When the Traits Don’t Fit the Frame: How 'Lack' and 'Disruption' Distort AuDHD Diagnosis

What gets counted as evidence—and what gets erased—when diagnostic tools are built for someone else’s nervous system.

Many AuDHD individuals are misdiagnosed or missed entirely—not because they lack traits, but because they don’t fit the diagnostic scripts. This piece calls for a shift from deficit-based frameworks to a culture of clinical witnessing.

Introduction: The Diagnostic Mirage

It began, as these things often do, with a contradiction. The psychologist smiled gently, closed her folder, and said, “You’re clearly very articulate and socially aware. That doesn’t really align with autism.” Another, years earlier, had leaned back in his chair and asked, “Have you ever even been sent out of class?”—as though the absence of disciplinary infractions could somehow negate lifelong executive dysfunction. In both cases, she left feeling not relieved, but erased. Because whilst the content of the stories may differ, this pattern is achingly familiar to many of us: navigating a diagnostic process only to be dismissed for presenting as too social for autism, too quiet for ADHD, or simply too functional to warrant concern. These moments do more than delay recognition—they expose the structural fault lines within the diagnostic frameworks themselves.

The illusion of objectivity in psychiatric diagnosis rests on behavioural evidence—on what can be observed, measured, or coded. But observable behaviour is never neutral. It is always interpreted through culturally constructed norms that reward certain traits and penalise others. Autism, as it is commonly understood, is framed through lack—a perceived absence of reciprocal gaze, flattened affect, or muted emotionality (Kanner, 1943; Dean et al., 2017). ADHD, conversely, is framed through disruption—traits that intrude upon others, marked by impulsivity, hyperactivity, or difficulty staying on task (Lai et al., 2021). Together, these frameworks create a diagnostic binary: to be recognisable, one must either fail to connect or fail to contain.

But for AuDHD individuals, this binary collapses. We often present as emotionally attuned, socially fluent, and intellectually engaged—at least on the surface. Yet this fluency is often a performance, honed through years of masking, camouflaging, and internalising distress (Evans et al., 2023; Pearson & Rose, 2020). The result is a paradox: we may appear empathic yet remain dysregulated, speak eloquently yet struggle to follow through on basic tasks, participate in conversations whilst enduring profound sensory overwhelm. Our traits do not fit neatly into the categories of lack or disruption—so we are often not recognised at all.

This erasure is not incidental. It is baked into the history of psychiatric classification, particularly through the behaviourist paradigms that shaped early autism research. Kanner’s descriptions of “aloof” and emotionally distant children established an archetype that privileged visible detachment (Kanner, 1943). Meanwhile, ADHD frameworks developed primarily through observing disruptive behaviours in white, cisgender boys within school settings (Mao et al., 2024), tying diagnostic validity to how well a child could conform to institutional norms. Those who internalised distress, especially girls, BIPOC individuals, and gender-diverse people, were not seen as struggling—they were seen as coping.

This reliance on surface presentation creates a dangerous substitution: presentation becomes proxy for pathology. If one does not present as visibly chaotic, avoidant, or disorganised, the presumption is often that there is no underlying issue. But this assumption systematically excludes those whose adaptive strategies—whether born of trauma, social pressure, or necessity—have hidden their distress. In this way, diagnostic systems reward the appearance of normalcy even as they punish the effort it takes to maintain it (McQuaid et al., 2021). Those who can camouflage effectively are not seen as resilient; they are disbelieved, dismissed, or told they are simply anxious, dramatic, or difficult.

Thus, the problem is not merely one of missed nuance—it is a structural design flaw. When diagnostic categories are defined by what is most visible, they inevitably exclude those whose divergence is internal, relational, or culturally obscured. And for many of us living at the intersections of neurodivergence, gender nonconformity, racialisation, and queerness, being unseen is not just an inconvenience—it is a sustained, systemic violence masquerading as clinical rigour.

The Quiet Middle – Where Masking Lives

If the diagnostic frameworks are shaped by what can be seen, then masking functions as a kind of clinical misdirection. It is not the absence of symptoms but a performance of control, precision-engineered under conditions of social threat. For many AuDHD individuals, especially those marginalised by gender, race, or class, this performance begins early and becomes habitual—not as a choice, but as a survival strategy (Craddock, 2024; Pearson & Rose, 2020). Masking is not simply “acting normal”; it is translating every impulse, gesture, or expression into something palatable to others, often without conscious intent. It is smiling through sensory pain, rehearsing scripts before every conversation, suppressing movement, managing volume, studying eye contact like choreography. It is holding the body hostage to ensure the mind remains acceptable.

This kind of adaptive fluency, whilst socially rewarded, thoroughly scrambles the clinical signal. When a person appears composed, articulate, and empathic, their distress is often disqualified in diagnostic spaces. Clinicians trained to identify autism through flat affect or ADHD through classroom disruption may overlook the quiet middle—the place where executive dysfunction coexists with perfectionism, or where sensory distress manifests as shutdown rather than outburst (Dean et al., 2017). The result is a wave of false negatives, particularly among late-diagnosed adults, who report years or decades of being told they were “just anxious,” “too emotional,” or “resilient” to a fault (Evans et al., 2023; McQuaid et al., 2021).

This invisibility is compounded by the intersectional forces shaping whose behaviour is considered credible, pathological, or worthy of concern. For example, autistic Black girls and women are frequently misread as oppositional or aggressive when they set boundaries or regulate through silence (Ames et al., 2022; Mandell et al., 2009). Autistic trans and nonbinary people may mask not just their neurotype, but their gender—producing layered camouflage that is difficult even for themselves to disentangle. In these contexts, the diagnostic process doesn’t simply miss people; it systematically filters out those who do not fit the prototype it was built to detect.

The consequences are profound. Delayed or missed diagnoses leave individuals vulnerable to chronic misattunement, compounding distress and eroding self-trust. Misdiagnoses are common—particularly with personality disorders, bipolar disorder, generalised anxiety, and trauma-related conditions—because the internal dysregulation of AuDHD often mimics these presentations in isolation (Stanich, 2024; Ruggieri, 2024). But the root causes are relational, sensory, and cognitive—not inherently pathological. Many are only recognised in moments of collapse: after a burnout, a breakdown, or the implosion of a relationship they could no longer sustain under the weight of performance.

By the time the diagnosis comes, it often arrives not as clarity but as grief: grief for the years lost, the supports denied, and the self misread by others—and perhaps, most painfully, by oneself. Because masking doesn’t just obscure visibility to clinicians. It distorts self-perception. And until diagnostic frameworks are rebuilt to recognise distress that presents through competence, not chaos, we will continue to disappear in plain sight.

When Norms Become Filters

If masking distorts the clinical signal, then diagnostic tools serve as amplifiers for those distortions—filtering visibility through norms that were never neutral to begin with. To understand the scale of this problem, we must ask a foundational question: who were these tools built to identify? The answer lies not just in clinical history, but in power—whose behaviour was pathologised, whose distress was noticed, and whose adaptation was dismissed as irrelevant.

Most widely used diagnostic instruments—such as the ADOS-2, Conners rating scales, and even the criteria codified in the DSM-5-TR—were normed primarily on white, cisgender boys in Western clinical and educational settings (Lai et al., 2021; Mao et al., 2024). Their design reflects not only a specific cultural baseline, but a particular behavioural profile: one that makes divergence visible through public disruption, not private distress. These tools are calibrated to detect outward signs of difference in environments where conformity is expected—classrooms, clinics, family homes—but are far less equipped to interpret internal struggle, relational exhaustion, or the kind of chronic self-monitoring that many neurodivergent people develop simply to survive.

This gap becomes even more evident when viewed through an intersectional lens. Black girls, for example, are frequently misread as defiant, oppositional, or “too mature” when they show signs of dysregulation or executive strain—leading to disciplinary consequences rather than diagnostic inquiry (Ames et al., 2022; Mandell et al., 2009). Similarly, queer and trans youth often develop camouflaging skills across multiple domains, learning to scan and modulate their presentation not just to avoid exclusion, but to avoid harm. For them, masking is not a deviation from the norm—it is the norm. And for autistic women and AFAB individuals, especially those who succeed at social mimicry, the cost of this perceived competence is often years of untreated distress and profound alienation from their own inner state (Craddock, 2024; Dean et al., 2017).

Yet these populations are often excluded from the foundational studies used to validate diagnostic tools. This creates a recursive loop—a kind of internalised survivorship bias within clinical research. Only those who were not masking were studied. Only those who fit the expected pattern were deemed diagnostically relevant. And so the tools themselves reinforce the original bias: they identify what they were built to recognise, and ignore what they were never trained to see.

This is not a matter of benign oversight. It is a systemic failure with cascading consequences. By treating diagnostic norms as universal rather than culturally contingent, the field has created a distorted mirror—one that reflects only a narrow slice of neurodivergent experience, whilst rendering the rest illegible. For those of us who fall outside the frame, the diagnostic process is not simply inadequate. It becomes a barrier to care, a mechanism of exclusion, and—often—a retraumatisation in its own right.

A Different Kind of Evidence

If diagnostic norms have become filters, then the task ahead is not simply to widen the aperture—but to change the lens entirely. The failure to recognise AuDHD traits in masked or multiply marginalised individuals is not a problem of clarity alone. It is a problem of method, of framework, and of what is permitted to count as evidence. For too long, psychiatric assessment has privileged observable behaviour over internal experience, standardised rubrics over relational context, and normative benchmarks over narrative truth. But there is another way to listen—one that begins not with the checklist, but with the person.

Emerging diagnostic approaches that centre narrative, developmental trajectories, and relational self-understanding offer a far more nuanced view of neurodivergence. Tools like the Camouflaging Autistic Traits Questionnaire (CAT-Q) explicitly measure the effort behind social performance, highlighting the cost of masking that would otherwise go unseen (Evans et al., 2023). The RAADS-R, whilst imperfect, attempts to capture internal states such as sensory sensitivity, language processing, and emotional complexity—areas often flattened in traditional interviews. And perhaps most crucially, clinician-guided conversations that centre lived experience—focusing on sensory overwhelm, shutdown patterns, chronic fatigue, and identity loss—can offer far more insight than a sterile behavioural inventory ever could.

But shifting the tools is only half the task. We must also shift the frameworks that interpret what those tools reveal. The Power Threat Meaning Framework (PTMF), developed as a non-pathologising alternative to psychiatric diagnosis, reframes distress not as disorder, but as a response to threat within a context of power (Johnstone & Boyle, 2018). It asks not “what’s wrong with you?” but “what has happened to you?”—a question far more compatible with the lived realities of neurodivergent people who have spent years contorting themselves into neurotypical expectations. Similarly, the Double Empathy Problem, articulated by Milton (2012), challenges the assumption that social difficulties lie solely within autistic people. Instead, it frames communication breakdown as relational—a mismatch of cultural norms, mutual perception, and interpretive frameworks between differently wired minds.

Taken together, these models reject the deficit-based premise at the heart of most diagnostic systems. They refuse the notion that divergence is inherently disordered, and instead position it as meaningful difference—difference that can only be understood in context. They also reposition lived experience not as anecdotal, but as central: the primary data from which any ethical assessment must begin. For those of us long silenced by the structures meant to categorise us, this shift is more than methodological. It is emancipatory. Because when we centre the stories we were once told to suppress, we don’t just improve diagnostic accuracy—we reclaim the narrative authority to name ourselves.

What We Miss When We Get It Wrong

When diagnostic systems fail to see us, the cost is not abstract. It is lived. It shows up in the silence after a misdiagnosis, in the years of unmet need, in the exhaustion of navigating systems that insist you are either too much or not enough to qualify for help. These failures do not simply delay support—they recalibrate the entire course of a person’s life. And the damage is cumulative.

One of the most insidious consequences is what might be called diagnostic attrition: the quiet erosion of recognition over time. For those who mask well or adapt visibly, especially in adulthood, existing diagnoses are sometimes withdrawn—not because the underlying difficulties have resolved, but because the performance of competence has become too convincing. This creates a cruel paradox: the better you’ve learned to survive, the less likely you are to be believed (Pearson & Rose, 2020; McQuaid et al., 2021). The system rewards adaptation, then punishes it with invisibility.

Even when a diagnosis is secured, misclassification remains a persistent threat. Autistic people are routinely misdiagnosed with borderline personality disorder, generalised anxiety, or bipolar disorder—particularly if they are femme-presenting, racialised, or queer (Ames et al., 2022; Craddock, 2024). These errors are not benign. They lead to inappropriate treatments, invalidating interventions, and clinical narratives that cast neurodivergent distress as manipulative, erratic, or pathological in fundamentally incorrect ways. The result is not care—it is containment. And what is missed in that misrecognition is not just diagnostic accuracy, but the opportunity for relational repair.

This misalignment also has material consequences. Without a recognised diagnosis, access to services becomes contingent on performance, privilege, or proximity to compliant archetypes. Accommodations in education and employment are denied. Support networks remain out of reach. And those of us whose needs are chronic but inconsistently visible are told, again and again, that we are either malingering or “coping fine.” The net effect is a pervasive sense of unbelonging—not just socially, but clinically. As though the system was built not just without us, but against us.

But perhaps the deepest wound comes from being persistently misread. To live in a body that speaks in difference—to feel, process, and relate in ways that others do not expect—and to be told, over and over, that your reality is incorrect or inconvenient, is a particular kind of harm. is not simply that one is misunderstood; it is that the misunderstanding is medicalised, institutionalised, and used to justify the withdrawal of care, rights, and personhood. Over time, this produces a corrosive internal narrative: maybe I’m just broken. Maybe I am the problem. And from there, the road to burnout, shutdown, and isolation becomes not a matter of if, but when.

The ethical imperative, then, is not simply to refine the tools or widen the criteria. It is to de-centre pathology as the organising principle of diagnosis. We must ask not only whether someone meets the threshold for a label, but whether that threshold was ever built to recognise them in the first place. This means creating systems that see beyond presentation, that treat distress as meaningful rather than deviant, and that place the person—not the pathology—at the centre of the story. Until then, the question remains not why so many AuDHD individuals are missed, but how the system has maintained the illusion of objectivity whilst disappearing so many of us in the process.

Conclusion: Toward a Diagnostic Culture of Witnessing

What would it mean to be seen—truly seen—not through the lens of lack or disruption, but through resonance, narrative, and relational truth? What if diagnosis were not a filter that sorts, excludes, or disciplines, but a mirror held up with care? To reimagine diagnostic culture in this way is to reject the clinical gaze as the sole arbiter of legitimacy and instead embrace a deeper, more ethical orientation: one rooted in witnessing.

To witness is not merely to observe; it is to attune, to hold complexity, to honour context. It means recognising that divergence often arrives bearing the marks of adaptation—that what looks like composure may in fact be pain, that fluency can be camouflage, and that behind every missed diagnosis is often a history of survival. The task is no longer to decode whether someone performs “enough” visible distress to meet a criterion, but to ask: what has this person had to survive to be missed for so long?

A diagnostic culture of witnessing would centre stories over scripts, ask better questions, and trust embodied knowledge. It would create space for diagnostic ambiguity, for working hypotheses, for relational co-construction rather than rigid classification. And crucially, it would affirm that our experiences—messy, nonlinear, self-knowing—are not secondary to the process, but the very ground on which it should stand.

This is not a call for diagnostic abandonment, but for diagnostic integrity. We still need language that names, frameworks that orient, access that protects. But these must emerge from a place of humility, not certainty—from an understanding that many of us have long been translating ourselves into terms someone else could understand. It is time to stop forcing the self to fit the schema, and instead shape the schema to reflect the self.

We are not asking to be exceptional cases. We are asking to be recognised as part of the whole. Not despite our complexity, but because of it. And in doing so, we reclaim the right not just to be classified, but to be heard.