of ADHD:
Clinical psychologist at the University of Canterbury, Julia J. Rucklidge, describes ADHD as a condition that involves symptoms like inattention, hyperactivity, and impulsivity. Rucklidge highlights how ADHD, like autism, differs depending on gender. Typically, boys exhibit more externally visible symptoms, such as hyperactivity and disruptive behavior, while girls are more likely to experience anxiety and depression as comorbid internalizing problems.
Vishton noted that the way in which ADHD symptoms are perceived differs greatly depending on the person’s gender.
“There might be lower expectations of boys being able to sit still and do the required work, which might lower the boys' performance overall,” Vishton said. “Some eight-year-old girl who does have problems sitting still, a teacher might not be as forgiving to that kid because, again, of the gender-based expectations.”
What constitutes masking behaviors? Neurodivergent individuals use masking behaviors to disguise and compensate for features and shortcomings related to autism, typically in a social context.
This is where the idea of performance comes into play. It is part of human nature to select certain behaviors in order to present yourself in a specific way. Vishton described how masking behaviors are often subconscious reflexes in response to the social world.
“This putting on a show, the presenting yourself to people, we do that constantly, so much so that we don't even think about it,” Vishton said.
Although everyone subconsciously presents themselves differently to other people to some degree, the existence of social stigmas around autism and ADHD, as well as the desire to conform socially, leads to the development of masking behaviors.
Masking behaviors within autism are generally separated into three categories. First, individuals compensating for difficulty in social settings will carefully observe others for behaviors to copy or form into a script. Second, many people mask autism-related characteristics by constantly monitoring eye contact, facial expressions, and gestures to create a neurotypical-presenting persona. The final technique is assimilation, which involves broader strategies used to fit in, such as performing and pretending while interacting with others.
Masking behaviors for those with ADHD generally involve suppressing loud speech and stimming behaviors, mimicking other people in social situations, forcing reactions to fit certain neurotypical standards, developing perfectionism, and other learned tendencies that are meant to “manage” or “cover up” typical hyperactive behaviors.
It is commonly believed that autism or ADHD could represent something “wrong” with someone, or that it would negatively reflect how that person is viewed. Society has a stigma against diagnoses and visible symptoms, which Vishton said furthers the desire to mask these conditions while also impeding the acquisition of a diagnosis.
Vishton also pointed out that parents, teachers, or other people around someone with autism may steer them away from a diagnosis because of fears that it will put up unnecessary barriers to their success. Job hirings, college admissions, and general social success are all scenarios where someone may fear that a label will impede their ability to grow and succeed.
In an educational setting, young girls and young boys face different standards for behavior, meaning there may be environmental pressures driving girls with ADHD or autism to suppress symptoms or traits of these conditions.
According to an academic article in Frontiers in Psychiatry, researchers observed that “camouflage seems to be more common among females who report more autistic symptoms themselves.” Since women exhibit a different set of symptoms than men, the notion that they can often mask or hide these traits likely contributes to a trend of underestimating autism rates in women.
Since girls are known to be better at developing masking behaviors and have more societal pressure to do so, it is unsurprising that data typically reflects a disparity between genders.
“Males are diagnosed with ASD three to four times more often than females,” the researchers wrote.
Although some studies conclude that autism is simply more common in men, the researchers concluded that females might also be diagnosed at a later age than males. This delay risks “reducing their possibilities of obtaining care,” contextualizing the real-world consequences of missed diagnoses in women with ADHD or autism.
Vishton shared how the diagnostic methods have changed in response to this trend, while also noting that misdiagnoses are a consistent problem in behavioral medicine.
“The diagnostic criteria and people seeking the diagnosis has changed a lot over the years,” he said.
Since masking behaviors are understudied, it is likely that some of these disparities and issues with diagnosing can be attributed to individuals who are able to mask certain traits. This “performance” leads to medical data not always aligning with the reality of one’s lived experience. As a result, many people fly under the radar or fail to receive medication or treatment that may help them. While this is only one factor in the large and complicated world of developmental and neurological conditions, understudied issues like these deserve more attention for the well-being and proper treatment of neurodivergent people.