Why ADHD May Not Always Look the Way Clinicians Expect

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A young West African woman recently came to see me for an ADHD assessment after moving to the UK to begin a Master’s programme.

Before the appointment, as is fairly typical practice in many adult ADHD services, she completed a pre-assessment questionnaire based on the Adult ADHD Self-Report Scale (ASRS). A parent informant questionnaire was also completed by her father.

At first glance, the questionnaires did not suggest ADHD.

Most individuals who ultimately meet criteria for ADHD tend to endorse multiple symptoms as occurring “often” or “very often.”

This woman rated almost all symptoms as only “sometimes” or “rarely”. Her father answered “no” to virtually every informant question asking whether she showed difficulties beyond what would be expected for someone her age.

Looking at the forms prior to the assessment, she seemed unlikely to meet the diagnostic criteria for ADHD.

But clinical assessment is not simply about scoring questionnaires. It is also about understanding context — and questioning what we think we are observing.

As we spoke, a more complex picture emerged.

She described growing up in a highly structured West African household and school environment with very clear expectations around behaviour, routine, discipline, and academic performance. Despite doing well academically, she had always experienced herself as significantly less organized and more messy than her siblings. She relied heavily on external structure to function.

The transition to university had been difficult, but moving countries for postgraduate study was what finally overwhelmed her coping mechanisms. Without the same degree of scaffolding, she began struggling to manage deadlines, organisation, attention, and daily tasks.

What initially appeared to be a low-symptom presentation began to look different once cultural and environmental context were considered.

But another detail from the assessment stayed with me even more.

The questionnaire asked patients to provide written examples whenever they endorsed symptoms as occurring “often” or “very often.” As we discussed her responses, she explained that part of the reason she avoided selecting higher ratings was because she did not want to have to elaborate further. The thought of expanding on her answers felt mentally effortful and overwhelming.

In other words, the structure of the questionnaire itself may have shaped the way her symptoms were reported.

What initially looked like minimal symptoms or lack of impairment may, in part, have reflected executive dysfunction interacting with the demands of the assessment process itself.

This is one reason why ADHD assessment cannot rely solely on surface measures or numerical thresholds. Questionnaires are useful tools, but they do not interpret themselves. The meaning of a response depends on context: cultural context, developmental context, environmental context, and the individual’s relationship to the assessment process itself.

It also highlights how major life transitions can expose difficulties that were previously contained by external structure. This is particularly important in individuals raised in environments with strong behavioural expectations, high levels of supervision, or rigid academic systems. When those structures fall away, longstanding difficulties may become newly visible.

Discussions about ADHD diagnosis often become polarised between “underdiagnosis” and “overdiagnosis.” But clinical reality is often more nuanced than either term allows. Sometimes the issue is not whether symptoms are present.

It is how they are interpreted.

And that distinction matters.