Potential reasons for ADHD delayed diagnosis in females
Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition less commonly diagnosed in females compared with males in childhood. Reference Faraone, Bellgrove, Brikell, Cortese, Hartman and Hollis1 Several studies have observed that females are diagnosed with ADHD on average later than males. Reference Dalsgaard, Thorsteinsson, Trabjerg, Schullehner, Plana-Ripoll and Brikell2,Reference Martin, Langley, Cooper, Rouquette, John and Sayal3 Timely ADHD diagnosis enables access to psychoeducation, educational and employment support and treatment. Females may receive a delayed diagnosis for a variety of reasons. The existing diagnostic criteria (e.g. DSM-V-TR 4 [American Psychiatric Association]) were informed using majority male samples Reference Lahey, Applegate, McBurnett, Biederman, Greenhill and Hynd5,Reference Clarke, Narrow, Regier, Kuramoto, Kupfer and Kuhl6 and may not fully capture the female presentation of ADHD, including more internalised (e.g. daydreaming, restless thoughts) or socially oriented presentations of ADHD. Reference Ohan and Johnston7,Reference Young, Adamo, Ásgeirsdóttir, Branney, Beckett and Colley8 Qualitative studies are needed to better characterise the presentation of female ADHD but these, along with mixed-methods studies, Reference Ohan and Johnston7,Reference Grskovic and Zentall9 are limited in both number and scope, with existing qualitative studies primarily including adults (middle to late adulthood Reference Morgan10 ) and few examining how the presentation of ADHD symptoms in females differs from the existing ADHD diagnostic criteria. Additionally, gendered sociocultural expectations and pressures may mean that females put more effort into masking (i.e. hiding or suppressing symptoms) and compensating (i.e. active strategies to help overcome symptoms), which may result in a delayed diagnosis. Again, preliminary qualitative studies are limited but have suggested that males and females with ADHD use compensatory strategies for their difficulties, Reference Bjerrum, Pedersen and Larsen11 with adult women with ADHD implicating such behaviours as being likely to play a role in their delayed diagnosis. Reference Morgan10
The current study
To address the gender inequality in ADHD diagnosis, we conducted a qualitative study to better understand the presentation of childhood ADHD in girls, from the perspective of young women and gender-diverse young adults with lived experiences of ADHD. Gender-diverse people were also included because people with ADHD are more likely to have a gender identity that falls outside the gender binary, Reference Warrier, Greenberg, Weir, Buckingham, Smith and Lai12 and their childhood experiences have not been taken into account by previous studies examining childhood ADHD presentation. The rationale for this study was to generate knowledge to inform the development of ADHD assessment tools that are gender inclusive, and to contribute to timely diagnoses by highlighting potential ADHD-related symptoms/behaviours that are missing from diagnostic criteria.
Method
Participants
Participants included those who identified as women, non-binary (including, but not limited to, those assigned female at birth [AFAB]) or transgender at the time of the study. Gender, not sex assigned at birth, was used to define eligibility. Participants were required to be 18–25 years old, have received a diagnosis of ADHD from a healthcare professional and live in the UK. Twelve participants were selected for recruitment, because qualitative themes tend to be identified and data saturation reached after relatively few interviews. Reference Morley and Tyrrell13 The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation, and with the Helsinki Declaration of 1975 as revised in 2013. All procedures involving human subjects/patients were approved by Cardiff University School of Medicine Research Ethics Committee (no. SMREC 23/28).
Procedure
Recruitment
Participants were recruited and identified through online advertisement by the National Centre for Mental Health (NCMH; www.ncmh.info), social media and by direct invitations to prospective participants by the UK Charity ADHD Foundation. Interested participants were directed to a website that includes the study information sheet, a screening questionnaire covering the eligibility criteria (including questions on, for example, current age and age at ADHD diagnosis) and a consent form for contact. Eligible participants were consecutively contacted in order of expression of interest to ensure a fair opportunity for all participants. Interviews were scheduled via video call, telephone call or in person, depending on participants’ preference. Before the interview, participants were emailed the information sheet (see supplementary material available at https://doi.org/10.1192/bjp.2025.10376) and a link to the online consent form. Participants provided written informed consent before taking part. Data collection was via individual interviews with a female psychology research assistant (T.W.) trained in qualitative methodologies. Participants received a £25 thank-you voucher and travel expenses (if applicable).
Development of study materials
Before data collection, input on the study materials (i.e. information sheet, consent form and interview schedule) was provided by a neurodivergent youth advisory group (YAG), recruited via the NCMH, including young people (14–25 years old) with lived experiences of neurodevelopmental conditions, and a parent of a young person with ADHD. The interview schedule was piloted with an adult with lived experiences of ADHD and a researcher with expertise in conducting qualitative interviews (L.A.L.). Study materials were refined based on this input.
Interviews
To elicit a detailed and in-depth description of participants’ lived experiences of ADHD, semi-structured interviews with open-ended questions were conducted, guided by an interview schedule (see supplementary material), with additional prompting questions if needed. Participants were asked to focus on their childhood and experiences in primary school (ages 4–11 years). There were five sections: (a) experience of ADHD diagnosis, (b) experiences during primary school, (c) detailed description of ADHD symptoms, (d) masking and compensatory strategies and (e) gender differences and strengths. For section three, following general questions, participants were asked to reflect on lists of potential behaviours that were presented on slides, including 12 previously proposed ‘female-sensitive’ ADHD items Reference Ohan and Johnston7,Reference Grskovic and Zentall9 (see supplementary material).
Participants had opportunities to take breaks. Each interview was audio recorded, with online interviews also video recorded. Audio recordings were transcribed verbatim by a professional transcription service and anonymised.
Analysis
For analysis, we used the framework method, a codebook approach to thematic analysis. We used a semantic approach to coding and a pragmatic mix of realistic/objective and interpretivist/subjectivist approaches. Framework analysis is well suited to using a combination of a priori (theoretical/deductive) information (e.g. existing ADHD diagnostic practices), as well as those identified from the data (inductive), to guide the development of a conceptual framework, which is then applied to the data. Reference Parkinson, Eatough, Holmes, Stapley and Midgley14 The framework method was chosen because it is a more structured form of thematic analysis and seemed the appropriate approach for the aim of using information provided by young adults with lived experiences of ADHD to build and expand on established ADHD diagnostic criteria, while also being open to discovery without being constrained by existing criteria. Transcripts were coded line by line (open coding) using NVivo 12 Plus (Lumivero, Denver, CO, USA, www.lumivero.com/products/nvivo/) on MS Windows.
The framework approach involved five non-linear stages. Reference Parkinson, Eatough, Holmes, Stapley and Midgley14 Stage one involved familiarisation of the qualitative data. Stage two involved developing an initial conceptual framework, where several transcripts were coded (T.W. and J.M.), with codes being grouped into categories. The initial framework roughly followed the interview schedule and was developed through discussion within the research team (T.W., I.B. and J.M.), while considering the study aims and initial codes/categories developed. The aim of the conceptual framework was to structure a large amount of data without moving onto interpretation. The framework included higher-order categories and subcategories. Stage three involved applying the conceptual framework to the data to index sections of the text into the developed categories. Interesting texts not fitting into the framework were coded into new categories, with the framework developed to accommodate them. One researcher (T.W.) coded 100% (12) of the transcripts while another (J.M.) independently coded 25% (3) of the transcripts, to ensure consistent application of the framework between researchers. Stage four involved charting the index data into the framework matrix, for easier management. For each category and subcategory in the mature conceptual framework (i.e. columns), coded sections of text were summarised for each participant (i.e. rows). Finally, through examination of the condensed data and referring to original transcripts, the research team (T.W., I.B. and J.M.), all of whom are female, discussed how best to interpret the data considering our study aim. We mapped together different categories and developed potential themes, best supported by the data, and viewed as relevant to understanding the experiences of ADHD in girls, and those who are gender-diverse, while going beyond the existing criteria.
Results
Twelve young adults (median age 22 years, range 18–25 years) with a self-reported clinical ADHD diagnosis were interviewed. All participants were AFAB, with ten individuals identifying as women and two as non-binary. Age at ADHD diagnosis ranged between 15 and 23 years (mean [s.d.] 19.8 [2.8]). The interviews took place online via video call (n = 10) and in person (n = 2), and lasted between 39 and 71 min (mean [s.d.] 54.3 [11.1]). During the interviews, 10 participants mentioned co-occurring conditions and related symptoms, including autism (n = 4), anxiety (n = 4), depression (n = 3), eating disorders (n = 2), dyslexia (n = 1) and dyspraxia (n = 1), although not all conditions were clinically diagnosed, with some participants on clinic waitlists. Most participants mentioned attending university (n = 10). All participants reported experiencing a range of ADHD symptoms listed in the diagnostic criteria.
Analysis revealed four core themes: (a) socially oriented and internalised symptoms, (b) social impacts, (c) masking and compensation and (d) the importance of context. All themes and subthemes were endorsed by all participants, through quotes/examples (see Tables 1–4).
Table 1 Verbatim quotes supporting subthemes for theme 1: socially oriented and internalised symptoms
Table 2 Verbatim quotes supporting subthemes for theme 2: social impacts
Table 3 Verbatim quotes supporting subthemes for theme 3: masking and compensation
Table 4 Verbatim quotes supporting subthemes for theme 4: context is important
Socially oriented and internalised symptoms (theme 1)
Socially oriented symptoms
All participants described experiencing ADHD-related symptoms that presented in social situations. Socially oriented inattentive symptoms included difficulties with conversations due to frequently losing track of thoughts (see quote 1 [Q1] in Table 1), getting distracted by other people, including talking to others during school lessons (Q2) and being forgetful about or late for social activities (Q3). Socially oriented hyperactive-impulsive symptoms included verbal impulsivity, such as frequently changing conversation topics (Q4), saying things without thinking (Q5) and switching between friends, resulting in difficulty in keeping friends (Q6).
All participants described experiencing intense emotional reactions in the context of difficult social experiences. These reactions were sometimes referred to by others, or by themselves afterwards, as over-reactions to minor things, including intense worrying, crying, excessive enthusiasm and being easily irritated and frustrated by others (Q7–9). Sensitivity to what other people think about them and sensitivity to rejection in social situations (e.g. misinterpreting or over-reacting to negative social cues) were mentioned frequently – for example, in reaction to criticism, discipline (e.g. detention) or perceived rejection (Q10–11).
Non-disruptive internalised symptoms
All participants reported experiencing symptoms related to ADHD that could be considered non-disruptive to others around them. Most participants reported frequently doodling or daydreaming during primary school lessons (Q12). One participant highlighted that these types of behaviours were often overlooked because people noticed only when they caused a problem to others, despite causing struggles for the young person themselves (Q13). Participants also described hyperactive-impulsive symptoms that were internal and were less obvious and disruptive to others, including a subjective need to move around and feeling trapped in their own body (Q14–15). Many participants described having an overactive mind and experiencing racing thoughts, impacting their sleep (Q16–17). Several participants described experiencing difficulties with time perception (Q18).
Mood and feelings
Many participants described that their symptoms had an emotional impact, including feelings of embarrassment and shame. Some participants reported frustration and upset when others questioned their behaviours, dismissed their struggles and were unhappy with them due to their symptoms (Q19). Participants also reported feelings of embarrassment when asking others to repeat what they were saying or when offered fidget toys to help manage their hyperactive behaviours (Q20–21). Additionally, participants reported that their ADHD-related struggles led to low self-esteem (Q22) and feelings of shame and anxiety regarding others’ perceptions of their struggles (Q23).
Social impacts (theme 2)
Friendships
All participants described that their ADHD had a negative impact on their relationships with others, including from the socially oriented symptoms described above. Many of the young people reported struggling to make and maintain friends, including having short-lived friendships, due to poor social skills and switching between friends (Q24–25 in Table 2). Participants mentioned symptoms such as being forgetful, talkative, late, sensitive to rejection and frequently changing conversation topics that could annoy or upset their friends (Q26–27). Other participants mentioned difficulties with forgiving others and repairing broken relationships (Q28).
Home and school
Similarly, participants reported that their ADHD symptoms caused tension and arguments at home with their families. Some participants mentioned that their parents did not believe they were struggling or had ADHD, and viewed them as lazy or thought their behaviours were intentional, straining their relationship (Q29–30). Some participants described poor relationships with teachers because they were often reprimanded for disrupting the class and were seen as not caring about their work (Q31). However, others mentioned that if teachers could look past their struggles and not be quick to judge or punish them, then they got on well (Q32).
Masking and compensation (theme 3)
Social motivation
When asked about masking and compensatory strategies, all participants endorsed a variety of behaviours and strategies to try and hide or overcome their ADHD difficulties. The predominant motivation for all masking efforts and strategies appeared to be a desire to ‘fit in’, by making behaviour more socially appropriate and avoiding getting into trouble or having others notice their symptoms (Q33–36 in Table 3).
Behaviours and strategies
Masking behaviours helped participants to hide or suppress their symptoms, and included being quiet or well behaved to avoid attention, fidgeting subtly and non-disruptively – such as tapping feet or fidgeting with items such as their hair or earrings – and pretending to pay attention (Q37–39). Participants also described using social information to appear more neurotypical, such as copying others’ mannerisms, behaviours and personalities (Q40–41). Additionally, participants described engaging in compensatory strategies as they grew older, including creating to-do lists and reminders, arriving early to avoid lateness and having high standards for their work (i.e. over-compensating), to avoid others thinking that they were struggling (Q42–44).
Overcompensation and exhaustion
While some strategies, such as being overly organised, appeared useful and effective in compensating for ADHD symptoms, and therefore potentially hiding participants’ difficulties (Q45), they also had a downside including overcompensation, i.e. taking strategies to the extreme (e.g. arriving too early; Q46–47). Furthermore, some participants found these strategies less effective, describing how lists and reminders were forgotten or ignored (Q48). Additionally, while pretending to pay attention seemed an effective masking approach, it was considered effortful and did not help them pay attention. Further, some participants highlighted how exhausting they found certain strategies; masking and compensation were harder when participants had less energy, and some found it more difficult as they grew older (Q49–50).
Context is important (theme 4)
All participants mentioned that the presentation of their ADHD symptoms and associated impact was dependent on the environmental context, including multiple different factors.
Feeling safe and comfortable
Most participants reported that their ADHD symptoms were more pronounced at home compared with at school (Q51–52 in Table 4); this was linked to whether an environment felt safe or comfortable. Many participants described that at home they felt no need to hide or suppress their behaviours, because their close friends and family knew and accepted their behaviours, compared with school where they wanted to ‘fit in’ (Q53–55). However, one participant mentioned that their ADHD symptoms were less pronounced at home because their parents were strict (Q56).
Support from others
External support or scaffolding from family and school staff appeared to reduce symptoms and associated difficulties. Scaffolding included receiving support to create a routine/schedule to stay on track with schoolwork, support to complete tasks and having accommodations at school to help reduce symptom impact on school performance (Q57–58). Many participants described that, once external support stopped as they got older, their ADHD symptoms became worse and they started to consider an ADHD diagnosis (Q59).
Interest and enjoyment
Many participants described that their attention difficulties were dependent on how interesting or enjoyable they found a task or activity. Most participants reported particularly struggling to pay attention and engage with uninteresting things. However, if interested, they could focus for longer periods than usual, to the point of hyperfocusing (Q60–61).
Sensory environment
Some participants reported noise sensitivity, with loud and busy environments making their attention and concentration difficulties more intense (Q62–63).
Discussion
This qualitative study aimed to better understand the manifestation of ADHD symptoms in young girls and gender-diverse youth, through detailed interviews with young adults with ADHD (including women and non-binary people AFAB). We identified four themes: (a) socially oriented and internalised symptoms, (b) social impact, (c) masking and compensation and (d) the importance of context. All themes had interrelated subthemes (see Tables 1–4).
In addition to descriptions of symptoms and difficulties that are well captured by current criteria and existing assessment tools, other ADHD-related symptoms were frequently mentioned. These included socially inattentive behaviours (e.g. difficulties during conversations due to losing track of their own thoughts), impulsivity related to emotional regulation (e.g. quick to anger), non-disruptive behaviours (e.g. doodling during lessons) and internalised symptoms (e.g. overthinking). Such behaviours are not captured in the existing diagnostic criteria and may not be interpreted as ADHD symptoms by teachers and clinicians.
Furthermore, participants also mentioned some examples of ADHD symptoms listed in existing ADHD criteria (i.e. DSM-5-TR) but which may not be recognised by others as reflecting ADHD because they are less behaviourally externalising, and disruptive to others, than the examples listed in the diagnostic criteria. These behaviours included verbally hyperactive-impulsive behaviours (e.g. ’saying things without thinking’, which may be related to the symptom ‘blurting out answers’ but is potentially less disruptive and distracting to those around them), and non-disruptive internalised symptoms (e.g. ’subjective need to move around’, similar to ‘feelings of restlessness’).
Our results are consistent with two previous studies attempting to characterise ‘female-sensitive’ ADHD behaviours. Reference Ohan and Johnston7,Reference Grskovic and Zentall9 These studies used literature searches, clinical expertise and interviews with people with lived experiences of ADHD, or parents, to create lists of symptoms linked to female ADHD. These included items related to verbal impulsivity, consistent with examples reported by our participants. The items assessed in those studies were rated higher in girls with compared without ADHD, correlated with existing ADHD symptoms and showed functional impact, indicating some validity for established criteria. Reference Ohan and Johnston7,Reference Grskovic and Zentall9 Furthermore, while impact is required for ADHD diagnosis and is not unique to females, our participants highlighted impact on social functioning as a primary area of impact attributed to their ADHD, including from socially oriented symptoms not well characterised by existing criteria.
Detailed masking and compensation strategies for ADHD were discussed by all participants, with clear motivation to avoid social rejection. This is consistent with research on autism Reference Livingston, Colvert and Happé15 indicating that people with ADHD also use techniques to minimise or compensate for their difficulties and thereby appear more neurotypical. Reference van der Putten, Mol, Groenman, Radhoe, Torenvliet and van Rentergem16 Some participants mentioned reductions in masking behaviours over adolescence, and that some strategies were ineffective or came at a negative cost to themselves because certain strategies were effortful and energy consuming. This is similar to individuals with tic disorders who can suppress their tics for short periods of time, although doing so can increase distress Reference Suh, Yoon, Hong, Lee, Lee and Kim17 and impair functioning. Reference Ueda, Kim, Greene and Black18 Few studies characterise detailed masking strategies used by people with ADHD, especially during childhood, but several mixed-gender qualitative studies concluded that strategies are regularly employed by adults with ADHD. Reference Morgan10,Reference Waite and Tran19 In women, masking has been attributed to later ADHD diagnosis. Reference Morgan10 Other factors previously linked to later ADHD diagnosis include external factors, such as supportive home or school environments. Reference Mitchell, Sibley, Hinshaw, Kennedy, Chronis-Tuscano and Arnold20 We identified several contextual factors that influenced ADHD symptoms and their impact. External support or scaffolding from family and school staff, including perceived safety and comfort of an environment, were important influences on ADHD manifestation. This is important when considering sex and gender differences, because studies have begun to suggest that females may be less likely to meet the ADHD pervasiveness criterion due to poor teacher–parent agreement. Reference Frick, Hesser and Sonuga-Barke21,Reference Gomez, Harvey, Quick, Scharer and Harris22 However, it is important to note that although females may be less likely to meet the ADHD pervasiveness criteria, it does not mean that they do not experience any negative impacts, because masking often comes at a steep cost to the individual and may be detrimental for them. Reference Miller, Rees and Pearson23 Other contextual factors that influenced ADHD included interest levels in a topic or external sensory distractions, which may not be gender specific.
Although our participants were women and non-binary young adults, the themes identified are unlikely to be unique to these groups, with ADHD symptoms likely to manifest socially and internally, cause social impact, be masked in certain situations and vary across context. The insights from this study have the potential to focus assessment of ADHD in young girls on key areas (e.g. social context). Some frequently described symptoms may benefit from validation using future assessment tools, such as difficulties in regulating emotions, which are also highlighted by previous studies. Reference Faraone, Rostain, Blader, Busch, Childress and Connor24 Ultimately, more gender-diverse assessment tools have the potential to improve the recognition and diagnosis of ADHD in all young people, particularly girls.
This study is novel because it explores the manifestation of childhood ADHD symptoms in females, going beyond the diagnostic criteria and including gender-diverse individuals. Limitations include that the sample was relatively small, self-selected and highly educated, with 10 of the 12 participants mentioning that they had attended university, which could mean that they were more likely to engage in masking and compensatory behaviours. Reference Livingston, Colvert and Happé15 As such, the sample is not representative of all young adults with ADHD, limiting the generalisability of the findings. Further, while inclusion of gender-diverse individuals is a strength of the study, there were only two such people. Future research should focus on including more individuals who fall outside the gender binary. Additionally, many participants mentioned co-occurring conditions, including anxiety, depression and autism. Some of the social impact and strategies described by participants could be partially explained by co-occurring conditions, even though participants were asked specifically about ADHD. Also, all participants received a relatively late ADHD diagnosis (15–23 years), which may have influenced the ease and accuracy of reflecting on their experiences of primary school. Additionally, this might mean that the study design possibly over-selected for ‘non-traditional’ ADHD symptoms and masking and compensatory behaviours because all participants had a late diagnosis of ADHD, limiting the generalisability of findings. However, this can also be considered a strength of the study because it reports ADHD symptoms and behaviours that may be missed, or overlooked, in females during childhood.
The findings of this qualitative study highlight that young girls and gender-diverse individuals with ADHD may experience ADHD-related symptoms not fully described in current diagnostic criteria. These symptoms appeared more socially oriented and internalised compared with those described by existing criteria, and particularly impact on social relationships. The results highlight that young girls and gender-diverse youth are socially motivated (e.g. avoiding social rejection and wanting to fit in) to engage in masking and compensatory behaviours. We also note the importance of environmental context. There is a need for more gender-inclusive ADHD assessment tools, including difficulties that go beyond existing symptom descriptions. This may aid earlier recognition and diagnosis of ADHD.
Supplementary material
The supplementary material is available online at https://doi.org/10.1192/bjp.2025.10376
Data availability
The data that support the findings of this study are available as excerpts in the paper (see Tables 1–4). The materials used in this research (e.g. information sheet, interview schedule) are available in the supplementary material. The full data transcripts are not publicly available, even upon request, because doing so would violate ethical approval and the agreement to which the participants consented.
Acknowledgements
This work was supported by the Wolfson Centre for Young People’s Mental Health, established with support from the Wolfson Foundation. The authors thank Dr Olga Eyre for her input on the presentation of the paper and verbatim quotes, Daniel Oakes from the NCMH for his help with REDCap and Megan Holland from the ADHD Foundation for her help with recruitment. We thank the YAG, recruited via the National Centre for Mental Health, which included young people aged 14–25 years with lived experiences of neurodevelopmental conditions, and parents who commented on study materials, as well as all of our study participants.
Author contributions
T.W. (first author): study design, data collection and analysis, manuscript writing and revision. I.B.: data analysis, manuscript editing. R.B.-J., L.A.L.: study design, manuscript editing. S.S.A., T.F., A.J., K.S., A.T.: manuscript editing. J.M. (senior author): acquisition of funding, study design, manuscript writing and editing, supervision.
Funding
This study was funded by the Welsh Government through Health and Care Research Wales (HCRW) via a National Institute for Health and Care Research (NIHR) Advanced Fellowship (no. NIHR-FS(A)-2022). T.F.’s research group received funds for research methods consultation with Place2Be, a third-sector organisation providing mental health interventions and training within schools. R.B.-J. was supported by a NIHR/HCRW post-doctoral fellowship programme (no. NIHR-PDF-2018).
Declaration of interest
K.S. and T.F. are NIHR senior Investigators. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. All other authors report no conflicts of interest.
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