ADHD is already known to be under-recognised in girls, whose symptoms are often less externally visible than those typically seen in boys. While hyperactive and impulsive behaviours, which are more common presentations in boys, tend to attract attention in classrooms and clinics, girls more frequently display inattentive patterns that can be mistaken for daydreaming, shyness or simply quiet behaviour. That baseline disparity makes the new findings especially striking: on top of a well-documented gender gap, the research suggests an additional delay tied specifically to linguistic and cultural background, compounding the disadvantage for girls from diverse families.

The research team, led by Dr Franziska Köder at the University of Oslo in collaboration with Dr Maria Garraffa of the University of East Anglia’s School of Health Sciences, analysed data from 70,102 children drawn from a large population-based cohort study in Norway. The researchers linked parental reports of attention difficulties with official ADHD diagnoses recorded in the country’s national healthcare system. This combination of subjective parental observation and objective clinical records allowed the team to distinguish between two different questions: whether children from multilingual and immigrant families show more attention difficulties, and whether those difficulties translate into diagnoses at the same rate and the same time as they do for other children.

The answer to the first question was yes, but to the second, no. Multilingual children were more likely to be rated by their parents as having more attention difficulties than monolingual children, yet they were no more likely to receive an ADHD diagnosis. In other words, parents in these families were noticing problems, but the concerns were not converting into clinical recognition at the expected rate. When the team examined the timing of diagnoses, the picture became even more concerning: girls whose mothers spoke a language other than Norwegian were diagnosed almost two and a half years later than girls with Norwegian-speaking parents, a delay that spans some of the most formative years of a child’s education.

Dr Garraffa emphasised that the study does not explain exactly why these disparities exist, but she and her colleagues believe a combination of cultural, linguistic and healthcare-system factors may be involved. Some parents may be less familiar with ADHD or less likely to seek help because of concerns about stigma. Others may encounter difficulties navigating healthcare services or communicating their concerns through language barriers. Each of these mechanisms could act at a different point along the diagnostic pathway, from the first moment a parent raises a concern with a health visitor or teacher, through referral and assessment, to the final clinical decision.

The study also uncovered evidence of potential underdiagnosis among children from immigrant backgrounds more broadly. ADHD diagnosis rates were significantly lower among children whose mothers came from parts of North Africa, the Middle East, Southeast Asia, East Asia and Oceania than among children with Norwegian-born mothers. This pattern held even though the cohort data suggested that attention difficulties were being reported in these families. Taken together, the results point to a systematic discrepancy between the level of need that parents perceive and describe, and the level of clinical recognition that children ultimately receive.

One further possibility highlighted by the researchers is that the assessment tools themselves may be part of the problem. Commonly used questionnaires for evaluating attention difficulties may not work equally well across different cultural and linguistic groups. Screening instruments are typically developed and validated in majority-language populations, and subtle differences in how attention, activity level and self-regulation are described across languages and cultures can affect how items are interpreted by parents and scored by clinicians. If a questionnaire systematically underestimates difficulties in multilingual families, children may fail to cross the thresholds that trigger referral, even when parents have flagged genuine concerns.

Although the study was conducted in Norway, the researchers argue that its implications are likely to extend well beyond the Scandinavian context, and they single out the United Kingdom as a country where similar inequalities deserve urgent investigation. Around 5.1 million people in England and Wales speak a main language other than English, and ADHD represents a substantial demand on UK health services, with an estimated 741,000 children and young people aged between five and 24 living with ADHD in England alone. Yet many children still go undiagnosed, which can lead to struggles at school, poor mental health and problems with relationships. When children do not receive a timely diagnosis, they miss out on targeted support, guidance and treatment that can help them manage their symptoms.

The consequences of delayed recognition can be severe and long-lasting. Undiagnosed ADHD is associated with academic underachievement, elevated rates of anxiety and depression, and difficulties with peer relationships and self-esteem, and these harms accumulate during precisely the years in which children are expected to master the foundations of learning. Dr Garraffa said that delayed diagnosis can affect children’s education, wellbeing and future opportunities long after symptoms first appear. A delay of two and a half years for girls from multilingual families, and nearly five years in some households, means support may arrive only after years of unexplained difficulty, missed learning and eroded confidence.

The researchers are calling for more culturally sensitive assessment approaches to ensure that children from multilingual and immigrant families are not disadvantaged when seeking support for ADHD. That could mean developing and validating screening tools across languages, training clinicians to recognise how ADHD can present differently across cultural contexts, and providing better pathways for families navigating unfamiliar healthcare systems. Although healthcare systems differ between countries, the team argues that the work highlights a potential inequality that deserves closer examination in all nations with increasingly diverse populations. For the girls whose diagnoses arrive years late, the cost of that inattention is measured not in statistics but in childhoods spent struggling without explanation. The study was funded by the Research Council of Norway as part of the AttCom project, which examines the role of attention in communication.

Subject of Research: Delayed ADHD diagnosis among girls from multilingual and immigrant families

Article Title: ADHD diagnosis gap for girls from immigrant backgrounds

Article References: ADHD diagnosis gap for girls from immigrant backgrounds. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: ADHD, girls, multilingualism, immigrant families, diagnosis delay, Norway, cohort study, health inequalities, child mental health, attention difficulties, cultural barriers, University of East Anglia