Unmasking ADHD: Understanding the Hidden Struggles
“The tendency to mask ADHD behaviours, can have profound consequences and these individuals often endure a silent struggle.”
As a therapist, my journey through the forest of mental health has been an ever-evolving expedition into the intricacies of the human mind.
The Silent Struggle: ADHD Masking and Its Impact
The tendency to mask ADHD behaviours can have profound consequences. Many people endure a silent struggle, navigating life with an invisible burden and as a therapist, my journey through mental health has been an ever-evolving exploration into the human mind’s complexities. One area that has always intrigued me is Attention Deficit Hyperactivity Disorder (ADHD), and not least because, it seems to feature in my own life too. Beyond the stereotypes of hyperactive children bouncing off the walls, there is a fascinating world of subtlety and complexity that lies beneath the surface. In particular, I find myself drawn to the question of how ADHD behaviours can often be masked, especially in females. It’s the ADHD enigma and I’ve been exploring its nature, global prevalence, and the unique challenges it presents….especially when it comes to masking.
Understanding ADHD: A Lifelong Neurodevelopmental Condition
ADHD is a neurodevelopmental difference that affects both children and adults. It’s characterised by a persistent pattern of inattention, hyperactivity (but often not), and impulsivity (but often not) that can interfere with daily functioning and quality of life. Despite popular misconceptions, ADHD doesn’t just 'disappear' when you hit adulthood….sorry to burst that bubble. In fact, studies suggest that around 60-70% of children with ADHD continue to experience symptoms into adulthood (Faraone et al., 2021). Yet, ADHD remains vastly underdiagnosed in adults, and many individuals only realise they’ve had it all along in their 30s, 40s, or even later. Can you imagine the relief (and mild shock) of hearing, "Oh, so that’s why I’ve always been like this!" This can be a relief to know, but it can also bring up resentment, grief for the past and other equally valid feelings and emotions.
The Global Prevalence of ADHD: More Than Just an Excuse for Being 'Distracted'
ADHD is not just a quirky western phenomenon. Its global prevalence varies, but estimates suggest that it affects around 5-10% of children worldwide (Thomas et al., 2015). In adults, the prevalence is around 2.5-4% (Simon et al., 2009). However, these numbers may be somewhat conservative. Why? Because of the that masking. People hide their symptoms, consciously or unconsciously, leading to a significant under-reporting of cases. If you’ve ever met someone who’s ‘always late’ or ‘constantly disorganised’ and thought, "Are they just careless or is there something more to this?" Well, ADHD could be playing a part.
Fun fact: ADHD was first formally identified as a condition by British pediatrician Sir George Still in 1902! He described a group of children who displayed impulsive behaviours, difficulty with attention, and a lack of control, marking the first documentation of what we now understand as ADHD. So, while the diagnosis has evolved, it’s fascinating to think that this condition has been recognised for over a century
How ADHD Manifests: More Than Just Hyperactivity (And No, It’s Not Just About Being 'Scatty')
When we think of ADHD, we often picture a hyperactive child who can’t sit still for more than two seconds. And yes, while hyperactivity is one of the symptoms, it's not the whole story. ADHD presents itself differently in each individual, making it a complex and multifaceted condition. It’s a bit like trying to assemble IKEA furniture without the instructions; one size doesn’t fit all.
For many, especially males, symptoms may not include jumping off the walls, but rather internal restlessness, difficulty sustaining attention, and chronic procrastination. These behaviours are often mistaken for laziness or lack of motivation, and sadly, it leads to missed diagnoses and a lifetime of unnecessary struggle. And let’s not forget, it’s easy to assume that someone who's constantly late is just a ‘disorganised person’, without realising that it’s much more than that.
Research snapshot: In a study by Barkley et al. (2008), 50-80% of adults with ADHD reported chronic procrastination as one of their most significant challenges.
The Unique Challenge of ADHD Masking: The Great Invisible Struggle
Masking ADHD symptoms is especially common in females, though it can affect anyone. Research shows that women with ADHD often internalise or camouflage their symptoms to avoid being labelled as "troublesome" or "irresponsible" (Quinn & Madhoo, 2014). Instead of acting out in the stereotypical way, women with ADHD often develop coping mechanisms such as perfectionism, overcompensation, or excessive organisation to manage their symptoms. It’s like being an undercover agent; trying to blend in with the crowd while secretly battling internal chaos.
And then there’s the “people-pleasing” element. Women with ADHD might try to ‘fit in’ socially by rehearsing interactions or overthinking conversations, all in an effort to avoid being perceived as forgetful or inattentive. If this sounds familiar, it’s because it’s a common struggle. Many people with ADHD find themselves trying to maintain an image of being put together, all while holding back a flood of mental distractions.
Interestingly According to a study by Nadeau (2005), women with ADHD are more likely to develop an eating disorder than their male counterparts, possibly due to the constant pressure to mask and cope with symptoms.
The Consequences of Late or Missed Diagnosis: How Much ‘Masking’ Is Too Much?
Masking can lead to serious consequences, especially when ADHD goes undiagnosed. It’s like holding a beach ball underwater: it’s exhausting, and eventually, it might pop up when you least expect it.
Some of the major issues that arise from missed or late diagnoses include:
Chronic stress and burnout: The mental effort required to constantly ‘fit in’ and mask symptoms can be overwhelming.
Imposter syndrome: Many people feel like they’re faking it, even when they’ve achieved a great deal. “Am I really good at this or am I just really good at pretending?”
Misdiagnosis: ADHD is often mistaken for conditions like anxiety, depression, or even bipolar disorder. So, if you’ve been told you’re ‘just anxious’ a hundred times, it might be worth getting a second opinion.
Increased risk of substance abuse: People might turn to substances like alcohol or caffeine to help self-medicate and cope with the mental exhaustion of masking.
Statistic alert: According to the National Institute of Mental Health (2021), adults with ADHD are at a much higher risk of substance abuse. This is partly due to the challenges of self-regulation and impulsivity; common traits of ADHD. Some individuals may turn to substances like alcohol, caffeine, sex or drugs to manage their symptoms or to self-medicate. In fact, research suggests that up to 30% of adults with ADHD report some form of substance misuse.
It’s a classic case of “what’s easier in the short term might make things harder in the long run”. Substances may offer temporary relief from the constant buzz of thoughts, the stress of disorganisation or the frustration of not being able to focus, but over time, they tend to compound the issues, leading to even greater mental health struggles. This makes it essential to address both ADHD and any related substance use as part of an integrated treatment plan.
A Personal Perspective: Hyperfocus, Disconnection, and Self-Awareness
As a therapist, my curiosity about ADHD masking extends beyond just my professional life; it’s deeply personal. I recognise many elements of ADHD in myself (hello hyperfocus!). Although I’ve never been formally diagnosed and the lengthy waiting lists for ADHD assessments in the UK mean that many adults like me, have never had their symptoms recognised.
For me, ADHD shows up in unpredictable waves of hyperfocus and mental exhaustion, as well as withdrawal and overwhelm. Take writing this article, for example. I’ve been entirely consumed by it with no room for anything else. But once it's done, I’ll probably spend the next few hours doing absolutely nothing productive whatsoever. It’s the classic ADHD cycle: intense focus followed by total detachment. It’s like being on a mental rollercoaster, and not the fun kind.
Reframing ADHD: Strengths and Challenges
I don't see ADHD as a disorder, in fact calling it that adds all the more stigma. It’s not so simply a collection of strengths and challenges that can shape a person’s life. It certainly isn't all doom and gloom though, and people with ADHD tend to be highly creative, adaptable and resilient as well as great problem solvers, capable of thinking outside the box. However, without proper recognition and support, these strengths can easily be overlooked, and the challenges can take centre stage. For me, in boxes I do not think, and everything to me, becomes a creative exercise in one way or another and a big reason why I love being a therapist, as it requires a lot of following perhaps slightly different neural pathways and creating the right safe space for each unique and individual client. BUT, this all comes with a rider of detachment and the need for absolute silence and space until I recharge the excitable neurons to fire again ready for that hit of dopamine; every ADHD-er's favourite spice.
Think of it this way: it’s like having a superpower that’s constantly misinterpreted. You might be able to jump from task to task with lightning speed, but without the right context, it can look like you’re just not finishing anything or not doing things like others would.
Breaking the Cycle: The Need for Greater Awareness
I work with a lot of people with ADHD and autism and I’m passionate about raising awareness of ADHD masking. By shedding light on the hidden struggles of those with ADHD, we can work towards:
More accurate diagnoses, especially for adults and women, who tend to be missed by traditional diagnostic criteria.
Better mental health support, acknowledging that ADHD plays a role in conditions like anxiety and depression.
Greater societal understanding, where neurodivergent people don’t feel forced to mask or ‘fit in’.
People finding it easier to advocate for themselves and show their true colours in the workplace and in social situations
