People with ADHD may develop coping or masking strategies to manage their symptoms, especially if they are undiagnosed for a long time.
For clinicians, recognizing ADHD in these complex or masked cases can be challenging. This FAQ and guide can help you explore possible masking and compensatory behaviors in complex cases, so you can better serve your patient population.
Understanding ADHD masking and compensation
Q. How can I tell if my patient is masking ADHD symptoms?
People with masked ADHD often appear to be coping well. Those around them are unlikely to spot symptoms. Patients may not raise concerns in clinical interviews because to them, the extra efforts required to achieve tasks are part of their normal life experience. This means that any clues to ADHD are often very subtle.
Q. What does ADHD masking and compensation look like in practice?
Any adaptive behavior, done consciously or subconsciously, to manage an ADHD symptom can be thought of as masking. A child who learns to suppress ADHD stimming behavior like fidgeting or bouncing, to avoid being told off in school, is adopting a masking behavior.
Patients who mask ADHD symptoms usually look to be coping well. They can meet education and work deadlines, achieve targets, and meet social expectations. However, doing so often requires a lot of extra effort, frequently not seen by others. Even the patient may not realize they’re overcompensating.
Such cases are thought of as “high functioning” ADHD patients.
Q. What are common ADHD coping strategies in high-functioning patients?
ADHD coping strategies often present as perfectionism, being highly organized, or being very focused on structure and routine. These adjustments become necessary to keep on track and are applied across all aspects of life.
Q. Do all patients with ADHD mask or develop coping strategies?
No, not all patients develop coping strategies. There is some evidence that women and girls develop better coping strategies than men and boys. The difference in social pressures and expectations between men and women can cause an increased need to mask.
Explore patient psychoeducation at different stages
We’ve developed a psychoeducation pack for clinicians to share with patients. The pack examines experiences of ADHD at different life stages and the conversations that may come up in the clinic between parents, children, teens, and adults with ADHD and their clinician.
Diagnosing ADHD in complex cases
Q. How can I test for ADHD when symptoms are masked or compensated?
It may be necessary to adapt testing protocols for ADHD patients with strong coping strategies. In highly complex cases, questionnaires may have limited use, and adapting clinical interviews may be more effective. Data from objective tests may also help to present a more complete picture.
Q. How can I adapt clinical interviews for patients who mask symptoms?
Asking open-ended questions about daily routines can help to reveal masking strategies that patients may be unaware of. Investigate further any examples of methods or techniques the patient uses to stay organized, manage their time, or handle tasks – are they over reliant on these? Would they be unable to cope if their usual routine was disrupted?
It can also be useful to ask how patients feel physically and emotionally when under stressful situations. Studies have highlighted that students with ADHD experience more sleep problems, worry more, are more prone to anxiety and depression, and have an increased risk for substance abuse compared to students without ADHD. A patient may not recognize their ADHD symptoms. Still, examples of perfectionism, fatigue, burnout, and feeling inadequate can all be clues that using coping strategies is taking a toll on them.
Q. Which ADHD testing tools work best for complex or borderline cases?
Subjective methodologies (rating scales and clinician interviews) alone may be unreliable if patients are masking their symptoms, as they wouldn’t report this behavior.
Objective ADHD tests can provide data on core symptoms of inattention, impulsivity, or hyperactivity that might not show up in subjective tests. Using a digital ADHD test alongside subjective measures has been found to be “particularly useful in complex and co-morbid cases,” aiding diagnosis even where symptoms aren’t reported.
Timing is also critical, in borderline cases or where patients have well-developed coping strategies, an interview during a period of high stress versus a period of low stress will likely yield very different results. By comparison, an objective test should present a more consistent assessment of symptoms.
Differentiating ADHD from other conditions
Q. How can I tell if overlapping symptoms are ADHD or another condition?
Overlapping symptoms are common, especially when ADHD coexists with anxiety, depression, or autism. Sometimes the presence of another condition is responsible for ADHD symptoms being masked, making diagnoses complex.
Looking for consistent patterns of inattention, impulsivity, or hyperactivity across different settings is step one. Assessing how these symptoms change under stress can help distinguish ADHD from other comorbidities.
Q. How do I differentiate ADHD from autism, anxiety, or depression?
There are certain red flags and nuances for clinicians to look out for when diagnosing ADHD, if comorbidities are a factor. These include non-verbal clues, how patients handle ideas like social reciprocity during conversation, and the use and understanding of language subtleties.
Inattentive ADHD can look a lot like depression or anxiety, while social withdrawal of an ADHD patient experiencing stress can be mistaken for autism-related behavior.
Treating and supporting patients who mask or cope
Q. How do I treat ADHD patients who have learned to mask or cope?
One of the challenges of caring for patients who have developed strong coping strategies is that a diagnosis may come as a surprise to them and their families. Patient attitudes to treatment may also be affected by feeling like they are already coping.
Discuss how treatment can reduce mental strain, improve daily functioning, and address symptoms such as emotional regulation that coping alone can’t manage. Collaborative care and psychoeducation help build trust and support treatment acceptance.
Q. How can I explain masking and coping strategies to patients or families?
When explaining ADHD masking and coping strategies, start by highlighting specific behaviors from the patient’s life that are indicative of masking, such as an overreliance on routines, checklists, etc. It’s important that the patient doesn’t feel there is any guilt or blame attached - they haven’t been hiding their symptoms, just adapting.
Explaining the impact of masking and coping may also help validate the patient's feelings of tiredness, exhaustion, and burnout. This can be a natural prompt to start conversations about treatment options.
Q. Why does treatment still matter for “high functioning” ADHD patients?
While patients may have developed effective coping skills, treatment can still play an important role. Individuals often expend significant mental and emotional energy to stay “high functioning”. It can lead to fatigue, burnout, and exhaustion.
There are also ADHD symptoms that are harder to manage through coping strategies, such as emotional dysregulation, that treatment may help with.
Key takeaways
- Look beyond surface-level coping: Perfectionism, hyper-organization, or strict routines can be subtle signs that point to ADHD
- Adapt diagnostic approaches that incorporate open-ended clinical interviews together with objective ADHD testing tools to unravel masked symptoms, ensuring a more accurate diagnosis
- Consider comorbidities: Symptoms that overlap with anxiety, depression, or autism make diagnoses complex. Therefore, assess patterns across contexts and environments
- Support by understanding: Help patients and their families understand that masking is an adaptation, not a form of deception. This will minimize feelings of guilt and facilitate treatment discussions
- Treatment still matters: Even "high functioning" ADHD patients benefit from support that reduces mental strain, improves self-regulation, and prevents burnout