Examining Medical Gaslighting and Outdated Diagnostic Practices in Adult ADHD & Autism Assessment and Treatment

Introduction

Navigating life with an unseen neurological difference can impact various aspects of daily existence, including focus, social interactions, and emotional regulation. This is a common scenario for adults with attention-deficit/hyperactivity disorder (ADHD) and autism, who often face challenges in obtaining recognition from healthcare professionals due to outdated diagnostic frameworks and certain biases.

Despite increased awareness of neurodivergence, the healthcare system presents obstacles that prevent adults from receiving timely and accurate diagnoses. Factors such as rigid childhood-based criteria and clinical gatekeeping have resulted in individuals being undiagnosed, misdiagnosed, or given ineffective treatment plans (Attoe & Climie, 2023; Milioni et al., 2017). Certain groups—such as women, ethnic minorities, and those exhibiting high-masking behaviors—may find it particularly challenging to validate their experiences while facing personal and professional consequences.

This article examines the limitations of traditional assessment methods of ADHD and autism diagnosis, the impact of medical gatekeeping, and the necessity for systemic reform. Additionally, it provides self-advocacy strategies for neurodivergent individuals and insights for medical professionals aiming to improve access to accurate and equitable diagnoses. Addressing and removing the barriers that hinder the proper diagnosis and support of neurodivergent adults is crucial for progressing toward an inclusive and informed healthcare system.

Outdated Diagnostic Methods and Their Consequences

Childhood-Centric Diagnostic Criteria

The historical focus on ADHD and autism as childhood disorders has led to the misconception that they must be evident early in life for diagnosis (Rivas-Vazquez et al., 2023). Many clinicians still follow rigid childhood-based models, overlooking nuanced adult presentations. As a result, many, especially women and ethnic minorities, are misdiagnosed (Pantazakos & Vanaken, 2023).

Gender Bias and Differential Presentation

Traditional diagnostic frameworks have been built around the typical male presentation of ADHD and autism, which includes hyperactivity and social withdrawal. Women, who are more likely to display inattentive ADHD or use masking strategies to camouflage autistic traits, are often diagnosed with conditions such as anxiety, depression, or borderline personality disorder (Attoe & Climie, 2023; Spicer et al., 2024). Studies show that many women receive their ADHD or autism diagnosis after their children are diagnosed, indicating a trend in recognizing these neurotypes in adults later in life (Martin, 2024). Women may develop perfectionist tendencies and rigid organization habits to manage ADHD symptoms. These coping mechanisms can conceal impairments, delaying diagnosis and appropriate intervention (Spicer et al., 2024).

Racial and Ethnic Disparities in Diagnosis

Ethnic minorities encounter significant barriers to diagnosis. Clinicians frequently attribute their difficulties to socioeconomic factors, behavioral issues, or cultural differences instead of considering neurodivergence (Pettersson et al., 2018). African American and Hispanic individuals with ADHD are often labeled as oppositional or defiant rather than being assessed for executive dysfunction (Milioni et al., 2017). Consequently, they are less likely to receive appropriate support and accommodations. Furthermore, cultural stigma surrounding mental health in certain communities discourages individuals from seeking assessments, leading to further delays in diagnoses and treatment (Pettersson et al., 2018).

Challenges with ADHD Assessment Tools

Standard neuropsychological tests like the Continuous Performance Test (CPT) and Wisconsin Card Sorting Test (WCST) often fail to distinguish ADHD from other psychiatric conditions in adults, leading to false negatives, especially for those with compensatory strategies. Traditional screening tools focus on hyperactivity and impulsivity, overlooking executive dysfunction and emotional dysregulation common in adult ADHD. Additionally, relying on childhood symptom recall complicates diagnosis due to inaccurate early-life behavior reporting, especially among individuals who have masked symptoms (Pettersson et al., 2018).

Medical Gaslighting and Gatekeeping in ADHD and Autism Diagnosis

Dismissal of Symptoms and Patient Advocacy

Many adults seeking an ADHD or autism diagnosis encounter challenges where healthcare professionals may minimize, dismiss, or misattribute their symptoms to unrelated causes. This may be due to outdated diagnostic models, lack of clinician education on neurodivergence in adults, and established ideas about typical ADHD or autistic profiles (Spicer et al., 2024; Taylor, 2024).

Common Dismissive Statements from Medical Professionals

When seeking help, neurodivergent adults often hear dismissive and invalidating remarks, including:

Statement	Details
“Everyone has trouble focusing sometimes.”	This statement disregards the severity and frequency of executive dysfunction in ADHD. While everyone may experience lapses in attention, those with ADHD struggle persistently and significantly, leading to impairment in work, relationships, and daily tasks (Michelini et al., 2024).
“You seem too high functioning to have autism.”	Many clinicians rely on outdated autism stereotypes, expecting severe speech delays or obvious social difficulties. However, autistic masking can lead some individuals, especially women, to hide their challenges, causing missed diagnoses and increased psychological distress (Pettersson et al., 2018).
“This is just anxiety or depression.”	ADHD and autism can co-occur with anxiety and depression but are distinct conditions. Using antidepressants or anti-anxiety medications instead of neurodivergent-focused treatments may delay accurate diagnosis and worsen executive dysfunction if neurodevelopmental issues are not addressed (Johnson & Smith, 2021; McDougall, 2024).
“You make eye contact, so you can’t be autistic.”	Some autistic individuals learn to make forced or compensatory eye contact due to societal pressure, but this does not mean they do not experience discomfort or challenges in social settings (Michelini et al., 2024).
“You’re just being rigid or picky.”	Many autistic individuals rely on routine and predictability to manage daily life. When disrupted, it can cause extreme distress, which is frequently misinterpreted as stubbornness or inflexibility (Taylor, 2024).

The Impact of Gaslighting on Neurodivergent Adults

Delayed or Missed Diagnoses

Many individuals experience symptoms for years without identifying the underlying cause. They may attribute their executive dysfunction to a perceived lack of effort or motivation (Attoe & Climie, 2023). By the time they receive an ADHD or autism diagnosis, they often have been affected by being repeatedly dismissed by professionals and their support systems (Spicer et al., 2024). Autistic adults are frequently misdiagnosed with borderline personality disorder (BPD), depression, or social anxiety disorder, leading to treatments that do not address their core challenges (Johnson & Smith, 2021).

Masking as a Survival Strategy

Repeated invalidation leads many neurodivergent individuals to develop masking behaviors to conform to neurotypical expectations (Milioni et al., 2017). Autistic masking commonly involves maintaining eye contact, suppressing self-stimulatory behaviors, mirroring social interactions, and closely analyzing conversations to blend in (Pettersson et al., 2018). The long-term consequences of chronic masking include autistic burnout, severe anxiety, and an increased risk of mental health crises and suicidality (Spicer et al., 2024).

Emotional and Psychological Toll

The consistent dismissal of symptoms can result in self-doubt, low self-esteem, and increased anxiety (French et al., 2023). Many adults feel the need to explain their difficulties to receive recognition from medical professionals. Some autistic individuals may avoid seeking medical care due to previous experiences of medical trauma, condescension, and dismissive treatment (Taylor, 2024).

Gender Bias in Medical Gaslighting

Women and nonbinary individuals face added challenges in getting an ADHD or autism diagnosis due to gender biases in medicine. ADHD research focused on hyperactive boys, leading to overlooked diagnoses in women with inattentive symptoms (Attoe & Climie, 2023). Women with autism often have intense interests in literature, psychology, animals, or creative hobbies, which are often dismissed rather than recognized as autistic traits. Their ability to mask social difficulties leads professionals to underestimate their struggles, often resulting in misdiagnoses of anxiety, depression, or borderline personality disorder instead of autism (Martin, 2024; Spicer et al., 2024).

The Role of Medical Gatekeeping

Medical gatekeeping can limit access to ADHD and autism diagnoses and treatment, particularly among adults. This happens due to strict referral requirements in general practice, where primary care providers may not provide referrals, assuming individuals are "functioning well enough" or misattributing symptoms (Pettersson et al., 2018). Diagnoses are typically conducted by certain specialists, such as psychiatrists and developmental/neuro psychologists, which makes access challenging and often results in long wait times (McDougall, 2024; French et al., 2023). Moreover, some providers require childhood records for diagnosis, which can disproportionately impact those without access to their family records or from marginalized backgrounds (Johnson & Smith, 2021).

The Impact of Psychiatric Provider Shortages and Insurance Panel Exodus

The shortage of psychiatric providers and psychologists' departure from insurance panels exacerbate issues of accessibility to neurodevelopmental evaluations and treatments (APA, 2024; HRSA, 2024). In the U.S., over 7,000 designated Health Professional Shortage Areas leave more than 122 million people without adequate mental health services, particularly in rural and underserved areas where over 60% of shortages are concentrated (HRSA, 2024). Even where providers are available, medical gatekeeping due to insurance limitations remains a problem. A survey by the APA (2024) found that 34% of psychologists do not accept insurance, citing low reimbursement rates and administrative burdens. This leads to high out-of-pocket costs for ADHD or autism assessments, making diagnoses financially inaccessible and resulting in long waitlists for those who must rely on insurance.

Provider shortages and limited insurance participation worsen barriers from medical gatekeeping, especially for low-income individuals who cannot get needed diagnoses and treatments. Misdiagnosed patients stay on ineffective treatment plans, harming their mental health. Systemic changes are necessary to increase psychiatric providers, encourage insurance participation, and expand diagnostic authority. Without these changes, shortages reinforce medical gatekeeping and disproportionately affect marginalized people. Addressing systemic barriers requires changes in medical education, policy reform, and advocacy for neurodivergent individuals (Taylor, 2024; Spicer et al., 2024).

Incorrect Diagnosis and Excessive Medication

ADHD and autism share overlapping symptoms with several psychiatric conditions, including anxiety, depression, bipolar disorder, and borderline personality disorder (BPD) (Johnson & Smith, 2021). These symptomatic similarities can lead to incorrect diagnoses and years of ineffective treatment, as clinicians may attribute executive dysfunction, sensory sensitivities, emotional dysregulation, or social difficulties to mood or personality disorders rather than recognizing them as traits of ADHD or autism.

A primary reason for misdiagnosis is the lack of clinician training in adult ADHD and ASD presentations. Historically, both conditions were believed to be exclusive to childhood, leading many medical professionals to view them as disorders individuals will outgrow rather than lifelong neurodevelopmental conditions (Michelini et al., 2024). Consequently, many adults, especially those with strong masking or coping mechanisms, are diagnosed with anxiety, depression, or mood disorders before their underlying neurodivergence is considered.

For example, individuals with inattentive-type ADHD often struggle with chronic forgetfulness, difficulty with organization, and emotional dysregulation—symptoms that can be mistaken for major depressive disorder (MDD) or generalized anxiety disorder (GAD) (McDougall, 2024). They may experience persistent feelings of failure, lack of motivation, and executive dysfunction, leading clinicians to prescribe selective serotonin reuptake inhibitors (SSRIs) or benzodiazepines. However, these medications do not target core impairments of ADHD, which can result in symptoms like increased fatigue, brain fog, and lack of motivation (Michelini et al., 2024).

Similarly, autistic individuals who experience sensory sensitivities, emotional dysregulation, and social anxiety are frequently misdiagnosed with bipolar disorder or BPD (French et al., 2023). The emotional intensity and shutdowns associated with autistic burnout can resemble mood swings of bipolar disorder, resulting in the use of mood stabilizers or antipsychotics (Spicer et al., 2024). In many cases, these treatments provide little relief and may cause side effects, exacerbating sensory sensitivities or cognitive difficulties.

The consequences of misdiagnosis and improper treatment can be significant. Many neurodivergent individuals spend years in therapy for mood or personality disorders, receiving treatments that do not address their actual challenges (Pettersson et al., 2018). Because their core executive dysfunction and sensory processing difficulties remain untreated, they continue to encounter difficulties with daily tasks, social interactions, and professional responsibilities, reinforcing feelings of inadequacy and self-doubt (Attoe & Climie, 2023).

Without proper screening and diagnostic protocols, neurodivergent individuals may continue to follow inappropriate treatment paths, delaying interventions that could improve their lives. This underscores the need for comprehensive training for mental health professionals to ensure that ADHD and autism are recognized, correctly diagnosed, and treated with tailored, neurodivergence-affirming approaches (McDougall, 2024).

Common Misdiagnoses and Their Impact

Many adults with undiagnosed ADHD experience chronic restlessness, racing thoughts, emotional dysregulation, and difficulty focusing. These symptoms closely resemble those of generalized anxiety disorder (GAD) or major depressive disorder (MDD) (Michelini et al., 2024). Due to this symptom overlap, individuals seeking help are often misdiagnosed with anxiety or depression, leading to a treatment path that does not address their core executive dysfunction. Traditional treatments for mood disorders typically involve Selective Serotonin Reuptake Inhibitors (SSRIs) or benzodiazepines, which can sometimes worsen ADHD symptoms by increasing fatigue or reducing motivation rather than addressing attentional deficits (McDougall, 2024). Without appropriate treatment, these individuals may cycle through multiple medications, experiencing only partial relief while their ADHD remains undetected and untreated.

Autistic individuals are frequently misdiagnosed with bipolar disorder or borderline personality disorder (BPD). Autistic adults, especially women and nonbinary individuals, may experience emotional fluctuations and sensory overloads that resemble the mood instability seen in bipolar disorder (French et al., 2023). However, while bipolar disorder involves distinct manic and depressive episodes, autistic individuals often experience sensory-driven meltdowns, shutdowns, and emotional dysregulation related to environmental stressors. Similarly, autistic burnout—caused by prolonged masking, social exhaustion, and sensory overwhelm is often mistaken for emotional dysregulation associated with BPD, leading to misdiagnoses and inappropriate treatment with mood stabilizers or antipsychotic medications (Spicer et al., 2024). These treatments may provide temporary symptom relief but do not address the root challenges of being autistic in a world designed for neurotypical people.

Masking significantly contributes to diagnostic errors. High-masking autistic adults often use social scripting and emotional suppression techniques that make their autism less apparent to clinicians (Pettersson et al., 2018). This ability to mimic neurotypical behavior can lead to an oversight of the individual’s underlying struggles, increasing the likelihood of a misdiagnosis of anxiety, depression, or personality disorders rather than autism. Similarly, women with both ADHD and ASD are frequently misdiagnosed because their symptoms tend to manifest internally rather than externally. Instead of being recognized as struggling with executive dysfunction, sensory sensitivities, or emotional regulation, they are often viewed as overly anxious, shy, or emotionally unstable, delaying access to the correct diagnosis and support (Attoe & Climie, 2023).

Masking in plain sight—hiding neurodivergence behind a forced smile in a world that demands conformity.

The failure to identify ADHD and autism in adults, particularly those who mask their symptoms, results in prolonged suffering, inappropriate treatments, and mental health deterioration. Until clinicians receive better training in recognizing the nuanced presentations of neurodivergence, many individuals will continue to be misdiagnosed and given treatments that do not address their core challenges.

Treatment-Resistant Depression and Undiagnosed ADHD

A notable number of adults with treatment-resistant depression (TRD) have undiagnosed ADHD, often unrecognized in psychiatric settings (Michelini et al., 2024). These patients frequently do not respond to standard antidepressants, experiencing ongoing executive dysfunction, emotional dysregulation, and chronic forgetfulness which are core symptoms of ADHD rather than depression or anxiety (McDougall, 2024).

Improvement is often seen when they receive stimulant medication or ADHD-specific therapy, targeting the neurological issues directly (Michelini et al., 2024). However, ADHD is still commonly viewed as a childhood disorder, leading to many adults, particularly those with inattentive symptoms, being overlooked. This underscores the need for better ADHD and ASD screening in psychiatric care, especially for those resistant to standard treatments (McDougall, 2024). Without proper diagnosis, these individuals face misdiagnosis and ineffective treatment, harming their mental health outcomes.

The Role of High IQ in ADHD Misdiagnosis

High-IQ individuals with ADHD often go undiagnosed due to compensatory mechanisms that mask symptoms (Milioni et al., 2017). Their success in academics and professions misleads others into thinking they do not have ADHD, despite experiencing executive dysfunction, emotional dysregulation, and attention difficulties. They use strong working memory and problem-solving skills to manage time, stay organized, and focus. They may hyperfocus on interesting tasks but struggle with mundane ones, which is often mistaken for a lack of discipline (Michelini et al., 2024). This success can obscure their challenges, leading clinicians to overlook ADHD as a diagnosis (French et al., 2023).

Challenges in Standard ADHD Diagnostic Testing

Many standard ADHD assessment tools overlook high-IQ compensatory effects, causing false-negative diagnoses (Milioni et al., 2017). High-IQ individuals often excel in traditional neuropsychological tests, masking real-world difficulties (Pettersson et al., 2018). This results in misdiagnoses such as anxiety or depression (McDougall, 2024). Without accurate diagnosis, they miss out on effective interventions, perpetuating frustration and mental health decline. Expanding ADHD diagnostic criteria to recognize compensatory strategies in high-IQ individuals is essential for providing proper support.

The Link Between Misdiagnosis and Mental Health Decline

Undiagnosed ADHD and autism can severely impact mental health over time, affecting nearly every aspect of life. Without a proper diagnosis, neurodivergent individuals often blame themselves for their struggles, thinking they are lazy or inadequate (French et al., 2023). This self-blame leads to worsening symptoms, including anxiety, depression, and suicidal thoughts (Spicer et al., 2024).

Anxiety and depression often become long-term issues for individuals with undiagnosed ADHD or autism. These issues can result in significant challenges related to employment, relationships, and daily tasks, which subsequently lead to persistent self-doubt and low self-esteem (Spicer et al., 2024). The ongoing struggle to meet neurotypical standards causes chronic distress and social isolation, resulting in long-term psychological damage. Chronic stress and burnout are prevalent as undiagnosed individuals strive to conform to neurotypical expectations. Autistic burnout is severe due to prolonged sensory overload and social exhaustion, frequently leading to shutdowns or mental health crises (Spicer et al., 2024).

A significant consequence of these challenges is the increased risk of suicidality. Research indicates that individuals with undiagnosed ADHD or autism exhibit higher rates of suicidal ideation and attempts compared to neurotypical individuals (Michelini et al., 2024). Adults with undiagnosed ADHD are reported to be five times more likely to attempt suicide, primarily due to executive dysfunction, emotional dysregulation, and chronic frustration (McDougall, 2024). Despite various treatments, many individuals fail to experience improvement because their underlying neurodevelopmental condition remains unaddressed (Michelini et al., 2024; French et al., 2023). Accordingly, effective screening for ADHD and autism is crucial to prevent misdiagnosis and mistreatment.

Denying Strengths: The Consequences of Medical Dismissal in ADHD and Autism Diagnosis

The invalidation of ADHD and autism by medical professionals does not merely delay diagnosis and treatment; it also prevents individuals from understanding the unique aspects of their neurotypes. Historically, traits associated with ADHD and autism have been linked to evolutionary advantages, enabling individuals to succeed in dynamic or specialized environments. However, when healthcare providers dismiss ADHD and autism as deficits, they support a model that focuses on differences as pathological rather than recognizing the potential benefits these neurotypes may offer.

ADHD: A Brain Built for Exploration and Innovation

ADHD traits like curiosity, impulsivity, and hyper-focus helped early humans survive in changing environments. Genetic markers for ADHD were common in nomadic groups where quick decisions were crucial (Goldman et al., 2021). Today, these traits are valuable in fields like entrepreneurship, emergency medicine, and creative industries. People with ADHD are also highly sensitive to their environment, which can be an asset for adapting and innovative thinking (Swanepoel et al., 2017). Viewing ADHD only as a "disorder" overlooks its potential for innovation.

Autism: A Brain Designed for Deep Focus and Precision

Autistic traits like attention to detail, strong memory, and pattern recognition were vital for survival in early societies. Now, these skills make many autistic individuals exceptional in STEM, art, and research (Dey et al., 2015). Recent studies suggest autism may be linked to human intelligence evolution. Genes, tied to both autism and cognitive development, likely enhanced problem-solving abilities (Dey et al., 2015). Some genetic mutations connected to autism may result in higher intelligence under certain conditions (Tsur et al., 2016). Sadly, many autistic individuals don't realize how their unique brain wiring aligns with valuable modern skills.

The Harm of a Deficit-Only Mindset

When ADHD and autism are viewed solely as disorders, individuals may internalize shame rather than recognize their strengths. Many individuals with ADHD and/or autism report experiencing self-doubt, imposter syndrome, and mental health challenges due to years of being perceived as "too much" or "not enough" (Pettersson et al., 2018). Additionally, outdated diagnostic models tend to focus on addressing perceived weaknesses rather than assisting individuals in leveraging their strengths (French et al., 2023).

A Better Approach: Recognizing Strengths and Supporting Growth

Supporting neurodivergent individuals requires moving beyond a deficit-based approach in medical and education systems.

Approach	Details
Evolutionary Benefits of ADHD and Autism	These neurotypes exist for a reason and have contributed to human success.
Teaching Individuals About Their Strengths	Helping people with ADHD and autism understand how their traits can be assets in the right environments.
Modifying Schools and Workplaces	Encouraging flexible learning and work structures that align with neurodivergent thinking.
Using Strengths-Based Assessments	Instead of just diagnosing challenges, assessments should also highlight cognitive advantages.

Conclusion

Improper ADHD and autism diagnoses may lead to mental health issues, inappropriate medication, chronic stress, and increased suicidality. High-IQ individuals, women, and racial minorities often face overlooked symptoms. Improved training for mental health professionals is needed to reduce misdiagnosis (Spicer et al., 2024; McDougall, 2024). Accurate diagnosis is vital for effective treatment. Outdated criteria and biases particularly disadvantage women, ethnic minorities, and high-masking individuals. Viewing ADHD and autism solely as deficits hinders recognizing their unique differences. Reforming education, enhancing screening, and advocacy can improve diagnostic equity. Changes are necessary to help neurodivergent individuals leverage their strengths and build fulfilling lives.

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