Masking Across Diagnoses: What Autism, ADHD, and Anxiety Have in Common

Masking, also called camouflaging, is the practice of hiding or compensating for the traits and symptoms of a condition such as autism, ADHD, or anxiety in order to meet social expectations. Research on masking is most developed in autism, but the pattern isn’t unique to it. Studies now describe similar strategies and costs in adults with ADHD, often called ADHD masking, and the anxiety literature covers overlapping behavior under a different name: safety behaviors. In each case, a client can appear composed and capable while spending a great deal of energy to do so.

Masking is not a diagnosis. It is a pattern of behavior that can hide the traits and symptoms a clinician is trying to assess and delay the right diagnosis. Because the pattern crosses conditions, the useful clinical question is less “which diagnosis does this belong to?” and more “what is this client working to conceal, and what is it costing them?”

What does masking look like in autism, ADHD, and anxiety?

Masking tends to involve two broad strategies: suppressing traits that draw attention, such as fidgeting or visible nervousness, and compensating for difficulties, such as rehearsing conversations or overpreparing. Which traits get suppressed and which get compensated for depend on the condition, so the same pattern can look quite different from one client to the next.

What does autism masking look like?

A 2017 study of 92 autistic adults described camouflaging as a process with three stages. People were motivated by a desire to fit in and to connect with others. Their strategies fell into two groups, masking and compensation. Almost all participants camouflaged to some degree, and the vast majority described unwanted consequences, including exhaustion. Because participants were recruited through a research database and social media, these figures describe the sample, not how common camouflaging is.

In practice, masking can mean suppressing repetitive movements or sounds, often called stims, such as hand flapping or rocking. Many autistic people use these behaviors to manage sensory input and emotions. Masking can also mean forcing eye contact or acting interested in topics that don't engage the person. Compensation can mean planning phrases and jokes before a conversation or copying the gestures and expressions of the people nearby.

The effort often shows up unevenly across settings. A person may stay composed in social situations and then become distressed at home, where the pressure lets up.

These strategies can be deliberate or automatic. Some are planned, such as scripting a conversation in advance. Others happen without the person noticing. For some people, masking stops being a tool for getting through a hard moment and becomes the default way they move through the world, so a client may not describe it as masking at all. Several participants in the 2017 study had camouflaged for years before they were diagnosed.

Masking also often serves a protective purpose. Autistic adults commonly describe it as a way to avoid bullying and rejection, and to get by at work, at school, or in friendships.

One widely used way to measure camouflaging is the Camouflaging Autistic Traits Questionnaire (CAT-Q), a 25-item self-report measure designed for people 16 and older. It asks people to rate statements about their own social behavior and gives a total score and three subscale scores:

• Compensation: strategies for getting around social difficulties
• Masking: efforts to hide autistic traits and appear more neurotypical
• Assimilation: attempts to blend in during social situations

In the CAT-Q, “masking” names one of the three parts, not the whole pattern. The CAT-Q measures self-reported camouflaging, not autism itself. It was developed and validated in autistic and non-autistic adults, not as a measure for ADHD or anxiety, so it can’t be used to compare masking across conditions. Within that scope, it shows how much and in what ways a person says they camouflage, though it may miss strategies they use without realizing it. Read scores alongside developmental history. For clients younger than 16, it’s better to rely on history and collateral reports.

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What is Masking?

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What is ADHD masking, and how do you know if someone is masking?

Research on ADHD masking is newer. A 2026 study in Research in Neurodiversity included 202 adults in British Columbia who reported a professional ADHD diagnosis. More than 91% said they camouflaged their traits to some extent, often to be seen as capable and likable. Strategies included pretending to pay attention, mimicking others, overpreparing, avoiding social situations, and holding back impulses such as fidgeting or interrupting. Because participants reported their own diagnoses and came from one province, the 91% figure is best read as a signal, not a prevalence estimate.

The cost is the clinically useful part. Participants said camouflaging takes a lot of cognitive effort, which can impair attention, memory, and focus and make core ADHD symptoms worse. In practice, the effort to look attentive can leave less attention available. Some described feeling irritable or anxious and needing days to recover after periods of intense masking. Heavy preparation, effortful suppression of restlessness, and long recovery time are the patterns most worth asking clients about.

How does masking relate to anxiety?

The term “masking” is less used for anxiety, but clinicians describe a related pattern under a different name: safety behaviors. The two overlap, but they aren’t interchangeable.

Safety behaviors are defined by their purpose. They are mental and behavioral strategies that people with social anxiety use to reduce distress and prevent a feared outcome, such as being judged or rejected. In the cognitive model, they are a response to fear, not to differences in social skills. Masking is defined by what it hides: the traits or symptoms of a condition, concealed to fit in or to make up for real difficulties. The two share a motivation, fear of negative evaluation and a wish to be accepted, and some behaviors count as both, such as rehearsing what to say. But masking can happen without anxiety driving it, as when someone hides traits to avoid bullying.

Safety behaviors are usually described as two main types.

Avoidance behaviors reduce involvement in the situation. They include speaking less, avoiding eye contact, and sharing little about oneself. Because they can make a person seem withdrawn or unfriendly, they tend to draw negative reactions from others.

Impression-management behaviors involve more activity, not less. They include closely monitoring one’s own behavior, rehearsing what to say, choosing words carefully, and preparing topics in advance. The person stays engaged in the conversation, but with a great deal of effort behind it. In studies of social interactions, people who used impression management were rated by conversation partners as less anxious and more likable. This is part of why a client with significant anxiety can look calm and capable, a presentation sometimes called high-functioning anxiety, though the term is colloquial, not a formal diagnosis.

A third type, identified more recently, involves hiding visible signs of anxiety, such as blushing.

These patterns can keep anxiety going. A client who rehearses every sentence and then gets through a meeting without trouble is likely to conclude that the rehearsing saved them. They never find out whether the meeting would have gone fine anyway.

	Autism	ADHD (adults)	Anxiety
What gets hidden	Repetitive movements (stims), sensory distress, social communication differences, intense interests	Inattention, restlessness, impulsive speech, disorganization	Worry and fear of negative evaluation
Common strategies	Forced eye contact, scripted conversation, copying others' expressions and gestures	Overpreparing, pretending to pay attention, suppressing fidgeting, rehearsing conversations	Rehearsing what to say, closely monitoring one's own behavior, speaking less
What it can look like in session	Socially fluent, sometimes rehearsed; distress shows up elsewhere, such as at home	Prepared and organized; the effort of masking may leave attention, memory, and energy depleted afterward	Calm and likable; worry may read as diligence or perfectionism

Why does masking appear across diagnoses?

The shared driver appears to be pressure to fit in and avoid negative judgment. Autistic adults described camouflaging to fit in and connect, adults with ADHD described masking to avoid judgment, rejection, or discrimination, and in the cognitive model of social anxiety, safety behaviors exist to reduce the risk of rejection.

Context also seems to matter. In a study of adults with ADHD or autism, participants reported masking their personality more at school, at work, and with family, and much less around neurodivergent peers. The ADHD researchers also linked masking to the stigma and negative social feedback that many participants had received since childhood. Taken together, this suggests masking responds to what an environment asks of a person.

Camouflaging is also not specific to autism, and both autistic and non-autistic people use it. In a general-population survey, higher camouflaging scores were predicted by social anxiety, self-consciousness about how others see them, internalized stigma, and both autistic and ADHD traits. In a 2024 study of adults in the Netherlands, adults with ADHD reported more camouflaging than a comparison group, but less than autistic adults. Because the CAT-Q was built around autistic experience and wasn’t developed for ADHD or anxiety, comparisons across conditions should be read with caution, and a high score doesn’t show which condition a client is masking.

Two cautions apply here. Most of this work relies on self-report. And the associations with poor mental health don't establish direction: masking may contribute to distress, distress may prompt more masking, or both may reflect something else.

How can masking delay diagnosis?

Clinical assessment often relies on what a client shows and says in a limited window, and masking narrows what is visible. Researchers have proposed that camouflaging is a barrier to timely autism diagnosis, and screening tools may not catch it either. Some autistic people may fall below thresholds on screening tools because of camouflaging, although camouflaging is not required for a diagnosis. Heavier camouflaging may also lower scores on measures of autistic traits.

ADHD can follow a similar path. Many adults have developed coping strategies that hide their symptoms. Leaning heavily on to-do lists, for example, can conceal difficulty with focus or impulsivity. Because the diagnostic criteria include symptoms from childhood, evaluators often ask about past school performance and behavior, which gives them something beyond how the client presents today. Participants in the 2026 ADHD study also said masking can lead others to dismiss their struggles and limit their access to support. Charlie Health's guide to getting tested for ADHD covers what a thorough evaluation involves.

Masking also changes what a client brings to you. A client may present with anxiety or depression while the neurodevelopmental pattern underneath goes unrecognized. Co-occurring conditions are common in autism, with ADHD and anxiety disorders the most frequently reported. Charlie Health clinicians have noted that internalizing social and sensory discomfort to appear neurotypical is one way misdiagnosis can happen.

Autistic women tend to report more camouflaging than autistic men, and researchers have proposed that this may partly explain why autism is often missed in women, though studies differ on how and where the difference shows up. Evidence on ADHD masking in women is thinner, and findings on gender differences are mixed.

What are the costs of sustained masking?

Masking often works in the short term. It can help a person get through school, hold down a job, or make friends, but the costs tend to build over time.

Burnout

Autistic burnout is not a formal diagnosis. It’s a term autistic people use for persistent exhaustion, loss of previously held skills, and lower tolerance for stimulation, lasting months. In a 2020 qualitative study, autistic adults described it as building when life stress accumulated and expectations outran their abilities, with too little support to relieve the load. The authors also warned against teaching autistic people to mask or push themselves to meet mainstream expectations. Charlie Health's guide to autistic burnout covers presentation and recovery.

Adults with ADHD describe a similar toll. In the 2026 ADHD study, some participants said periods of intense masking left them irritable or anxious and that recovery could take days. "ADHD masking burnout" isn't a formal term, but that recovery time is worth asking about in assessment.

Anxiety, depression, and sense of self

In autistic adults, camouflaging has been associated with more social anxiety, more general anxiety, depression, and lower wellbeing. Participants in the 2017 autism study described a threat to their sense of self. Adults in the ADHD study reported depression, low self-esteem, and feelings of inauthenticity, along with uncertainty about who they are.

Suicide risk

In a one-time online survey of 164 autistic adults, higher levels of camouflaging were associated with greater suicidality, as were non-suicidal self-injury and unmet support needs. This is a group-level association. It doesn’t show that camouflaging causes suicidality, and it can’t tell you whether any one client is at risk.

If you or someone you know is thinking about suicide, call or text 988 to reach the 988 Suicide & Crisis Lifeline. If there is immediate danger, call 911.

How do you screen for masking?

A client who has, or may have, autism, ADHD, or anxiety can seem to be doing well while working hard to look that way. No single measure captures masking across all three conditions, so start with history and with the gap between settings. Because masking can be automatic, a client may not recognize the term, so ask about behavior and effort, not whether they mask.

Screening for masking is not diagnosis. These prompts can show whether masking may be affecting what you’re seeing, but they don’t confirm that a client is masking or identify a condition. Any of these presentations should prompt a closer look:

• If a client is composed in session, ask how behavior and mood differ at home, at school or work, and with people they trust.
• If a client is high-achieving and thoroughly prepared, ask how much time and effort go into routine demands, and what happens when preparation isn't possible.
• If a client reports few symptoms but significant fatigue, ask about recovery time after social or performance demands, including whether exhaustion lasts days.
• If anxiety or depression is the presenting problem, ask about developmental history, with collateral from parents or school records where possible.
• If a client's skills or sensory tolerance are declining, ask whether abilities that used to be reliable have slipped, which may point to burnout.
• If a client expresses hopelessness or feeling trapped, ask directly about suicidal thoughts. If a client discloses them, follow your safety protocol and share the 988 Suicide & Crisis Lifeline (call or text 988). If there is immediate danger, call 911.

When a client needs more than weekly care

Masking alone isn’t a reason for more intensive care. That decision should rest on a client’s clinical severity, functional impairment, risk, and treatment needs, using your usual level-of-care criteria. Masking matters because it can hide how severe those things are, so a client who seems to be doing well may need a closer look before you decide.

More than weekly therapy may be warranted when symptoms are severe or worsening, when they significantly interfere with school, work, or home life, or when a client is still struggling despite regular outpatient therapy. The same applies to a client stepping down from a hospitalization, residential program, or emergency department visit. Clients in active crisis, or who need 24/7 supervision, need a higher level of care than an intensive outpatient program.

When an intensive outpatient program fits, Charlie Health’s virtual IOP serves kids, teens, and adults. Care is delivered with a neurodivergent-affirming approach, and you can place a client in as little as 24 hours.

Refer a client to Charlie Health or learn more about neurodivergence care at Charlie Health.