Welcome to the discussion

This is part of Dr Neff's lastest newsletter:

"Today, I want to speak to something that often gets missed in the conversation:The mental health cost of being a low support needs, high-masking, or late-identified Autistic or ADHD adult.

Those of us who fly under the radar.Who appear “fine” to others.But quietly suffer behind closed doors.

The Invisible Terrain

For many of us, the version of Autism or ADHD we live doesn’t come with visible support needs. But behind closed doors, the internal experience can be dark. Disorienting.Overwhelmingly lonely — often shaped by competing internal demands.

We suffer. Our families suffer.And over time, generational cycles of trauma, burnout, and addiction can take root.

This is the part that often gets overlooked — in media portrayals, in systems of care, and in some of the critiques aimed at late-diagnosed adults and the rise in neurodivergent self-identification.

Because here’s the truth:Autistic and ADHD adults with fewer traditional support needs often carry very high mental health needs.¹

The Data Behind It

This isn’t just anecdotal. The numbers paint a sobering picture — one that too often gets overlooked in mainstream conversations about autism and ADHD.

While prevalence rates need to be interpreted with caution, here are a few studies that paint a dim picture.

About 70–80% of Autistic and ADHD folx will experience at least one co-occurring mental health condition.²

Anxiety. Depression. PTSD. OCD. Bipolar. Eating disorders.These aren’t exceptions — they’re often the rule.

Suicidality is also significantly elevated among Autistic people. A large Swedish study found that Autistic adults without intellectual disability were more than seven times more likely to die by suicide compared to non-autistic peers.³

Another UK study found that 41% of people who died by suicide likely met criteria for autism — many had never been diagnosed.⁴ 

And in a recent meta-analysis, over a third of Autistic and possibly Autistic people without intellectual disability reported suicidal thoughts. Nearly a quarter had made a suicide attempt.⁵These are not fringe cases.These are common — and they speak to the depth of unmet need.

Many Autistic people carry deep and chronic mental health distress without ever being recognized as Autistic.

And without that recognition, it’s easy to internalize the wrong story about why life feels so hard.

The pattern holds for ADHD as well. People with ADHD are significantly more likely to experience mental health challenges like anxiety, depression, and bipolar conditions. And when it comes to suicidality, the numbers are sobering. A recent meta-analysis found that people with ADHD were more than three times as likely to experience suicidal thoughts, over twice as likely to attempt suicide — and nearly seven times more likely to die by suicide than those without ADHD.⁶ Rates of self-harm, substance use, and emotional dysregulation are also consistently elevated — especially when ADHD goes undiagnosed, unsupported, or misunderstood.

Yeah… I know.It’s a lot.It’s heavy.And it’s also why I do this work.

This isn’t to say that those with higher support needs, or earlier access to diagnosis, don’t also struggle with mental health. Many do. This isn’t an “us vs. them” narrative. It’s a both/and.

Across the spectrum, we tend to struggle — sometimes quietly, sometimes in ways that are misunderstood. And when you’re masking, performing neurotypicality, and don’t understand why everything feels so hard … it can add a layer of confusion and isolation to the experience.

Misdiagnosis, Misunderstanding, and Missed Roots

When the neurodivergent foundation is missed, we often treat symptoms without ever touching the root.

The person may languish in treatment for years — perhaps it’s labeled as “treatment-resistant depression.”

We stay stuck in therapy for years — both client and clinician wondering why nothing’s changing.

Or we get distrustful of the system and give up on seeking help.

When identification is not understood. We mistake sensory overload for generalized anxiety.Routine disruption for anger issues. Executive functioning collapse for laziness or burnout.

We collect the fallen leaves, but never get underneath the soil to the roots.

Substance Use & Eating Disorders

Many Autistic or ADHD adults — especially those undiagnosed — turn to substances to soothe what they don’t yet have language for.

Social lubricant.

A way to unwind.

To numb out the too-muchness of the day.

To self-soothe or temporarily regulate a nervous system that’s running on fumes.

To slow down the rumination loops, shame spirals and overthinking mind.

One study found 20% of people seeking support for substance use likely met criteria for autism.⁷ When the root causes driving the substance use is not understood … it’s difficult to get traction in treatment.

Another study found nearly 27.5% of females in eating disorder treatment may be Autistic — most undiagnosed.⁸ For many, food rigidity isn’t about body image. It’s about control. Sensory sensitivities. A need for predictability in a chaotic world. Again … when the route cause is not understood … it’s difficult to get traction in treatment.

Psychiatric Settings Miss Us, Too

Even in mental health systems, we’re hidden in plain sight. A Swedish study found nearly 1 in 5 adults in outpatient psychiatric care met criteria for autism. But only 0.5% had a diagnosis on record.⁹

These gaps matter. They cost people years of understanding, care, and often, safety.

That means people are showing up in therapy and psychiatric care with Autistic and ADHD brains … but that part of them often goes unseen. So they’re treated for the surface symptoms: anxiety, shutdown, “treatment-resistant” depression. And they often get stuck, wondering why nothing is working."

I really identify with this post. I think all the groups of 'dysfunctional people' like addicts, homeless, etc., have high numbers of undiagnosed autistic adults because people develop unhealthy coping mechanisms or simply can't cope without support.

I went to doctors and psychiatrists for years in my thirties and forties. I was diagnosed with depression, anxiety, and social anxiety, and took medication for years without getting any better. When I finally gave up, I didn't go back to the doctor for over 15 years. And then when I told the doctor that I was trying to get diagnosed and then later told another doctor that I was diagnosed autistic, both had the same response. They don't recommend adults pursue an autism diagnosis - they don't see any reason for it.

I don't have the words for how that made me feel.

Here are the footnotes for Dr Neff's post:

1 As noted in the study on premature mortality: “High-functioning ASD often presents with co-existing psychiatric disorders.” See Hirvikoski et al. for more on differing causes of mortality between Autistic individuals with lower vs. higher support needs.

Note: This study uses the term “Asperger’s” to refer to individuals without co-occurring intellectual disability — but that’s not the same as being high-masking. The relationship between masking, support needs, and diagnostic categories is complex and doesn’t map neatly onto older clinical labels. Importantly, we can’t assume that “high masking” always equates to greater mental health distress than those who don’t mask. Many Autistic people with lower support needs are unable to mask — and they make up a significant portion of this study’s sample. It’s important to be mindful of statistical appropriation here: this study is about support needs (Level 1, 2, or 3), not masking.

2 Regarding ADHD see: Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC psychiatry, 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3

3 Hirvikoski T, Mittendorfer-Rutz E, Boman M, Larsson H, Lichtenstein P, Bölte S. Premature mortality in autism spectrum disorder. Br J Psychiatry. 2016;208(3):232–8.

4 Cassidy S, Au-Yeung S, Robertson A, et al. Autism and autistic traits in those who died by suicide in England. The British Journal of Psychiatry. 2022;221(5):683-691. doi:10.1192/bjp.2022.21

5 Newell, V., Phillips, L., Jones, C. et al. A systematic review and meta-analysis of suicidality in autistic and possibly autistic people without co-occurring intellectual disability. Molecular Autism 14, 12 (2023). https://doi.org/10.1186/s13229-023-00544-7

6 Septier, M., Stordeur, C., Zhang, J., Delorme, R., & Cortese, S. (2019). Association between suicidal spectrum behaviors and Attention-Deficit/Hyperactivity Disorder: A systematic review and meta-analysis. Neuroscience and Biobehavioral Reviews, 103, 109–118. https://doi.org/10.1016/j.neubiorev.2019.05.022

7 McKowen, J., Woodward, D., Yule, A. M., DiSalvo, M., Rao, V., Greenbaum, J., Joshi, G., & Wilens, T. E. (2022). Characterizing autistic traits in treatment-seeking young adults with substance use disorders. The American journal on addictions, 31(2), 108–114. https://doi.org/10.1111/ajad.13247

8 Parsons M. A. (2023). Autism diagnosis in females by eating disorder professionals. Journal of eating disorders, 11(1), 73. https://doi.org/10.1186/s40337-023-00785-0

9 Nyrenius, J., Eberhard, J., Ghaziuddin, M., Gillberg, C., & Billstedt, E. (2023). The 'lost generation' in adult psychiatry: psychiatric, neurodevelopmental and sociodemographic characteristics of psychiatric patients with autism unrecognised in childhood. BJPsych open, 9(3), e89. https://doi.org/10.1192/bjo.2023.13