Adult ADHD Masking Measure(AAMM)

ADHD Masking: Uncovering the Hidden Challenges

By: Jay Getten LCPC LMFT

Introduction

Masking has become a widely discussed topic recently, especially regarding autism and ADHD. This behavior involves concealing or suppressing symptoms to conform to societal expectations or avoid stigma, often impacting individuals significantly. Although typically linked with autism, recent research shows that masking is also common among people with ADHD, though it appears differently and is motivated by various reasons. ADHD masking can include efforts to manage hyperactivity, refrain from impulsive remarks, or adapt to environments that favor neurotypical behaviors. The ongoing effort to seem "normal" can result in significant mental and physical stress, affecting overall well-being. In this blog, we will examine the intricacies of ADHD masking, look into its psychological effects, the toll on physical and mental health, and discuss ways to support unmasking and healthy coping mechanisms.

What is ADHD Masking?

Masking, also referred to as camouflaging or impression management, involves behaviors that individuals with ADHD use to conceal their symptoms to seem more "neurotypical" (Lovering, 2022; Williams, 2023). For those with ADHD, this often means 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 appear in various forms. Common instances include sitting excessively still during meetings, refraining from interrupting others, arriving very early to appointments to cope with time management difficulties, and imitating socially acceptable behaviors (Cuncic, 2024; Lovering, 2022). Additionally, masking can involve strict routines, such as recording everything to compensate for memory issues, or overly organizing tasks to avoid seeming disorganized. In social situations, individuals may suppress their natural tendencies, like fidgeting or showing emotions, to avoid being perceived as disruptive or inattentive.

While masking might assist individuals in temporarily blending in, it also requires them to hide significant parts of themselves, leading to emotional exhaustion, identity issues, and a sense of inauthenticity. Over time, the continuous effort to appear neurotypical can damage self-esteem, making it hard for individuals to fully accept their neurodivergence. The ongoing pressure often results in mental fatigue, causing people to feel isolated and misunderstood, even in ostensibly safe environments.

ADHD vs. Autism Masking

A study by van der Putten et al. (2024) investigated whether camouflaging—a behavior traditionally associated with autism—is also common among individuals with ADHD (van der Putten et al., 2024). The study revealed that while adults with ADHD do engage in camouflaging behaviors, they do so to a lesser extent compared to autistic individuals. In particular, adults with ADHD scored higher on behaviors related to assimilation—attempting to fit in with others—than neurotypical adults, but lower than autistic individuals. Interestingly, autism traits, rather than ADHD traits, were stronger predictors of camouflaging behaviors, suggesting that current camouflaging measures may not fully capture ADHD-specific masking behaviors.

The study also highlighted that the motivations behind camouflaging differ between autistic individuals and those with ADHD. While autistic individuals often camouflage to avoid sensory overload or due to difficulties in social communication, individuals with ADHD tend to camouflage primarily to meet expectations around productivity and focus. This distinction is crucial, as it emphasizes that the reasons for masking are often context-specific and rooted in different challenges faced by each neurotype.

Moreover, the study found that adults with ADHD who had higher scores on camouflaging were more likely to report elevated levels of stress and burnout. The effort required to maintain an image of competence in various settings can be mentally exhausting and contribute to emotional fatigue. The findings underscore the importance of creating supportive environments that recognize and accommodate neurodivergent behaviors, reducing the need for individuals to constantly mask.

The researchers called for more nuanced tools that can better differentiate between camouflaging behaviors seen in ADHD and autism. These tools would help clinicians understand the specific struggles faced by individuals with ADHD, thereby improving diagnostic accuracy and tailoring support strategies more effectively. This differentiation is key to providing adequate mental health interventions that address the unique experiences of those who mask due to ADHD, rather than relying solely on frameworks designed primarily for autism (van der Putten et al., 2024).

Why Masking Happens

Masking often stems from a desire to avoid the stigma and negative judgments associated with ADHD traits. People with ADHD may feel pressure to "keep up" with their neurotypical peers, especially in environments like school or the workplace. The societal expectation to conform can lead individuals with ADHD to mask as a means of meeting these expectations or avoiding embarrassment (Lovering, 2022; Williams, 2023). This pressure is particularly high in environments that value productivity, focus, and social norms that do not easily accommodate neurodivergent behaviors.

For children, masking can start early, often in response to feedback from teachers, parents, or peers. This early pressure to appear "normal" can create 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 negative consequences, such as punishment or social exclusion. As these children grow 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 significant factor in masking. According to Hallowell (2022), many individuals who mask their ADHD symptoms are misdiagnosed with anxiety or depression, as these conditions often share overlapping symptoms. This can lead to inappropriate treatments that address only part of the problem. For instance, individuals may receive medications like SSRIs for anxiety or depression without receiving the stimulant medications or behavioral interventions needed for ADHD. This misdiagnosis not only prolongs suffering but also 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 plays a substantial role in why people mask. Individuals with ADHD often experience repeated negative feedback that their behaviors are inappropriate, annoying, or disruptive. Over time, this can lead to a deep-seated fear of being judged or ostracized, further reinforcing the masking cycle. Masking becomes a way to avoid criticism, maintain relationships, and preserve self-worth, even if it comes at the cost of authenticity and mental well-being.

In professional settings, masking is particularly common, as the demands for productivity and maintaining a certain image are high. People with ADHD may go to great lengths to appear organized, punctual, and focused, even if it means working far beyond their limits to compensate for challenges. This can lead to burnout, as the effort required to sustain the mask often leaves little energy for genuine self-care and rest.

The social and professional costs of not masking can feel incredibly high, making it difficult 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 important 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 comes with considerable physical health costs. The constant effort to suppress natural ADHD behaviors—such as fidgeting, hyperactivity, or emotional expressions—can lead to chronic physical stress. This stress response can manifest in physical symptoms like muscle tension, headaches, gastrointestinal issues, and fatigue. For individuals who mask extensively, the body is often in a state of heightened alertness, which can compromise immune function over time, making them more susceptible 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 even cardiovascular issues.

The physical health toll of masking underscores 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.

Moreover, masking behaviors may delay a proper diagnosis of ADHD. Without an accurate diagnosis, individuals are often left without 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 significant and can have long-lasting effects on an individual's well-being. When individuals with ADHD mask their symptoms, they are often suppressing their natural tendencies and attempting to meet external expectations, which can lead to profound psychological stress. This continuous suppression can contribute to anxiety, depression, and chronic low self-esteem. Individuals may feel disconnected from their authentic selves, which can result in a persistent sense of inauthenticity and emotional exhaustion (Cuncic, 2024; Saline, 2024)

One of the most damaging effects of masking is the development of anxiety. The constant vigilance required to monitor and adjust one's behavior can leave individuals in a state of heightened anxiety, as they continuously worry about slipping up or revealing their true selves. Over time, this anxiety can become overwhelming, leading to panic attacks, social withdrawal, and an inability to relax, even in situations that should feel safe.

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

The long-term practice of masking can also lead to 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 now choosing to embrace their true selves by unmasking—a process that involves reducing masking behaviors and being open about their neurodivergence. Unmasking can be a liberating experience, allowing individuals to live more authentically and improving their mental health and relationships (ADDitude Editors, 2023).

However, unmasking is not without challenges. It requires creating environments that support neurodivergent individuals, whether that means setting boundaries in social situations, communicating openly about ADHD symptoms, or finding supportive communities that value diversity. Seeking professional support through therapy, ADHD coaching, and medication can also help individuals reduce their reliance on masking as a coping strategy (Saline, 2024; Williams, 2023).

Unmasking often begins with self-awareness—recognizing when and why one is masking. For many individuals, the realization that they have been masking for most of their lives can be an emotional experience. It involves acknowledging the times when they felt they needed to hide their true selves to fit in, and recognizing the emotional toll this has taken. This self-reflection is an important first step, allowing individuals to begin exploring who they are without the mask.

Another critical aspect of unmasking is building a supportive network. Friends, family, and colleagues who understand ADHD and are accepting of neurodivergent behaviors can provide the safe space needed for unmasking. This might involve educating loved ones about ADHD traits, explaining how masking has affected one's life, and expressing the desire to live more authentically. In environments where others are knowledgeable and supportive, individuals can feel less pressured to conform and more comfortable in expressing their natural selves.

In addition to seeking social support, unmasking often requires developing coping strategies that do not involve masking. These might include practicing self-compassion, learning stress management techniques, and setting realistic expectations. For instance, instead of striving for perfection or exhausting oneself to appear hyper-competent, individuals can learn to embrace their strengths and acknowledge their limitations. Mindfulness practices, such as meditation or deep breathing exercises, can also help individuals remain present and reduce the anxiety that often accompanies unmasking.

Unmasking can also lead to a reevaluation of life choices. Some individuals may find that certain environments—whether social, professional, or even familial—are not conducive to their well-being without masking. This can lead to significant changes, such as changing jobs, seeking new friendships, or altering routines to align better with their true needs and preferences. Although these changes can be daunting, they are often necessary for reducing stress and enhancing life satisfaction.

Despite the challenges, many who have chosen to unmask report positive outcomes, including improved self-esteem, deeper relationships, and a greater sense of fulfillment. By no longer hiding their ADHD traits, individuals can connect with others in more meaningful ways, fostering genuine relationships based on understanding and acceptance. Moreover, unmasking allows individuals to engage more fully in activities they enjoy, without the constant worry of appearing "different" or "less capable." These changes can significantly enhance both mental and emotional well-being.

Ultimately, unmasking is about embracing one's neurodivergence and living authentically, without the constant burden of trying to fit into neurotypical expectations. It is a courageous journey that requires patience, resilience, and support, but the rewards—greater self-acceptance, emotional freedom, and stronger connections—are well worth the effort.

The Adult ADHD Masking Measure (AAMM)

Behavioral Health Consulting Solutions (BHCS) recently introduced the Adult ADHD Masking Measure (AAMM), a self-assessment tool designed to help identify masking behaviors in adults with ADHD. The AAMM aims to provide clinicians with insights into how frequently individuals mask or suppress ADHD symptoms, offering a more nuanced understanding of these coping mechanisms (Behavioral Health Consulting Solutions, 2024).

The AAMM consists of 28 items that assess the frequency of various masking behaviors, such as hiding struggles to appear more competent, mimicking others in social situations, or suppressing physical symptoms like fidgeting (Adult ADHD Masking Measure, 2024). Each statement is rated on a scale from 0 (Never) to 4 (Very Often), allowing clinicians and individuals to gauge the extent of masking. Sample statements include, “I pretend to be ‘fine’ when I’m not” and “I suppress strong emotions until I feel physical symptoms.” The AAMM provides a scoring range from 0 to 112, with higher scores indicating more frequent masking behaviors.

The tool is still undergoing validation and is intended to be used as a supplementary assessment alongside other diagnostic measures. Scores can offer preliminary insights into the degree of masking, but they do not replace professional evaluations (Adult ADHD Masking Measure, 2024). It is crucial for clinicians to interpret the results in the context of everyone’s unique circumstances.

BHCS encourages mental health professionals to use the AAMM to better understand the hidden challenges their clients may be facing, particularly those who might not fit the typical ADHD profile due to effective masking. The AAMM serves as a promising step toward improving the diagnostic process and ensuring individuals with ADHD receive appropriate support and recognition for their struggles.

Download the AAMM here

Conclusion

ADHD masking is a complex and nuanced behavior with significant implications for mental health, diagnosis, and overall well-being. While masking might help individuals navigate social situations by allowing them to blend in or avoid judgment, it often leads to negative emotional and psychological outcomes, such as anxiety, depression, and chronic stress. These outcomes are often compounded by the constant internal conflict between presenting as neurotypical and managing the challenges of ADHD. By understanding and addressing ADHD masking, both individuals and healthcare professionals can work toward more effective and compassionate 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