Masking in autism and ADHD: discuss

[Doctor Eliza]

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This thread is prompted by a close friend seeking psychotherapy with a master’s level clinician who decided to do a “deep dive assessment” into “neurodiversity” and has spent like 6 sessions giving questionnaires and interviewing her. Her verdict was ADHD and high functioning autism. (I strongly doubt this diagnostic picture as her friend of 30 yrs.) The therapist’s explanation was that the combination of the two creates an “offsetting effect which makes it easier to mask.” I don’t really understand how that would work.

So, what’s your take on masking? What is the difference between masking and adapting? And if you are not showing your symptoms how do you have enough functional impairment to qualify for the diagnosis?

Would love some of the great minds here to weigh in. I know I am skeptical about the concept due to the excessive use of the term masking on social media and in pop psych. And I’m feeling protective of my friend being treated by someone likely practicing out of scope. But I can be convinced to reconsider.

 

[lg1527]

I don’t dismiss the concept of masking, but it’s definitely making assessments more challenging. When every absence of observable difficulty during testing, at school, or in the community is attributed to masking, it becomes hard to tell what’s true adaptation versus concealment. I also believe social media has amplified this to the point where any lack of impairment is seen as proof of masking. Would love to know if there’s actual research that helps distinguish the two.

 

[cara susanna]

I saw a psychiatrist on Reddit say that masking isn't a thing, and I've been curious ever since.

 

[WisNeuro]

Not my area of expertise by any means, but I have not seen a good formal definition that lends itself to empirical study that differentiates pathological "masking" from aspects of impression management that everyone engages in to some extent.

 

[AcronymAllergy]

Autism admittedly isn't my area of expertise, but this sounds sort of like saying that if a person has both depression and anxiety, it creates an "offsetting effect" that makes it difficult to detect both for some mysterious reason...?

 

[WisNeuro]

Autism admittedly isn't my area of expertise, but this sounds sort of like saying that if a person has both depression and anxiety, it creates an "offsetting effect" that makes it difficult to detect both for some mysterious reason...?

I once had a provider want me to change my report that found no evidence of ADHD, because she argued that the patient's PTSD made the ADHD undetectable. Despite no childhood report of symptoms either...

 

[oliversacks4thewin]

I'll wade into this, as a pediatric psychologist, who works in a neurology department of a hospital, and conducted their dissertation on ASD, but will still be careful, as it is tricky.

First, the comorbidity of ASD and ADHD is quite high (estimates placing it anywhere from 20% to 50%), so one should be well equipped to see both co-occurring, if they are planning on being involved in diagnosing and treating. I worry about a provider who is in this arena, who feels like comorbid ADHD obfuscates the picture.

From my understanding masking is defined as" involving hiding or inhibiting behaviors that may be perceived as socially atypical (such as stimming, directness in communication, or atypical facial expressions), imitating neurotypical social behaviors, and using learned social scripts to navigate interactions." I think of it as a flow chart that the person affected by ASD can base situations on. If the flowchart does not work, the house of cards falls apart so to speak. There are numerous scenarios where this would be the case, as I tend to think the rule is ASD symptom expression and the exception is the ability to effectively navigate utilizing these compensatory strategies. The dysfunction should still be prominent in scenarios, especially novel situations, where no flow-chart or, close approximation, exists yet. I'll defer to my more expertise colleagues on how they parse this apart more, as I am sure you will get some stellar reflections on this.

 

[PsyDr]

What's the difference between "coping" and "masking"?

 

[aim-agm]

The statement that the combo of ADHD “offsetting effect which makes it easier to mask” may be somewhat correct (at least the "offsetting effect" part), but I think it confuses different definitions of "mask." Here's a recent article looking at ADHD and ASD- Self-reported symptoms of attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and affective lability in discriminating adult ADHD, ASD and their co-occurrence - PubMed

The authors suggest that the symptoms of ASD can "overshadow" those of ASD, thus masking some of the symptoms of ASD, which can lead to a diagnosis later in life for those with both conditions. This "masking" is not a conscious process undertaken by the individual to hide symptoms, but rather an effect of ADHD symptoms whereby they make ASD symptoms more difficult to identify as a part of ASD. Contrast this with the active process of masking, whereby the individual consciously and purposefully engages in some sort of behavior (e.g., social masking such as just hiding ASD symptoms from others; using practiced social scripts to give and appearance of spontaneous and adaptive social behavior). Note this study (and pretty much all like it) are retrospective and correlational. Doesn't mean they don't have value, but they do come with limitations.

A better word would be "confound" or something

 

[ClinicalABA]

A better word would be "confound" or something

Better word than what? (and I'm not saying that snarkily or anything- I'm just not understanding).

 

[aim-agm]

Better word than what? (and I'm not saying that snarkily or anything- I'm just not understanding).

Sorry, than "masking" - the phenomenon they are describing doesn't have a relation to what is generally meant by masking (i.e. their "passive masking" doesn't have parallels to "active masking" other than making diagnosis more difficult) so a different term would be more optimal.

 

[ClinicalABA]

I see what you are getting at. I think the term "symptom overshadowing" is somewhat used to describe this. I don't think "confound" is the correct term in its common usage sense to mean some variable that affects two other variables (usually an IV and a DV). I think you can have ASD and ADHD separately- without a common related variable- yet have the symptoms of one interfere with the expression and detection of the symptoms of the other. It just semantics, but semantics are important, especially in the current climate of misinformation about ASD (c.f., the distinction between cause and correlation)

 

[AcronymAllergy]

The statement that the combo of ADHD “offsetting effect which makes it easier to mask” may be somewhat correct (at least the "offsetting effect" part), but I think it confuses different definitions of "mask." Here's a recent article looking at ADHD and ASD- Self-reported symptoms of attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and affective lability in discriminating adult ADHD, ASD and their co-occurrence - PubMed

The authors suggest that the symptoms of ASD can "overshadow" those of ASD, thus masking some of the symptoms of ASD, which can lead to a diagnosis later in life for those with both conditions. This "masking" is not a conscious process undertaken by the individual to hide symptoms, but rather an effect of ADHD symptoms whereby they make ASD symptoms more difficult to identify as a part of ASD. Contrast this with the active process of masking, whereby the individual consciously and purposefully engages in some sort of behavior (e.g., social masking such as just hiding ASD symptoms from others; using practiced social scripts to give and appearance of spontaneous and adaptive social behavior). Note this study (and pretty much all like it) are retrospective and correlational. Doesn't mean they don't have value, but they do come with limitations.

While their isn't any one accepted conceptualization of or definition of masking, some of what I've read and heard individuals with ASD say about it suggests that it differs from adapting in that it results in the individual enduring a situation until escape is possible, rather than benefiting from the situation. It presumably comes with some negative costs, such as increased anxiety, lack of access to positive reinforcement during the situation in which the masking occurs, and perpetuation of self-talk and beliefs about being "different" and not accepted. Contrast this with an adaptive skill, such as asserting one's needs in social situations so that you can access positive reinforcers related to those needs.

TLDR: ADHD symptoms may overshadow symptoms of ASD and thus make it more difficult to identify ASD as a separate diagnostic entity, but this is not attributable to a "masking" process that is consciously and purposefully engage in by the individual to hide symptoms in order to endure situations until escape is possible.

Now see, this makes sense. Back when I did ADHD evals, a version of this was often the referral reason, just with diagnoses other than ASD. For example, patient has a history of bipolar or PTSD or significant anxiety, but they and/or the provider are now also thinking the patient may have previously-undiagnosed ADHD.

The version in the OP made it sound like the psychotherapist was saying ASD and ADHD essentially canceled each other out somehow. At least that was my read of it.

 

[Fan_of_Meehl]

I don’t dismiss the concept of masking, but it’s definitely making assessments more challenging. When every absence of observable difficulty during testing, at school, or in the community is attributed to masking, it becomes hard to tell what’s true adaptation versus concealment. I also believe social media has amplified this to the point where any lack of impairment is seen as proof of masking. Would love to know if there’s actual research that helps distinguish the two.

In the philosophy of science, a properly posed meaningful scientific statement (e.g., "patient Y has disorder X") has to make an observable difference (in terms of its observational consequences) whether it is 'true' or 'false.' A statement that makes no difference in the world whether it is true or false cannot even be evaluated as to its truth value and is therefore not even a meaningful scientific statement.

 

[Doctor Eliza]

The version in the OP made it sound like the psychotherapist was saying ASD and ADHD essentially canceled each other out somehow. At least that was my read of it.

Yes, that is what the patient understood the clinician to be saying.

 

[oliversacks4thewin]

I see what you are getting at. I think the term "symptom overshadowing" is somewhat used to describe this. I don't think "confound" is the correct term in its common usage sense to mean some variable that affects two other variables (usually an IV and a DV). I think you can have ASD and ADHD separately- without a common related variable- yet have the symptoms of one interfere with the expression and detection of the symptoms of the other. It just semantics, but semantics are important, especially in the current climate of misinformation about ASD (c.f., the distinction between cause and correlation)

I just knew you were going to swing in with a ton of great insight into this subject matter! Thank you so much!

Given that both are considered neurodevelopmental conditions, what becomes the salient pieces for parsing out the difference between the two; especially in the patient cases of ASD, where social demands have finally met a limit of capacities to demonstrate the dysfunction? I feel like these are the cases that sometimes go undetected until later in life. I often speak to how individuals with ADHD will miss social cueing too, but this more of a secondary result of inattention/disinhibition/impulsivity, etc. In the cases of comorbidity, it just feels like the capacity for this skill is, at baseline, impaired, but it's sometimes harder to articulate in what way. Is there something in the literature that speaks more to that specific impairment, from your knowledge? I know we have both discussed ToM and I believe, social intuition, before related to this, but it feels like these do not entirely encapsulate those differences from the secondary to primary component.

 

[megamaramon]

I've had parents tell me their 4-year-old is "masking" their autism symptoms when in public and "unmask" at home. I'm like...that's not what masking is. There's a massive misunderstanding of masking in both the public and the profession.

My understanding of masking is that it's a learned behavior that takes a lot of executive functioning to manage. Small children don't have that capability.

 

[ClinicalABA]

I just knew you were going to swing in with a ton of great insight into this subject matter! Thank you so much!

Given that both are considered neurodevelopmental conditions, what becomes the salient pieces for parsing out the difference between the two; especially in the patient cases of ASD, where social demands have finally met a limit of capacities to demonstrate the dysfunction? I feel like these are the cases that sometimes go undetected until later in life. I often speak to how individuals with ADHD will miss social cueing too, but this more of a secondary result of inattention/disinhibition/impulsivity, etc. In the cases of comorbidity, it just feels like the capacity for this skill is, at baseline, impaired, but it's sometimes harder to articulate in what way. Is there something in the literature that speaks more to that specific impairment, from your knowledge? I know we have both discussed ToM and I believe, social intuition, before related to this, but it feels like these do not entirely encapsulate those differences from the secondary to primary component.

Beyond some of the findings in the paper I cited above, I don't know a lot of this area. Because I work with such young kids (under two mostly), ADHD is not an appropriate diagnosis. Pretty much every toddler I see professionally or have known personally would meet the symptom criteria for ADHD! I think that's another reason why early detection is so important- it's just plain easier, with much less differential diagnoses to identify or rule out (I'm basically looking at ASD vs. Language Disorder vs. Global Delay, with a smattering of Broader Autism Phenotype thrown in, often when there are siblings or parents with "full blown" ASD. Things that could overshadow or complicate ASD, such as ADHD, OCD and other anxieties (anxieties largely involve verbal behaviors, albeit self-verbalizations, and most of the kids I see don't have the language to be really that anxious), thought disorders, even just social skills deficits, aren't really an issue with the really young ones. Because ASD typically manifests much younger that the other "disorders" do, the time to identify it is when they are young. Anecdotally, a lot of the kiddos i dx will go on to be diagnosed later with other things.

Parents often ask me about ADHD as it seems like there toddler or preschooler with ASD just bops from one toy to the next, with no real sustained attention. I think this is more related play skills than attentional deficits. Without language/story based play (e.g., pretending to be a mommy feeding and changing a baby doll) and/or an understanding of what the toys represent socially (e.g., the toy minivan represents mom's minivan and thus is attached to a memory that can be translated into a play narrative), all that's left to do with the toys is investigate their physical properties- how they feel, what they sound like, how they taste, what the do kinetically (like the spinning wheels on a toy vehicle. This can be done very quickly, so there is no need to spend a lot of time with each toy. Thus the moving between toys is actually not evidence of lack of attention, but conversely of the child having really good attention for tasks that don't really take that long. Often, as I am sure you've seen, this children can pay really good (excessive?) attention to certain physical properties (the ubiquitous staring at spinning wheels or fans). It has just always seemed very distinct from the attentional difficulties associated with ADHD. The social world is often what grounds us to a place or an item, and navigating this takes a lot of time and effort.

 

[ClinicalABA]

I've had parents tell me their 4-year-old is "masking" their autism symptoms when in public and "unmask" at home. I'm like...that's not what masking is. There's a massive misunderstanding of masking in both the public and the profession.

My understanding of masking is that it's a learned behavior that takes a lot of executive functioning to manage. Small children don't have that capability.

Yeah-the whole "does better at school than at home" thing that makes teachers suspicious and parents feel guilty that they are doing something wrong. I have a case now with a preschooler who is apparently good following directions at school, but not at home. Things is at school she really doesn't need to understand the words or the intent of the teacher- there's 5-10 other kids there, and if at least one of them understands the teacher and starts to comply, all you need to do is copy what they are doing. What seems like a social communication task is actually a much simpler visual-spatial problem solving task. At home, when its just her and the parents ask her to do something, it's not that she doesn't respond, but that she can't respond because a) the language doesn't always make sense; and b) the ToM stuff comes into play and she may not comprehend that her parents are even trying to get her to do something. There's also the potential that the majority of things she has to do at school are highly preferred and involve immediate positive reinforcement being what is possible at home, where you need to do not-so-much-fun things as sit for dinner, use the potty, and get ready for bed.

 

[R. Matey]

What's the difference between "coping" and "masking"?

Or how is masking different than safety behaviors endemic to social anxiety disorder?

 

[cara susanna]

I'm also struggling to figure out how masking is different from compensatory strategies

 

[WisNeuro]

I'm also struggling to figure out how masking is different from compensatory strategies

Yeah, this is where I'm trying to understand the difference between modifying your behaviors to achieve better outcomes in social situations, be it called compensatory strategies or social monitoring with insight, and what it seems like people are talking about in terms of masking.

Are we referring to a different phenomenon completely, or the tail end of what is generally a normal behavior?

 

[Therapist4Chnge]

Beyond some of the findings in the paper I cited above...

I really appreciate your contributions here, as your posts are insightful and specific.

My first research was in ADHD and early language acquisition, and the behavioral stuff was always a challenge for all involved. I was peds trained and I also did educational and behavioral intervention work for young children with ADHD, but the really young ones were the hardest to differentiate symptoms. At 6 or 7+ I felt solid, but below that was definitely full of different challenges. I was fortunate to receive 2yr of peds and adult didactics during my fellowship (along with 2yr of peds & adult neurology didactics), which really helped solidify that the neurologic underpinnings are super interesting...but I had little to no interest dealing with all of the "extra" stuff with schools, parents, et al.

 

[Therapist4Chnge]

I'm also struggling to figure out how masking is different from compensatory strategies

Yeah, this is where pop psych is making things more difficult for clinicians. I hear it A LOT with adults and Gen-Z and Gen-A, but I think conceptually they are definitely misapplying it. They *are* compensatory strategies, but I feel like when people use "masking" there is more of a, "I shouldn't have to pretend to be a normie" feel to it. It's learned behavior that has demonstrated a positive result (whether that is gaining a reward or decreasing something unpleasant), and it's how many learn to get by at work, etc. I think how they often frame it is about how much effort and energy it takes to use the various compensatory strategies. I like to frame it through their active choice, so we can talk more plainly about when that is more helpful and less helpful, and where they should apply their energy. In some instances the "choice" still feels pressured because they were afraid they'd get fired if they couldn't "get along" with others.

A practical example is I had a neurodivergent worker sustain multiple ortho injuries, and he got stuck in an office setting (as a field worker) for months. Thankfully no brain injury, but he really struggled to tolerate "small talk" and getting dropped in the middle of a social ecosystem he did not understand nor want. People would be a mix of friendly and nosey, and his previous compensatory strategies weren't working bc he saw these people daily instead of a couple of times per month like prior to injury. We eventually helped him classify his answer based on the type of person asking, so he learned some canned responses that would require much less engagement and cut down on the frequency of interactions, and ultimately cut down how much he had to wear himself out by "masking"...according to how pop psych uses the term.

 

[Ceke2002]

This thread is prompted by a close friend seeking psychotherapy with a master’s level clinician who decided to do a “deep dive assessment” into “neurodiversity” and has spent like 6 sessions giving questionnaires and interviewing her. Her verdict was ADHD and high functioning autism. (I strongly doubt this diagnostic picture as her friend of 30 yrs.) The therapist’s explanation was that the combination of the two creates an “offsetting effect which makes it easier to mask.” I don’t really understand how that would work.

So, what’s your take on masking? What is the difference between masking and adapting? And if you are not showing your symptoms how do you have enough functional impairment to qualify for the diagnosis?

Would love some of the great minds here to weigh in. I know I am skeptical about the concept due to the excessive use of the term masking on social media and in pop psych. And I’m feeling protective of my friend being treated by someone likely practicing out of scope. But I can be convinced to reconsider.

As someone who is diagnosed with ADHD I do find the term 'masking' to be a confusing one. Maybe it means something else to someone with ASD, but for me I have different tactics I've developed over time so that I can self manage some of my ADHD symptoms without medication, but I don't consider that 'masking', as in covering something up. I mean strategies aside the ADHD is still there, I'm not covering anything up.

 

[oliversacks4thewin]

I will say I also struggle with the concept of "masking" being something different, but from my readings and patient interactions, it seems to me to be suggested as an unconsciousness compensation. To quote the great (?) Rick Astley, I understand it to be a concept of "you know the rules, and so do I" of social interactions. The individual with ASD follows the established concepts of social reciprocity, because it fits the logical paradigm in their schema, but if you were to directly ask them about how to cope, they would struggle to identify how they engage in this from a conceptual perspective. I believe the theory is that this has been behaviorally reinforced with negative outcomes from previous social situations, so it gets folded into the "structural flowchart" I mentioned earlier, over time. A compensatory strategy, ala one from a rehabilitation paradigm, builds the conceptual structure first and then applies it to in vivo settings. So, like reverse engineering compensatory strategies?

 

[Ceke2002]

I really appreciate your contributions here, as your posts are insightful and specific.

My first research was in ADHD and early language acquisition, and the behavioral stuff was always a challenge for all involved. I was peds trained and I also did educational and behavioral intervention work for young children with ADHD, but the really young ones were the hardest to differentiate symptoms. At 6 or 7+ I felt solid, but below that was definitely full of different challenges. I was fortunate to receive 2yr of peds and adult didactics during my fellowship (along with 2yr of peds & adult neurology didactics), which really helped solidify that the neurologic underpinnings are super interesting...but I had little to no interest dealing with all of the "extra" stuff with schools, parents, et al.

The bolded part is something I've always been curious about. I was diagnosed in 1975 (hyperkinetic reaction of childhood, obviously) at the age of 3. My assumption has always been that my behaviour was so far out of the norm for my age group that it warranted assessment and diagnosis. But how do you look at the average 3 year old and determine if it's ADHD or they're just a toddler?

 

[WisNeuro]

So, for example, I'm kind of an dingus, and I generally don't like most people. But, social interactions go much better, as well as outcomes, if I don't overtly act this way towards people. So, I change my behavior to more prosocial, and I don't act how I'd rather act. Am I masking?

 

[Ceke2002]

I will say I also struggle with the concept of "masking" being something different, but from my readings and patient interactions, it seems to me to be suggested as an unconsciousness compensation. To quote the great (?) Rick Astley, I understand it to be a concept of "you know the rules, and so do I" of social interactions. The individual with ASD follows the established concepts of social reciprocity, because it fits the logical paradigm in their schema, but if you were to directly ask them about how to cope, they would struggle to identify how they engage in this from a conceptual perspective. I believe the theory is that this has been behaviorally reinforced with negative outcomes from previous social situations, so it gets folded into the "structural flowchart" I mentioned earlier, over time. A compensatory strategy, ala one from a rehabilitation paradigm, builds the conceptual structure first and then applies it to in vivo settings. So, like reverse engineering compensatory strategies?

That actually makes more sense than just seeing the term bandied about online with no actual explanation of meaning attached to it. I suppose from that point of thinking I would have to say that I engage in 'masking' sometimes, I've just never thought of it in those terms. For example I used to have a really bad 'habit' (for want of a better descriptor) of wandering off in the middle of a conversation. Most of the time I didn't even know I was doing it until I found myself standing somewhere else with a friend tapping me on the shoulder to remind me that apparently just randomly walking away from someone mid conversation was actually very inconsiderate. Obviously, not being a complete idiot, I already knew that, so I set about trying different strategies, in order to better fit with social norms/expectations, until I found something that worked. I've been using those strategies to 'mask' now for so long that I couldn't tell you exactly what it was that I came up with in the first place; conversation happens and I instinctively rat around in my brain for the 'don't wander off in the middle of a conversation' skill set, and unless I'm really tired or unwell it's just kind of there.

 

[ClinicalABA]

The bolded part is something I've always been curious about. I was diagnosed in 1975 (hyperkinetic reaction of childhood, obviously) at the age of 3. My assumption has always been that my behaviour was so far out of the norm for my age group that it warranted assessment and diagnosis. But how do you look at the average 3 year old and determine if it's ADHD or they're just a toddler?

I'd argue that you probably can't and shouldn't. While there are no age restrictions for diagnosis in DSM5, it does say that it very difficult to distinguish symptoms from normal behavioral variability for children under 4.

 

[WisNeuro]

Do we really need a restriction on ahole on the site?

 

[ClinicalABA]

Do we really need a restriction on ahole on the site?

Not sure what this means...

 

[WisNeuro]

Not sure what this means...

The site's autocensor controls. Certain words are flagged and changed. Which, for certain slurs, sure, go nuts. But, common swears?

 

[ClinicalABA]

The site's autocensor controls. Certain words are flagged and changed. Which, for certain slurs, sure, go nuts. But, common swears?

Ah- i get it- you're referencing a restriction on the word, not the person!

 

[Ollie123]

As with nearly everything, I don't doubt the phenomenon of "masking" is real but it has also been completely mangled by the online reddit-world and has lost all meaning. I think an analogy to other disorders here helps. There are plenty of depressed people who excel at "faking" excessive happiness in social contexts (see: legions of depressed comedians). This seems a form of masking. It sounds exhausting and generally doesn't make the depression better. While there is certainly overlap and shades of grey, I would argue this is distinct from coping. It may reduce functional impairment, but generally not symptoms themselves (perhaps indirectly through retention of social support, etc., etc....hence "shades of grey"). Obviously this looks a bit different in ASD/ADHD where functional impairment is a bit more diagnostically center-stage than it is in depression, but I think the general idea holds. Basically, coping is done to benefit you, but may incidentally benefit others. Masking is done to benefit others, but may incidentally benefit you. It largely is impression management, but I think its reasonable to assume that falls on a continuum. That's just how I've always thought about it.

Now in reddit-land, I think it has become "I self-diagnosed ASD despite having no actual symptoms of ASD. My boss is a jerk who gets mad I keep telling customers to go to hell. How do I get him to understand I shouldn't have to mask and he has to accommodate my ASD?" This is an entirely distinct situation with little-to-no bearing on reality.

Back to the original post, that sounds completely insane but also doesn't surprise me even a little given the state of mental health care. I could certainly see it complicating diagnosis which is always true when there is "a lot going on." Portraying it as "These disorders cancel each other out".........🤣🤣🤣

 

[Fan_of_Meehl]

As with nearly everything, I don't doubt the phenomenon of "masking" is real but it has also been completely mangled by the online reddit-world and has lost all meaning. I think an analogy to other disorders here helps. There are plenty of depressed people who excel at "faking" excessive happiness in social contexts (see: legions of depressed comedians). This seems a form of masking. It sounds exhausting and generally doesn't make the depression better. While there is certainly overlap and shades of grey, I would argue this is distinct from coping. It may reduce functional impairment, but generally not symptoms themselves (perhaps indirectly through retention of social support, etc., etc....hence "shades of grey"). Obviously this looks a bit different in ASD/ADHD where functional impairment is a bit more diagnostically center-stage than it is in depression, but I think the general idea holds. Basically, coping is done to benefit you, but may incidentally benefit others. Masking is done to benefit others, but may incidentally benefit you. It largely is impression management, but I think its reasonable to assume that falls on a continuum. That's just how I've always thought about it.

Now in reddit-land, I think it has become "I self-diagnosed ASD despite having no actual symptoms of ASD. My boss is a jerk who gets mad I keep telling customers to go to hell. How do I get him to understand I shouldn't have to mask and he has to accommodate my ASD?" This is an entirely distinct situation with little-to-no bearing on reality.

Back to the original post, that sounds completely insane but also doesn't surprise me even a little given the state of mental health care. I could certainly see it complicating diagnosis which is always true when there is "a lot going on." Portraying it as "These disorders cancel each other out".........🤣🤣🤣

The entire phenomenon/epidemic of self-diagnosing mental health conditions needs to end yesterday.

 

[Ceke2002]

I'd argue that you probably can't and shouldn't. While there are no age restrictions for diagnosis in DSM5, it does say that it very difficult to distinguish symptoms from normal behavioral variability for children under 4.

This is pretty much what I've always thought. From what I understand being diagnosed under the age of 4 was rare, even for 1975 standards. I wasn't told until much later on that I was also assessed for autism at the same time; obviously as I got older the diagnosis I got became more clear, but at age 3 how the blankety blanks did they observe me and go, "Yep that's hyperkinetic reaction of childhood" as opposed to autism or even "Sure there's some behavioural concerns, on the other hand she might just be toddler".

 

[ClinicalABA]

This is pretty much what I've always thought. From what I understand being diagnosed under the age of 4 was rare, even for 1975 standards. I wasn't told until much later on that I was also assessed for autism at the same time; obviously as I got older the diagnosis I got became more clear, but at age 3 how the blankety blanks did they observe me and go, "Yep that's hyperkinetic reaction of childhood" as opposed to autism or even "Sure there's some behavioural concerns, on the other hand she might just be toddler".

If you're talking 1974, that's DSM-2 and IIRC what we now call ASD would have been something like "schizophrenia- child type!" I actually like the term "hyperkinetic reaction of childhood" vs. "ADHD" to describe that really young kiddo who is just bopping around like a tornado. It's more of behavioral description, without the implied (and ultimately assumed) internal cause of an "attention deficit."

 

[ClinicalABA]

The entire phenomenon/epidemic of self-diagnosing mental health conditions needs to end yesterday.

Another advantage of working with toddlers- they rarely self-diagnose😉

 

[Ceke2002]

If you're talking 1974, that's DSM-2 and IIRC what we now call ASD would have been something like "schizophrenia- child type!" I actually like the term "hyperkinetic reaction of childhood" vs. "ADHD" to describe that really young kiddo who is just bopping around like a tornado. It's more of behavioral description, without the implied (and ultimately assumed) internal cause of an "attention deficit."

It would've been around the time when the DSM III was published that my parents mentioned the autism testing, or as my Mum put it, "they thought you might be have been a minda (Australian slur term for mentally challenged)", before clarifying they did tests to see if I was like one of the kids on the posters (very early autism awareness). Strange conversation to have with your child.

I like the term "hyperkinetic reaction of childhood" as well. From the little I remember, and from what I was told later on, I think the main concern with having me assessed in the first place was the sheer level of hyperactivity, which was to the point that I assume there would've been some genuine issues regarding whether I was a danger to myself (again for want of a better description). Some of my greatest "HRoC" hits included: repeatedly running head first into locked doors, because waiting for a door to be opened took too long; randomly sprinting off in whatever direction I was facing at the time, including straight into on coming traffic, and being found up a tree, trying to climb into the Giraffe enclosure at the zoo. WTAF?

I don't really remember any of the "Attention Deficit" side of ADHD until around the age of 5-6 at the earliest. That was around the time I was really struggling to learn how to ride a bike, because I kept getting distracted by birds flying over head and crashing into stobie poles.

 

[Doctor Eliza]

Thanks, folks! I knew I could count on some thought-provoking dialogue!

 

[oliversacks4thewin]

As with nearly everything, I don't doubt the phenomenon of "masking" is real but it has also been completely mangled by the online reddit-world and has lost all meaning. I think an analogy to other disorders here helps. There are plenty of depressed people who excel at "faking" excessive happiness in social contexts (see: legions of depressed comedians). This seems a form of masking. It sounds exhausting and generally doesn't make the depression better. While there is certainly overlap and shades of grey, I would argue this is distinct from coping. It may reduce functional impairment, but generally not symptoms themselves (perhaps indirectly through retention of social support, etc., etc....hence "shades of grey"). Obviously this looks a bit different in ASD/ADHD where functional impairment is a bit more diagnostically center-stage than it is in depression, but I think the general idea holds. Basically, coping is done to benefit you, but may incidentally benefit others. Masking is done to benefit others, but may incidentally benefit you. It largely is impression management, but I think its reasonable to assume that falls on a continuum. That's just how I've always thought about it.

Now in reddit-land, I think it has become "I self-diagnosed ASD despite having no actual symptoms of ASD. My boss is a jerk who gets mad I keep telling customers to go to hell. How do I get him to understand I shouldn't have to mask and he has to accommodate my ASD?" This is an entirely distinct situation with little-to-no bearing on reality.

Back to the original post, that sounds completely insane but also doesn't surprise me even a little given the state of mental health care. I could certainly see it complicating diagnosis which is always true when there is "a lot going on." Portraying it as "These disorders cancel each other out".........🤣🤣🤣

This is the camp I tend to fall into, as well. I'm open to the exploration of the topic, but also recognize, it's technically not a DSM criteria...

There are measurements that attempt to parse apart what makes masking unique, like the CAT-Q, mentioned in the following article: Camouflaging in autism spectrum disorder: Examining the roles of sex, gender identity, and diagnostic timing - PubMed but I recognize their construct validity is still shaky, at best. I do like that studies on these alludes to recognition in social anxiety and ADHD, as it highlights everything you have all said. That these are all behaviors, endured with discomfort, and attempts to cope/compensate around.

I fully appreciate your sentiment @WisNeuro as it seems to excuse all poor behavior by calling it "masking." I feel like the misuse of the construct in the mainstream, makes it harder to define for sure. In my experience, patients with overt ASD still demonstrate masking-like behaviors, where they will attempt to match social reciprocity, so they "don't seem weird." In fact, I have had a number of individuals with ASD who will fiercely maintain eye contact with me, because, I am certain, there were negative consequences for not doing so in the past, even though the new eye contact, is now abnormal. It's not exactly a prosocial behavior but kind of like an attempt to be seen as socially more to the norm, even if it is clearly not. When I think about "masking" these are more of the kinds of behaviors I'm thinking of. It's an attempt to adhere to the "rules" but is based on observed data, rather than inherent fundamental understanding of the concept.

 

[R. Matey]

There are measurements that attempt to parse apart what makes masking unique, like the CAT-Q, mentioned in the following article: Camouflaging in autism spectrum disorder: Examining the roles of sex, gender identity, and diagnostic timing - PubMed but I recognize their construct validity is still shaky, at best. I do like that studies on these alludes to recognition in social anxiety and ADHD, as it highlights everything you have all said. That these are all behaviors, endured with discomfort, and attempts to cope/compensate around.

I don't think there's enough research on the CAT-Q for clinical use, personally. Many of the items look like safety behavior items that I would expect from a social anxiety measure and if you look at the original validation article, correlations with GAD and social anxiety measures are very strong, despite a moderate sample size and differences in scale anchors.

 

[Therapist4Chnge]

Another advantage of working with toddlers- they rarely self-diagnose😉

I had a patient (who also claimed DID) that her outbursts were just BPD "flare ups"...and she couldn't be held accountable for her "medical condition", like when people had seizures.

 

[Fan_of_Meehl]

I had a patient (who also claimed DID) that her outbursts were just BPD "flare ups"...and she couldn't be held accountable for her "medical condition", like when people had seizures.

I'm always a big fan of doing cognitive-behavioral 'chain' analyses and/or functional assessments (e.g., what are the antecedents and consequences) of these sorts of clinical phenomena. It's amazing what patterns emerge.

 

[bcliff]

I actually like the term "hyperkinetic reaction of childhood"

It also removes the frustrating "and/or" element of our current ADHD diagnostic label (i.e., attention-deficit [and/or] hyperactivity disorder), which has watered down the diagnosis to something largely unfalsifiable IMO. The emphasis on hyperkinesis also fits with the neurobiological models of the disorder that implicate frontostriatal circuitry (which is admittedly a literature I take with a large grain of salt).

Given its origins as "hyperkinesis" and the subcortical link I mentioned above, I've posed questions to pediatric colleagues about whether they think of (hyperactive-impulsive) ADHD as a movement disorder. All have said that they do not.

 

[R. Matey]

Idk if anyone else has a copy of the DSM-II, but its not like the criteria for Hyperkinetic Disorder of Childhood were ultra specific. I do think the attention deficit components were probably overstated in future iterations of the DSM though.

 

[cara susanna]

It also removes the frustrating "and/or" element of our current ADHD diagnostic label (i.e., attention-deficit [and/or] hyperactivity disorder), which has watered down the diagnosis to something largely unfalsifiable IMO. The emphasis on hyperkinesis also fits with the neurobiological models of the disorder that implicate frontostriatal circuitry (which is admittedly a literature I take with a large grain of salt).

Given its origins as "hyperkinesis" and the subcortical link I mentioned above, I've posed questions to pediatric colleagues about whether they think of (hyperactive-impulsive) ADHD as a movement disorder. All have said that they do not.

That's interesting, because there was a neuropsychologist who told me that it was extremely rare to find childhood ADHD without any hyperactivity. I'm honestly not sure if that's true because I am by no means an expert.

 

[bcliff]

That's interesting, because there was a neuropsychologist who told me that it was extremely rare to find childhood ADHD without any hyperactivity. I'm honestly not sure if that's true because I am by no means an expert.

I don't work with children, so I can't comment.

Here's a paper I cite when physicians refer adults to me for differential diagnosis of ADHD.

For reference, when I say movement disorder, I mean something akin to Parkinson's (also treated dopaminergically) or Huntington's.

 

[R. Matey]

That's interesting, because there was a neuropsychologist who told me that it was extremely rare to find childhood ADHD without any hyperactivity. I'm honestly not sure if that's true because I am by no means an expert.

It's a common trajectory (hyperactivity in childhood, followed by inattentiveness in adulthood) of ADHD symptoms, but I think it's overstating the data to say that deviations are extremely rare.