Challenges in diagnosing attention-deficit/hyperactivity disorder in pediatric practice: A regional and global perspective

Abstract

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders of childhood, yet its diagnosis remains complex and fraught with challenges. Pediatricians, often the first point of contact for concerned families, play a pivotal role in the diagnostic process. However, they face numerous obstacles that can hinder accurate and timely diagnosis, particularly in resource-limited or culturally diverse settings such as the Middle East and North Africa (MENA) and Arabian Gulf regions. This narrative review explores the key challenges pediatricians face in diagnosing ADHD and highlights practical and emerging solutions. The article offers both a global perspective and a contextualized view relevant to the MENA region. A narrative literature review was conducted using PubMed, Scopus, and Google Scholar, focusing on peer-reviewed studies, clinical guidelines, and epidemiological data from 2010 to 2025 related to pediatric ADHD diagnosis, especially in MENA regions. The review identifies six major diagnostic barriers: (1) Symptom overlap with other conditions [e.g., autism spectrum disorder (ASD), anxiety, learning disabilities]; (2) Reliance on subjective informant reports; (3) Cultural and societal influences including stigma and gender bias; (4) Variability in ADHD training and time constraints in clinical practice; (5) Limited access to multidisciplinary evaluations; and (6) Systemic referral and communication inefficiencies. Comorbidities are highly prevalent and frequently complicate the diagnostic picture. Delayed or inaccurate diagnosis can lead to academic underperformance, family stress, missed interventions, and long-term psychological consequences. Emerging solutions include digital screening tools, artificial intelligence-assisted analysis, structured reporting platforms, and improved training and referral models. Regional data from the Arabian Gulf highlight variable prevalence rates (1.3%-22%) and underscore the need for culturally sensitive diagnostic strategies. To improve diagnostic accuracy and patient outcomes, pediatricians must be supported through better training, interdisciplinary collaboration, validated tools, and policy-level reforms. Tailoring these approaches to local contexts will be key to addressing the growing burden of ADHD, particularly in the MENA region.

Key Words: Attention-deficit/hyperactivity disorder; Pediatric diagnosis; Comorbidity; Middle East and North Africa region; Diagnostic challenges; Subjective assessment

Core Tip: This review highlights the multifaceted challenges pediatricians face in diagnosing attention-deficit/hyperactivity disorder (ADHD), including symptom overlap, informant bias, cultural stigma, and limited access to specialized care, particularly in the Middle East and North Africa region. It emphasizes the critical role of pediatricians as frontline diagnosticians and the consequences of delayed or inaccurate diagnosis on academic performance, family well-being, and long-term mental health. The article also explores emerging solutions, including digital tools, multidisciplinary collaboration, and culturally sensitive screening. Strengthening pediatric training and diagnostic systems is crucial for ensuring the timely and accurate identification of ADHD and improving outcomes for affected children and their families.

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in children, characterized by persistent patterns of inattention, hyperactivity, and impulsivity that interfere with growth and daily life. Usually appearing in early childhood, ADHD often continues into adolescence and adulthood, with noticeable differences in how symptoms manifest and their severity. Its primary traits can significantly disrupt academic achievement, strain relationships with peers and family, and affect emotional health, emphasizing the importance of early detection and treatment[1]. Globally, ADHD affects an estimated 5%-7% of school-aged children, though reported prevalence varies widely across regions due to differences in diagnostic frameworks, public awareness, and access to healthcare services[2]. Over recent decades, the number of ADHD diagnoses has increased, driven by improved recognition, expanded diagnostic criteria, and increased societal awareness. However, this growth has sparked ongoing debates, with concerns about underdiagnosis in resource-limited settings and overdiagnosis in others[3]. Such disparities highlight ongoing inconsistencies in assessment practices and the challenges of clinical decision-making.

The consequences of undiagnosed or poorly managed ADHD can be severe. Children affected by it face increased risks of academic difficulties, social rejection, low self-esteem, and psychiatric issues such as anxiety, depression, and substance use disorders. Therefore, early and accurate diagnosis is crucial for initiating evidence-based treatments that can reduce these outcomes and support healthier developmental pathways[4]. Despite ADHD's high prevalence and known impact, diagnosing it remains complex and nuanced. Pediatricians, often the first healthcare providers families encounter, play a key role in identifying and managing ADHD. However, they face several diagnostic challenges: (1) Symptoms that overlap with other developmental or psychiatric conditions; (2) Heavy dependence on subjective reports from parents and teachers; (3) Observer biases; (4) Time constraints in primary care; and (5) Limited access to comprehensive, multidisciplinary assessments[5].

This review offers a pediatrician’s perspective on the main challenges of diagnosing ADHD. It aims to identify key barriers to accurate diagnosis, discuss practical and emerging solutions, and highlight the urgent need for improved screening tools, targeted training, and interdisciplinary collaboration. By addressing these issues, the article seeks to help pediatricians make more confident, timely, and evidence-based diagnostic decisions – ultimately enhancing outcomes for children suspected of having ADHD.

ADHD IN THE ARABIAN GULF AND MIDDLE EAST AND NORTH AFRICA REGION

In the Arabian Gulf and the broader Middle East and North Africa (MENA) region, awareness and diagnosis of ADHD have increased in recent years. However, many challenges remain, some of which are similar to – yet also different in size and context from – those seen worldwide. Reported prevalence rates across the region vary significantly, ranging from as low as 1.3% in Yemen to over 14% in Tunisia, and even exceeding 20% in some Iranian studies (Figure 1)[6-10]. A recent systematic review found an overall pooled prevalence of 10.3% (95%CI: 8.1-12.9) among children and adolescents in the MENA region, with significant differences due to variations in methodology, diagnostic criteria, population traits, and local clinical practices[6]. Compared to high-income countries, the MENA region faces greater challenges in infrastructure, diagnostic training, and referral systems. Child psychiatrists, developmental-behavioral pediatricians, and educational psychologists are scarce, especially outside major urban areas[11]. As a result, general pediatricians often carry the full responsibility of identifying ADHD, despite dealing with time constraints and limited behavioral health training. Although international diagnostic frameworks like the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the International Classification of Diseases, 11^th Revision (ICD-11) are increasingly used, localized, culturally adapted diagnostic protocols are still lacking, leading to inconsistencies in practice and a high risk of both underdiagnosis and overdiagnosis. Additionally, time constraints in primary care, inadequate training in behavioral pediatrics, and weak referral systems further impede the diagnostic process[12].

Figure 1 The attention-deficit/hyperactivity disorder prevalence in the Middle East and North Africa and Arabian Gulf regions.

Cultural beliefs and stigma further complicate the diagnostic landscape. In many MENA societies, behaviors such as inattention or impulsivity are often misattributed to poor discipline, weak parenting, or even supernatural causes, which delays medical consultation[13]. Psychiatric labels carry social stigma, discouraging families from acknowledging behavioral concerns or accepting referrals. Teachers – despite often being the first to observe disruptive behaviors – may lack formal training in neurodevelopmental disorders and are not always included in the care team, limiting their diagnostic contributions[14]. Adding to these problems is a lack of solid epidemiological data. Most studies are cross-sectional, school-based, and focus on urban populations, leaving out rural or low-income communities. National registries and long-term studies are almost non-existent, which limits understanding of long-term outcomes and system-wide planning. Without this data, regional healthcare systems are not well-prepared to estimate the actual burden of ADHD or to assess the effectiveness of current diagnostic pathways[15].

Enhancing ADHD diagnosis in the Arabian Gulf and MENA region requires a contextually sensitive, systems-level approach. This includes public awareness campaigns tailored to local values, structured training programs for pediatricians and teachers, culturally validated screening tools, and investment in multidisciplinary collaboration models. Aligning regional efforts with global evidence – while respecting sociocultural realities – will be essential to closing the diagnostic gap and ensuring children across the MENA region receive early, accurate, and equitable ADHD care[6].

The wide variability in ADHD prevalence across MENA countries – ranging from 1.3% in Yemen to over 20% in Iran – likely reflects differences in diagnostic practices, study methodologies, cultural perceptions, and healthcare infrastructure. Underdiagnosis may occur in regions with limited mental health resources or stigma around psychiatric diagnoses, while overdiagnosis may stem from heightened awareness or broader criteria application. Standardizing diagnostic protocols and conducting population-based studies could help yield more reliable prevalence estimates.

DIAGNOSTIC CRITERIA AND FRAMEWORKS

The diagnosis of ADHD depends on well-established clinical criteria and standardized assessment tools. Two main diagnostic systems are recognized worldwide: (1) The DSM-5; and (2) ICD-11. Both aim to give clinicians clear operational definitions of ADHD but differ slightly in how they understand and categorize the disorder[16]. According to the DSM-5, ADHD is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that disrupts functioning or development. The criteria state that symptoms must be present for at least six months, be inconsistent with the person's developmental level, and cause significant impairment in at least two settings (such as home or school)[17]. The DSM-5 identifies three subtypes based on the predominant symptoms: (1) Predominantly inattentive; (2) Predominantly hyperactive-impulsive; and (3) Combined presentation. The diagnosis also requires that several symptoms were present before the age of 12 and cannot be better explained by another mental disorder[18]. In contrast, the ICD-11, issued by the World Health Organization (WHO), classifies ADHD under “neurodevelopmental disorders” and uses the term “attention deficit hyperactivity disorder”. It highlights impaired attention, hyperactivity, and impulsivity as core domains but is less focused on symptom subtyping[19]. ICD-11 also offers broader descriptors, which may improve cross-cultural applicability but can sometimes lack the specificity seen in DSM-5 criteria. Despite minor differences, both systems share essential diagnostic components and are often used interchangeably in international clinical practice, depending on the regional healthcare system[12]. Table 1 compares the criteria for ADHD in both DSM-5 and ICD-11.

Table 1 Comparison of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and International Classification of Diseases, 11^th Revision diagnostic criteria for attention-deficit/hyperactivity disorder.

Feature	Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Academy of Pediatrics, 2013)	International Classification of Diseases, 11th Revision (World Health Organization, 2022)
Disorder name	Attention-deficit/hyperactivity disorder (ADHD)	Attention deficit hyperactivity disorder (ADHD)
Classification	Neurodevelopmental disorders	Neurodevelopmental disorders
Core symptom domains	Inattention, hyperactivity/impulsivity (two domains)	Inattention, hyperactivity/impulsivity (two domains)
Subtypes/presentations	Three presentations: Predominantly Inattentive; predominantly hyperactive/impulsive; combined	No subtypes; describes severity of symptoms and predominant pattern
Symptom criteria	≥ 6 symptoms (children)/≥ 5 (adolescents/adults) in each domain lasting ≥ 6 months	At least several symptoms from both domains are required (no strict numeric threshold)
Age of onset	Symptoms must be present before age 12	Symptoms must begin during the developmental period, typically before age 12
Impairment requirement	Symptoms must cause clear impairment in social, academic, or occupational functioning	Symptoms must interfere with personal, family, social, educational, or occupational life
Cross-situational presence	Symptoms must be present in two or more settings	Symptoms must be evident in more than one context
Comorbidity approach	Allows ADHD diagnosis with ASD and other psychiatric conditions	Also allows ADHD with comorbid conditions, including ASD
Severity specifiers	Mild, moderate, severe based on the number and impact of symptoms	Descriptive text is used to indicate severity and functional impact
Emphasis	Symptom count and strict threshold adherence	Clinical judgment, functional impairment, and contextual factors

Table 1 shows that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition is more quantitative and structured, using specific symptom counts and subtypes. In contrast, the International Classification of Diseases, 11^th Revision (ICD-11) adopts a more clinician judgment-based approach, emphasizing functional impairment without strict numeric thresholds. Both systems now recognize comorbidity with autism spectrum disorder, which was not allowed in earlier ICD versions. ADHD: Attention-deficit/hyperactivity disorder; ASD: Autism spectrum disorder.

Clinical guidelines from reputable organizations like the American Academy of Pediatrics (AAP), the National Institute for Health and Care Excellence (NICE), and the Centers for Disease Control and Prevention offer vital support for practitioners in applying these criteria[20]. These guidelines highlight a thorough diagnostic process that combines clinical interviews, behavioral observations, input from multiple informants (usually parents and teachers), and standardized rating scales. They also underline the importance of ruling out other possible explanations and evaluating for comorbid conditions (Table 2). Several validated tools assist in the diagnostic process (Table 3). Commonly used rating scales include the Vanderbilt ADHD Diagnostic Rating Scales, which are widely used in primary care settings, and the Conners Comprehensive Behavior Rating Scales, which provide more detailed behavioral profiling[21,22]. Questionnaires such as the ADHD Rating Scale-5, Swanson, Nolan, and Pelham Questionnaire (version IV), and the Strengths and Difficulties Questionnaire are also frequently employed to gather structured symptom data across different environments[23,24]. While these tools improve objectivity and consistency, they serve as adjuncts to clinical judgment rather than definitive diagnostic instruments. Overall, accurate ADHD diagnosis requires careful application of standardized criteria within a comprehensive, context-sensitive clinical framework, supported by guideline-driven use of validated assessment tools[25].

Table 2 Attention-deficit/hyperactivity disorder symptoms vs common mimicking conditions.

Attention-deficit/hyperactivity disorder symptom/feature	Possible mimicking conditions	Key differentiating features
Inattention	Learning disabilities (e.g., dyslexia, auditory processing disorder); absence seizures; depression	Learning disabilities often show specific academic skill deficits; absence seizures involve brief staring spells with no awareness; depression may show inattention with low mood and anhedonia
Hyperactivity	Anxiety disorders; ASD; sensory processing disorder	Anxiety often causes fidgeting from internal distress, not impulsivity; ASD may involve repetitive behaviors and poor social reciprocity; sensory issues are context-dependent and linked to specific stimuli
Impulsivity	Bipolar disorder; ODD; normal developmental behavior in preschoolers	Bipolar disorder includes episodic mood elevation and risk-taking; ODD involves deliberate defiance rather than spontaneous impulsivity; preschool impulsivity often improves with age and structure
Difficulty sustaining attention	Sleep disorders (e.g., obstructive sleep apnea, insufficient sleep); trauma and PTSD	Sleep disorders show fatigue, snoring, and poor morning arousal; PTSD may include hypervigilance, intrusive thoughts, and avoidance
Poor academic performance	Intellectual disability; specific learning disorders; environmental neglect	Intellectual disability involves global developmental delay; learning disorders are subject-specific; environmental factors often improve with intervention
Behavioral problems in school	Language disorders; hearing impairment; conduct disorder	Language/hearing issues lead to frustration-based behaviors; conduct disorder involves intentional aggression and rule-breaking

ASD: Autism spectrum disorder; ODD: Oppositional defiant disorder; PTSD: Post-traumatic stress disorder.

Table 3 Common rating scales used in attention-deficit/hyperactivity disorder assessment.

Rating scale	Target informants	Purpose	Age group	Common use setting	Strengths	Limitations
Vanderbilt ADHD diagnostic rating scale	Parents, teachers	Symptom assessment and impairment screening; aligned with DSM criteria	6-12 years	Primary care, pediatrics	Freely available; easy to administer; covers ADHD and comorbidities (ODD, anxiety, etc.)	Limited depth; may be less sensitive in older adolescents; relies on subjective reports
Conners Comprehensive Behavior Rating Scales	Parents, teachers, youth	Detailed behavioral profiling, ADHD symptoms, and comorbid conditions	6-18 years	Specialized clinics, research	Comprehensive; validated for multiple disorders; norm-referenced	Requires purchase; time-consuming; may be impractical in busy primary care settings
ADHD rating scale-5	Parents, teachers	Frequency-based symptom rating aligned with DSM-5	5-17 years	Pediatric/psychology clinics	Updated for DSM-5; relatively quick to administer; standardized scoring	Focused solely on ADHD; does not assess broader behavioral issues
Swanson, Nolan, and Pelham Questionnaire (version IV)	Parents, teachers	Screens for ADHD and ODD	6-18 years	School and clinical settings	Freely accessible; based on DSM-IV; includes ODD items	Slightly outdated (DSM-IV); limited coverage of impairment
Strengths and difficulties questionnaire	Parents, teachers, self	Broad behavioral and emotional screening including attention problems	4-17 years	Schools, research, screening	Brief; assesses strengths as well as difficulties; available in many languages	Less specific for ADHD; may miss subtleties in symptom severity
CBCL	Parents	Comprehensive behavioral and emotional problem screening	6-18 years	Mental health and research	Strong psychometric properties; assesses broad psychopathology	Requires purchase and scoring software; not ADHD-specific
Teacher report form	Teachers	Teacher’s view of behavior; complements CBCL	6-18 years	Schools, research	Valuable classroom perspective; standardized tool	Limited to teacher input; not ideal for initial screening alone

ADHD: Attention-deficit/hyperactivity disorder; CBCL: Child behavior checklist; DSM: Diagnostic and Statistical Manual of Mental Disorders; ODD: Oppositional defiant disorder.

COMORBID CONDITIONS OF ADHD

ADHD rarely occurs in isolation. A significant proportion of children diagnosed with ADHD experience one or more comorbid psychiatric, developmental, or medical conditions that complicate diagnosis, management, and prognosis. Recognizing these comorbidities is essential, as they can alter symptom presentation, affect treatment response, and increase the overall burden on the child and family[26].

Children with ADHD commonly exhibit academic underachievement. However, up to 30%-50% may also have specific learning disorders (SLDs), such as dyslexia, dyscalculia, or dysgraphia. These conditions can exacerbate attentional challenges and often go unrecognized unless formal psychoeducational testing is conducted. ADHD and SLDs often present with overlapping symptoms such as distractibility and poor school performance, requiring careful evaluation to ensure both conditions are identified and appropriately supported[27]. Oppositional behaviors such as defiance, argumentativeness, and hostility toward authority figures are present in about 40%-60% of children with ADHD, particularly those with the hyperactive-impulsive subtype. In more severe cases, conduct disorder may develop, characterized by aggression, deceitfulness, and serious rule violations. These comorbidities are particularly important as they predict more severe functional impairment, social difficulties, and a higher risk of juvenile delinquency[28].

Generalized anxiety disorder, separation anxiety, and social anxiety are frequently observed in children with ADHD. Anxiety can mask or mimic ADHD symptoms (e.g., in attention due to worry), making differential diagnosis challenging. Moreover, anxiety may influence the child’s response to stimulant medications and requires parallel treatment to address internalizing distress[29]. Major depressive disorder and disruptive mood dysregulation disorder are more prevalent in children with ADHD than in the general population. Children may present with irritability, low mood, or emotional lability, which can be mistakenly attributed solely to ADHD. Comorbid mood disorders increase the risk of suicidality, especially during adolescence, and must be carefully screened during ADHD evaluations[30].

ADHD and ASD often co-occur, with estimates suggesting 20%-50% overlap. While the DSM-5 now allows a dual diagnosis, differentiating the core attentional deficits of ADHD from the social communication deficits of ASD requires nuanced assessment. Children with both conditions tend to have more complex needs and require a multidisciplinary approach[31]. Tic disorders, including Tourette syndrome, are also more common in children with ADHD. Stimulant medications may exacerbate tics in some individuals, although this is not universally observed. The presence of tics may require adjustments in pharmacological management or consideration of behavioral therapies[32].

Sleep difficulties, such as insomnia, delayed sleep phase syndrome, and restless leg syndrome, are highly prevalent in children with ADHD. These disorders can worsen attention and behavior, and in some cases, mimic ADHD. Addressing sleep issues is a critical component of ADHD management[33]. The presence of comorbid conditions can complicate the diagnostic process and may alter treatment priorities. A comprehensive assessment should include a thorough history, collateral information from multiple informants, and appropriate use of screening tools. Management plans must be individualized, often requiring coordination with mental health professionals, educational specialists, and families to address the full spectrum of the child’s needs.

THE PEDIATRICIAN'S CENTRAL ROLE IN ADHD DIAGNOSIS

Pediatricians are the first point of contact when assessing children with behavioral or academic concerns, placing them at the forefront of identifying ADHD. Due to their ongoing relationships with families through regular health visits, immunizations, and developmental check-ups, pediatricians are uniquely positioned to recognize early signs of inattention, hyperactivity, and impulsiveness. Often, concerns about a child’s behavior are initially raised by parents or teachers, leading to pediatric consultations long before a mental health specialist becomes involved[34]. Within the pediatric setting, ADHD evaluation is complex and takes a holistic approach. The diagnostic process usually begins with a detailed clinical history covering developmental, academic, social, and family factors. Pediatricians are trained to observe behavior carefully during consultations and to inquire about symptom patterns across various settings (home, school, social environments), which is crucial for assessing symptom severity – a key aspect of diagnosing ADHD[35]. Standardized questionnaires completed by parents and teachers, such as the Vanderbilt ADHD Rating Scale or the ADHD Rating Scale-5, are often used to gather objective information. A comprehensive physical exam is also vital, not only to rule out medical conditions that mimic ADHD symptoms (e.g., vision or hearing problems, thyroid issues) but also to identify potential neurological or syndromic clues[36]. Table 4 highlights warning signs that may suggest alternative or additional diagnoses in ADHD assessment.

Table 4 Red flags suggesting alternative or additional diagnoses in attention-deficit/hyperactivity disorder evaluation.

Red flag	Possible alternative/comorbid diagnosis	Clinical considerations
Global developmental delay or speech-language regression	ASD, intellectual disability	Consider formal developmental assessment; atypical social interaction or communication delays may indicate ASD rather than ADHD
Sudden onset of attention issues or behavioral changes	Trauma, acute stress reaction, seizure disorder	Explore psychosocial history, trauma exposure, or neurologic causes (e.g., seizures or head injury)
Nighttime symptoms (e.g., restlessness, tiredness in day)	Sleep disorders (e.g., obstructive sleep apnea, restless legs syndrome)	Sleep studies or ear, nose, and throat referral may be needed; ADHD-like symptoms can result from poor sleep quality
Severe mood swings, irritability, or aggression	Pediatric bipolar disorder, disruptive mood dysregulation disorder	Consider psychiatric referral; ADHD rarely causes episodic rage or mood lability independent of context
Excessive worry, fearfulness, or physical complaints	Anxiety disorders	Anxiety can lead to poor attention and school avoidance; distinguish internalizing symptoms from inattentiveness
Social withdrawal, anhedonia, poor appetite or sleep	Depression	Mood screening is warranted if signs of low motivation, fatigue, or sadness dominate
Academic difficulties in reading, writing, or math only	Specific learning disorders	Targeted psychoeducational testing may be needed to rule out dyslexia, dysgraphia, or dyscalculia
Oppositional or defiant behavior predominates	ODD, conduct disorder	Consider whether attention problems are secondary to behavior regulation or environmental issues
Seizure-like episodes, staring spells	Absence seizures, epilepsy	Neurology consult or electroencephalography may be indicated; brief inattentive spells could be seizure activity
Hallucinations, paranoia, disorganized thinking	Early-onset psychosis	Rare in children; prompt psychiatric evaluation is critical

ADHD: Attention-deficit/hyperactivity disorder; ASD: Autism spectrum disorder; ODD: Oppositional defiant disorder.

The pediatrician’s role goes beyond initial screening; they are often responsible for coordinating referrals to psychologists, child psychiatrists, or educational specialists when necessary[37]. Additionally, pediatricians must evaluate common comorbidities – such as learning disorders, anxiety, or sleep disturbances – that could influence the presentation and treatment of ADHD[38]. Early diagnosis by pediatricians is crucial because early detection and intervention are closely linked to improved long-term outcomes. Prompt treatment – whether behavioral, educational, pharmacologic, or a combination – can significantly lessen academic difficulties, enhance social skills, and prevent secondary emotional and behavioral issues. In this way, pediatricians serve not just as diagnosticians but also as advocates, educators, and care coordinators in managing children with ADHD over time[39].

CHALLENGES FACED BY PAEDIATRICIANS

Although pediatricians are often the first healthcare professionals to evaluate children with suspected ADHD, they face a complex landscape of diagnostic challenges. From overlapping symptomatology with other neurodevelopmental and psychiatric conditions to subjective reporting, cultural influences, and systemic barriers, the pathway to an accurate diagnosis is rarely straightforward. These challenges are particularly pronounced in busy primary care settings, where time constraints, limited training in behavioral health, and restricted access to multidisciplinary resources further complicate the process. Understanding these barriers is essential to improving diagnostic accuracy and optimizing care for children with ADHD. Table 5 summaries these challenges.

Table 5 Challenges faced by pediatricians in attention-deficit/hyperactivity disorder diagnosis.

Problem	Key challenge	Description
Symptom overlap with other conditions	Overlapping presentations with other disorders	ADHD symptoms may resemble or coexist with conditions like autism spectrum disorder, anxiety, depression, learning disabilities, sleep disorders, or trauma, complicating differential diagnosis
Subjectivity in assessment	Reliance on subjective reports	Diagnosis depends heavily on parental and teacher observations, which can vary due to bias, setting (home vs school), and lack of objective behavioral tools
Cultural and societal influences	Influence of social norms and stigma	Cultural expectations may lead to misinterpretation of normal behaviors; stigma may delay help-seeking, and gender biases may result in underdiagnosis in girls
Parental and teacher bias	Inconsistent or biased reporting	Emotional, cultural, or educational factors can lead to under-reporting or over-reporting by parents and teachers, leading to diagnostic ambiguity
Time constraints and limited training	Limited time and inadequate behavioral training	Short consultation times and variable ADHD training during residency limit pediatricians’ ability to conduct detailed developmental assessments
Lack of access to multidisciplinary evaluation	Systemic barriers to specialist referral and evaluation	Long waitlists, fragmented pathways, geographic and financial disparities, and high pediatric workloads hinder access to comprehensive ADHD assessment

ADHD: Attention-deficit/hyperactivity disorder.

Symptoms overlap with other conditions

One of the most formidable challenges pediatricians face in diagnosing ADHD is the significant symptom overlap with other pediatric neurodevelopmental, psychiatric, and medical conditions. ADHD shares core features – such as inattention, hyperactivity, and impulsivity – with a broad range of disorders, making accurate differential diagnosis a complex task[40]. ADHD primarily impacts inhibition and sustained attention, leading to hyperactivity and inattention, while ASD is more associated with deficits in cognitive flexibility. Children with ASD often display difficulties with attention, sensory regulation, and social impulsivity that may be misinterpreted as ADHD. While both disorders can co-occur, distinguishing between them is essential because treatment strategies differ significantly[41]. In ASD, inattentiveness may stem from sensory overstimulation or restricted interests rather than true deficits in attention control. Social withdrawal or communication challenges seen in ASD may also mimic inattentiveness or disinterest typical of ADHD, leading to diagnostic confusion, especially in younger children[42]. Internalizing disorders like anxiety and depression frequently manifest with concentration difficulties, restlessness, and irritability – symptoms that strongly resemble ADHD[43]. However, in these cases, attention problems are typically secondary to emotional distress rather than core executive dysfunction. A child with generalized anxiety may appear inattentive because of excessive worry or preoccupation, while a depressed child may struggle with motivation and energy, leading to underperformance that mimics inattentiveness[44].

Learning disorders, such as dyslexia or dyscalculia, can also appear with seeming inattention, especially in school. A child who consistently struggles with reading or math may seem distracted or unmotivated, leading to suspicions of ADHD. However, these signs might stem from frustration or an inability to keep up due to a skill-specific deficit, rather than a widespread attention issue[45]. Sleep deprivation – whether from behavioral insomnia, obstructive sleep apnea, or other sleep problems – can cause daytime hyperactivity, poor focus, and emotional instability, resembling ADHD. Pediatricians should consider sleep habits as part of the diagnostic process, particularly in children with sudden or fluctuating symptoms of inattention and impulsivity[46].

The diagnostic process is further complicated by the fact that ADHD frequently coexists with many of these conditions. Studies suggest that up to 60%-80% of children with ADHD have at least one comorbid disorder, including oppositional defiant disorder (ODD), anxiety, depression, and learning disabilities. These comorbidities can obscure the primary diagnosis or alter the clinical presentation, making it difficult to determine whether ADHD is the primary issue or a secondary manifestation[44,47,48]. Disentangling primary ADHD from conditions that mimic or coexist with it requires careful clinical judgment (Table 6). Pediatricians must evaluate the full developmental history, symptom trajectory, environmental context, and multi-informant reports to determine the root cause of presenting symptoms. A one-size-fits-all approach is inadequate; instead, pediatricians must engage in a nuanced, case-by-case evaluation that considers the intricate interplay between neurodevelopmental, psychological, academic, and environmental factors[5]. The extensive symptom overlap between ADHD and other pediatric conditions underscores the importance of comprehensive, structured assessments. Without this, there is a risk of misdiagnosis or delayed intervention, which can have significant long-term consequences for the child’s development and well-being[49].

Table 6 Symptom overlap between attention-deficit/hyperactivity disorder and common mimicking/co-occurring conditions.

Condition	Overlapping symptoms with attention-deficit/hyperactivity disorder	Distinguishing features
Autism spectrum disorder	Inattention, impulsivity, hyperactivity, social difficulties	Restricted/repetitive behaviors, impaired social communication, sensory sensitivities, poor non-verbal cues, early developmental delays
Anxiety disorders	Restlessness, inattention, fidgeting, irritability	Worry, somatic complaints, symptoms worsen in specific situations, avoidance behavior, sleep disturbance tied to fear
Depression	Poor concentration, low motivation, irritability, social withdrawal	Anhedonia, persistent sadness, low energy, appetite/sleep changes, feelings of worthlessness
Learning disabilities (e.g., dyslexia)	Inattention, academic underachievement, task avoidance	Difficulty in specific academic domains (e.g., reading/spelling/math), performance improves with support, frustration limited to academic tasks
Sleep disorders (e.g., obstructive sleep apnea, insomnia)	Inattention, hyperactivity, emotional dysregulation	Snoring, restless sleep, daytime fatigue, symptoms improve with sleep correction, abrupt symptom onset
Oppositional defiant disorder	Impulsivity, defiance, difficulty following instructions	Intentional defiance, argumentative behavior, irritability toward authority, behavior mainly situational
Trauma/post-traumatic stress disorder	Inattention, irritability, hypervigilance, sleep problems	History of trauma, intrusive thoughts, avoidance behaviors, exaggerated startle response, emotional numbing

Clinical vignette: A complex diagnostic challenge in a pediatric setting

Case presentation: Omar, a 9-year-old boy, was brought to the pediatric clinic by his mother due to ongoing concerns about poor academic performance, forgetfulness, and difficulty following instructions both at home and at school. His teacher reported that he was frequently distracted in class, rarely completed assignments on time, and often left his seat without permission. Based on these concerns, his mother suspected that Omar had ADHD and requested an evaluation.

Initial assessment: During the clinical interview, Omar appeared friendly but restless, shifting in his chair and interrupting frequently. His mother described him as "always on the go" and "easily bored". A review of systems was unremarkable, and no significant perinatal or medical history was noted. The Vanderbilt ADHD Rating Scales were distributed to both the parent and teacher.

Diagnostic challenge: While the teacher’s Vanderbilt form reflected clear signs of inattention and hyperactivity consistent with ADHD, the parental form showed moderate concerns but did not meet diagnostic thresholds. Further questioning revealed that Omar’s symptoms worsened significantly only during math and reading activities. Interestingly, his behavior at home was relatively manageable, especially when engaged in video games or playtime.

A detailed academic history uncovered that Omar struggled with reading comprehension and had never fully mastered phonics, despite receiving average grades. A brief screening for learning disabilities suggested possible dyslexia. Moreover, the mother admitted that Omar had a disrupted sleep schedule, averaging only 5–6 hours of sleep per night due to late-night screen use.

Resolution: Given the context of selective academic difficulties, inconsistent symptom presentation across settings, and poor sleep hygiene, the pediatrician with held an immediate ADHD diagnosis. Instead, Omar was referred for psychoeducational testing and behavioral sleep counseling. A multidisciplinary approach was initiated, involving the school counselor and a child psychologist.

Key learning point: This case illustrates how overlapping conditions – such as SLDs and sleep deprivation – can mimic or exacerbate ADHD-like symptoms. It highlights the importance of a comprehensive and nuanced assessment, reinforcing the pediatrician’s role in avoiding premature or inaccurate labeling.

Subjectivity in assessment and informant bias

A key challenge in diagnosing ADHD is the heavy reliance on subjective assessments instead of objective clinical tests. Unlike conditions confirmed through laboratory tests or imaging, ADHD is diagnosed mainly through behavioral observations from multiple informants – most often parents and teachers. Although these perspectives are vital for assessing symptoms in different settings, they are naturally affected by a variety of personal, cultural, and contextual biases[50]. Parents may either underreport or overreport their child’s symptoms due to emotional factors like denial, guilt, or fear of stigma. Sometimes, parents downplay worries to avoid psychiatric labels, while at other times, they might unintentionally exaggerate symptoms out of frustration or to get school accommodations. Cultural beliefs also play a role; in many communities, hyperactivity or inattentiveness is viewed as a parenting fault or behavioral issue rather than a neurodevelopmental disorder, which can delay help-seeking or lead to inaccurate reports[51]. Teachers, meanwhile, offer valuable insights into behavior in structured academic settings. However, their observations can vary depending on factors such as training, classroom dynamics, personal expectations, and environmental conditions. A well-organized classroom with effective behavioral management may suppress ADHD symptoms, while an overstimulating or chaotic classroom might amplify them[52]. Additionally, differences between school environments and home life can lead to discrepancies between teacher and parent reports, which complicate the diagnostic process, especially since the DSM-5 requires symptoms to be present in at least two settings[53].

To standardize data collection, clinicians often utilize rating scales such as the Vanderbilt ADHD Diagnostic Rating Scales and the Conners Rating Scales. While helpful, these tools are not diagnostic on their own and rely heavily on how informants interpret questions. For example, items such as "often fidgets" or "has difficulty sustaining attention" may be understood and rated differently depending on the informant's expectations, experiences, and familiarity with child development[54]. Furthermore, ADHD symptoms may not be easily visible during short pediatric visits, which are often scheduled and time-constrained. Unlike some developmental disorders (e.g., autism), where key behaviors are evident during interaction, ADHD symptoms, such as inattention or impulsivity, might not show up in a clinical setting. This lack of standardized in-clinic behavioral observation means clinicians must primarily rely on second-hand reports, often without the opportunity to observe behaviors directly[55]. Adding to this complexity is the lack of objective diagnostic markers – such as imaging or laboratory tests – that can confirm or rule out ADHD. The clinical interview, while a cornerstone of evaluation, is also prone to bias and limited by time. Pediatricians must therefore balance empathy with skepticism, triangulate data from multiple informants, identify patterns overtime, and stay alert to alternative explanations like anxiety, learning disabilities, trauma, or sleep disorders[56]. Ultimately, improving the accuracy of ADHD diagnosis requires not only structured tools but also thoughtful interpretation of informant data. Pediatricians must approach each case with a critical eye, considering both the content and context of reports, while remaining attuned to the limitations inherent in subjective observation[57].

Cultural and societal influences

Cultural and societal contexts greatly influence how ADHD symptoms are identified, understood, and managed. These factors can directly impact how pediatricians diagnose and treat ADHD, often introducing subtle but significant biases that complicate the diagnostic process. Cultural norms strongly shape perceptions of what is considered "normal" childhood behavior[58]. In some cultures, high energy and impulsiveness may be seen as signs of creativity or liveliness rather than a disorder, leading to underdiagnosis of ADHD[59]. Conversely, in more academically competitive or discipline-oriented societies, even mild inattentiveness or restlessness can be viewed as problematic, increasing the risk of overdiagnosis[60]. Pediatricians must interpret behaviors with care and sensitivity from a culturally informed perspective, especially when working with families from diverse backgrounds. Failing to distinguish between culturally typical behavior and clinically significant symptoms can lead to both overdiagnosis and underdiagnosis, potentially impacting a child’s academic and social development over the long term[61].

Boys are diagnosed with ADHD at significantly higher rates than girls, partly because of gendered expressions of symptoms and societal expectations. Boys often display more obvious hyperactivity and impulsivity – behaviors that are disruptive and more likely to draw adult attention[62]. In contrast, girls tend to show inattentive symptoms, which can be mistaken for shyness, laziness, or low motivation, often leading to these issues being overlooked[63]. Additionally, educators and caregivers may have unconscious gender biases that color how behavior is perceived and reported. As a result, many girls with ADHD remain undiagnosed or are diagnosed later, typically only after developing secondary issues like anxiety, low self-esteem, or academic difficulties[64]. In many cultures, mental health disorders – including ADHD – are still highly stigmatized. Families might feel shame or fear social judgment if their child is labeled with a behavioral or psychiatric condition. This stigma can lead to underreporting symptoms, resistance to evaluation, or refusal of treatment, especially medications like stimulants[65]. Furthermore, some parents may minimize or deny behavioral concerns out of worries about labeling, academic exclusion, or being viewed as poor caregivers. Pediatricians need to handle these conversations thoughtfully, building trust while educating families about ADHD and the importance of early intervention[39].

Time constraints and limited training

A significant yet underrecognized challenge faced by pediatricians in diagnosing ADHD is the dual burden of limited time and insufficient specialized training. In the context of a busy general pediatric clinic, time constraints are a persistent obstacle. Appointments are typically brief and focused on immediate health concerns, leaving little opportunity for the in-depth developmental and behavioral assessments that ADHD diagnosis demands[66]. A comprehensive evaluation – including detailed history-taking, behavioral observation, analysis of rating scales, and differential diagnosis – often requires far more time than what is allotted in standard visits. As a result, pediatricians may struggle to collect adequate information across multiple settings or fully explore co-occurring symptoms and contextual factors that can mimic or mask ADHD[67]. Compounding this issue is the variability in training during pediatric residency programs. While general pediatrics curricula address developmental and behavioral conditions, the depth of exposure to ADHD-specific evaluation, management strategies, and comorbidity screening can differ substantially between institutions[68]. Many pediatricians report feeling underprepared to diagnose and manage complex behavioral disorders, especially when overlapping with conditions like ASD, anxiety, or learning disabilities. This lack of structured, hands-on training may lead to delayed recognition, overreliance on rating scales, or unnecessary referrals, further burdening specialty services[69]. Furthermore, without proper training, pediatricians might find it challenging to confidently differentiate between normal developmental behaviors and clinical disorders, especially in borderline or subtle cases. Diagnosing ADHD accurately requires not only clinical expertise but also familiarity with evolving diagnostic criteria and tools – resources often lacking in training and continuing medical education (CME)[70]. As a result, these gaps in knowledge and time constraints limit primary care pediatricians' ability to effectively identify ADHD, leading to delays in diagnosis and potentially hindering early intervention efforts.

Lack of access to multidisciplinary evaluation

An accurate diagnosis of ADHD often requires input from a multidisciplinary team, including child psychologists, psychiatrists, educational specialists, and sometimes neurologists. However, access to such comprehensive evaluation services remains a significant barrier, especially in resource-limited or underserved settings[71]. One common challenge is the long waiting lists for specialist appointments, with some families waiting months – if not longer – for assessments by child psychology or psychiatry services. These delays not only postpone diagnosis but also delay the start of interventions that could enhance academic performance and social development during critical childhood years[72].

Geographic and socioeconomic disparities further widen the gap in access to care. In rural or low-income areas, specialized centers for developmental and behavioral evaluations may be scarce or completely unavailable. Even in urban settings, disparities in access are clear, with families from lower socioeconomic backgrounds often unable to navigate fragmented referral systems or afford private assessments[73]. The lack of integrated care pathways worsens the situation; referrals from primary care to mental health or educational services are often disjointed, delayed, or poorly coordinated, leaving families without clear guidance or follow-up. Resource constraints also include cost and insurance barriers. Comprehensive evaluations – especially those involving neuropsychological testing – can be costly, and not all insurance plans provide enough coverage for behavioral and developmental assessments. For families paying out-of-pocket, this financial burden may discourage or even prevent pursuing a formal diagnosis[74].

Meanwhile, pediatricians, who are often expected to initiate and coordinate these assessments, face many constraints. High patient volumes, limited consultation time, and rising administrative duties make it hard for them to conduct thorough developmental evaluations. While some attempt to offset this with screening tools or follow-ups, the lack of specialized support decreases diagnostic confidence. This increases the risk of either underdiagnosis or misdiagnosis[75]. Overall, these systemic issues underscore a pressing need for healthcare systems to enhance access to multidisciplinary care, streamline referral processes, and invest in integrated behavioral health services within primary care, particularly in underserved areas. Without such structural changes, pediatricians will continue to struggle with providing timely and accurate ADHD diagnoses[76].

CONSEQUENCES OF DELAYED OR INACCURATE DIAGNOSIS

Delayed or inaccurate diagnosis of ADHD can have profound and lasting consequences on a child’s development, family dynamics, and long-term mental health (Table 7). One of the most immediate and visible impacts is academic underachievement. Children with undiagnosed or misdiagnosed ADHD often struggle with attention, impulse control, task completion, and organization – all of which are critical for school success[77]. These difficulties may be misinterpreted by educators and parents as laziness or defiance, leading to negative labeling and disciplinary actions rather than the provision of appropriate support and intervention. Over time, repeated academic failure can erode self-esteem and motivation, setting the stage for disengagement from learning and reduced educational attainment[78].

Table 7 Practice implications of delayed or inaccurate attention-deficit/hyperactivity disorder diagnosis.

Consequences of delayed ADHD diagnosis
Misdiagnosed ADHD often presents as academic failure and behavioral issues
Delays increase family stress and disrupt home dynamics
Risk of comorbidities (e.g., anxiety, depression, oppositional defiant disorder) rises with untreated ADHD
Missed early intervention leads to entrenched symptoms and harder treatment
Accurate, timely diagnosis improves outcomes across education, behavior, and mental health

ADHD: Attention-deficit/hyperactivity disorder.

Family stress is another significant consequence. In the absence of a precise diagnosis, caregivers may feel frustrated, helpless, or even blamed for their child’s behavior. Daily routines can become sources of conflict, particularly around homework, sleep, and behavioral expectations[79]. Siblings may also be affected by the disruptions and the disproportionate attention often given to the child with undiagnosed ADHD. This emotional strain can impact parental mental health and family cohesion, further complicating the child’s behavioral presentation[80]. Crucially, missed or inaccurate diagnoses increase the risk of developing comorbid psychiatric and behavioral conditions. Children with untreated ADHD are more likely to develop anxiety disorders, depression, ODD, conduct disorder, and substance use issues during adolescence and adulthood[78]. These conditions may remain hidden until they reach a crisis point, requiring more intensive interventions later on. Early recognition and appropriate management of ADHD can prevent or mitigate the severity of these co-occurring disorders[81].

Another important consequence of diagnostic delays is missing the opportunity for early intervention. Behavioral therapies, school accommodations, parent training, and, when appropriate, medication can greatly improve a child’s functioning if started early[82]. However, without a prompt and accurate diagnosis, these evidence-based treatments are often not provided or not implemented correctly. The longer the delay, the more deeply rooted the behavioral, academic, and emotional issues may become, making later treatment more challenging and less effective. A delayed or incorrect ADHD diagnosis creates a ripple effect beyond the individual child, impacting educational progress, family well-being, and future mental health. Recognizing these risks underscores the importance of accurate, timely, and well-informed diagnostic practices in pediatric settings[83].

PROPOSED SOLUTIONS AND EMERGING APPROACHES

Different solutions could help pediatricians address challenges in diagnosing children with ADHD, summarized in Figure 2.

Figure 2 Proposed solutions to diagnostic challenges in pediatric attention-deficit/hyperactivity disorder.

Development and implementation of improved screening and diagnostic tools

As the demand for timely and accurate ADHD diagnosis continues to grow, there is a pressing need for improved screening and diagnostic tools that overcome the limitations of current subjective and fragmented methods. Emerging technologies – especially digital health innovations and artificial intelligence (AI) – offer promising potential to support pediatricians with more efficient, standardized, and accessible evaluation processes. Validated digital tools, including AI-assisted screening platforms, are being created to help combine data from multiple informants and identify behavioral patterns that suggest ADHD. These tools can provide initial risk assessments, highlight inconsistencies, and even produce structured reports to aid clinical decision-making[84]. Real-time digital platforms' inputs from parents and teachers are another essential development. These systems facilitate quick collection of behavior ratings from home and school, reducing delays and enhancing the consistency of reports from multiple informants[85]. Some platforms incorporate standardized rating scales, such as the Vanderbilt or Conners forms, enabling automatic scoring and comparison to normative data. Additionally, mobile behavior-tracking apps are used by caregivers and educators to record specific behaviors and changes in symptoms over time, providing a more detailed and dynamic perspective than static questionnaires alone[86].

To reduce subjectivity, researchers have explored adding objective measures to ADHD assessment. Continuous performance tests (CPTs), which assess sustained attention, impulsivity, and response inhibition under controlled conditions, are increasingly utilized to support diagnostic interviews. Although still limited by accessibility and interpretative variability, CPTs provide measurable data that can aid clinical judgment[87]. Looking ahead, neuroimaging and electroencephalography (EEG)-based biomarkers are being researched to identify neurophysiological signs of ADHD. However, their routine use in clinical settings remains limited by cost, practicality, and a lack of validation for standalone diagnosis[88]. Importantly, there is a growing recognition of the need for culturally sensitive tools. Many rating scales and screening methods have been developed and standardized within Western populations, which limits their effectiveness across different cultural and linguistic groups[89]. Future efforts should focus on creating and validating tools that include local norms and educational standards, especially in multicultural and low-resource settings[90].

Technology-assisted screening, while not a replacement for clinical judgment, can serve as an essential support for overburdened pediatricians. Utilizing digital platforms for data collection, behavior monitoring, and initial analysis can help pediatric practices enhance diagnostic accuracy, minimize delays, and make informed referrals when necessary. When thoughtfully applied, these innovations have the potential to make the ADHD diagnostic process more objective, fair, and efficient[91].

Multidisciplinary collaboration

Effective diagnosis and management of ADHD increasingly require a collaborative, multidisciplinary approach that leverages the expertise of professionals across medical, psychological, and educational fields[92]. Pediatricians, as the first point of contact, are well-positioned to lead these efforts by forming partnerships with child psychologists, psychiatrists, school counselors, and other specialists. Such collaboration not only improves diagnostic accuracy but also guarantees comprehensive and personalized care plans[93]. Pediatrician-psychologist collaborations are especially valuable for integrating structured behavioral assessments, cognitive testing, and evidence-based therapies into the child’s care. These alliances can reduce dependence on subjective evaluations and provide pediatricians with specialized insights to guide treatment decisions[94]. School-based ADHD teams – including special educators, school psychologists, and counselors – can also play a central role in both identifying and monitoring symptoms in the classroom setting. Regular communication between pediatricians and school staff helps bridge gaps between medical and educational perspectives, providing a more complete picture of the child’s functioning across different environments[95]. Meanwhile, collaboration with child psychiatry is essential, especially for complex or comorbid cases that need medication management or further diagnostic clarification. In areas where child psychiatrists are limited, shared care models can be used, where pediatricians handle routine ADHD cases with consultative support from mental health professionals[96].

Strong referral networks are vital to this multidisciplinary approach. Clear referral pathways to child psychiatrists, psychologists, neurologists, and educational specialists make the diagnostic process smoother and help families navigate the system more easily[37]. These networks should be well-organized, prompt, and attentive to the specific needs of each case, preventing fragmentation and overlapping care. Additionally, shared care models that focus on ongoing collaboration rather than one-time consultations are increasingly seen as best practice, especially in areas with limited mental health resources[97].

Central to all collaborative efforts is the need for clear, consistent, and two-way communication. Effective communication strategies – whether through written reports, shared electronic health records, or case conferences – ensure that pediatricians, teachers, parents, and specialists consistently understand the child’s needs and progress[98]. When multidisciplinary collaboration is fully achieved, it enables pediatricians to make better-informed decisions, supports early intervention, and ultimately improves outcomes for children with ADHD.

Capacity building for pediatricians

Given their frontline role in identifying and managing ADHD, pediatricians must be equipped with the necessary skills, knowledge, and tools to handle the complexity of this condition. Building capacity in behavioral pediatrics through targeted training and ongoing professional development is essential for improving diagnostic accuracy and confidence[38]. A key strategy is the integration of comprehensive CME programs focused on behavioral and developmental disorders. These programs can improve pediatricians’ ability to differentiate ADHD from other conditions, recognize comorbidities, and apply evidence-based assessment tools more accurately[37]. Structured diagnosis templates and checklists – based on established guidelines like those from the AAP or NICE – can help pediatricians systematically gather clinical data, reduce assessment variability, and ensure no critical elements are missed. These templates also serve as a valuable framework during short consultations, guiding history-taking, behavior evaluation, and referral decisions[99,100].

ADHD-specific training should be emphasized during both residency and post-graduate education, with particular focus on nuanced presentations, symptom overlap, and the interpretation of rating scales. Exposure to real-life case scenarios, role-play, and decision-making simulations can further reinforce diagnostic skills[101]. Additionally, telehealth consultations with child psychiatrists and developmental-behavioral pediatricians can offer timely support to general pediatricians managing complex cases, especially in underserved or rural areas. These virtual collaborations improve access to expert input without requiring the child to undergo multiple in-person evaluations[75]. Furthermore, the significance of ongoing professional development cannot be overstated. ADHD guidelines, tools, and research evolve quickly, and pediatricians must stay updated on these changes to follow best practices. Engaging in professional forums, workshops, journal clubs, and online learning platforms can promote continuous learning and clinical excellence[37]. By strengthening pediatricians' skills through structured training and practical support, healthcare systems can greatly enhance early detection, lower misdiagnosis rates, and provide more timely and effective care for children with ADHD.

Policy and system-level interventions

Addressing the diagnostic challenges of ADHD requires targeted policy reforms and systemic enhancements that support frontline clinicians, especially pediatricians, and improve access to comprehensive care. A vital step is to strengthen referral networks, ensuring timely and efficient routes to child psychologists, psychiatrists, neurologists, and educational specialists[92]. Policymakers should focus on creating integrated care systems where interdisciplinary teams can collaborate through shared protocols and communication platforms, thereby reducing delays and fragmentation in the diagnostic process. Centralized referral systems and regional ADHD centers can act as hubs for evaluation and management, aiding pediatricians in both urban and rural areas[102]. Insurance coverage for behavioral evaluations is another crucial aspect of fair ADHD care. In many areas, comprehensive assessments – especially psychological testing – are underfunded or not covered by insurance, causing financial hardship for families and leading to disparities in diagnosis. Policymakers should advocate for broader coverage that includes initial evaluations, follow-up visits, and essential diagnostic tools, such as rating scales and neuropsychological tests. Increasing public health funding to support these services in community clinics and schools can help reach underserved populations[103].

Furthermore, implementing national ADHD diagnostic protocols can significantly reduce variability in clinical practice. Standardized guidelines – developed or approved at the national level – promote consistency in symptom assessment, use of validated tools, referral criteria, and documentation procedures[38]. These protocols should be culturally sensitive and adaptable to local contexts while aligning with evidence-based international standards such as those from the AAP, the NICE, or the WHO. National training programs and quality assurance initiatives can also support the adoption and proper implementation of these protocols[104]. Ultimately, policy-level actions can provide the structural support pediatricians need to deliver accurate, timely, and comprehensive ADHD diagnoses. By reducing systemic barriers, encouraging interdisciplinary collaboration, and advancing standardized care pathways, health systems can better address the needs of children with ADHD and improve long-term developmental and psychosocial outcomes[39].

Empowering parents and teachers

Parents and teachers are essential partners in identifying and managing ADHD, providing valuable observational data from home and school. Their effectiveness relies heavily on their understanding of the condition. Therefore, education and awareness efforts are crucial to empower these key stakeholders[105]. Providing accessible, evidence-based resources about ADHD – including symptoms, developmental stages, and common comorbidities – can help clarify the condition and reduce stigma. Training programs, workshops, and informational handouts designed for both caregivers and educators can facilitate earlier symptom recognition and foster more informed interactions with healthcare providers[71].

In addition to general education, pediatricians and mental health professionals should offer structured guidance on how to observe and report behaviors objectively. Parental and teacher reports are often influenced by stress, expectations, or limited understanding of age-appropriate behavior, which can lead to over-reporting or under-reporting of symptoms[53]. Structured reporting tools, such as the Vanderbilt or Conners rating scales, can help standardize observations and reduce subjectivity. However, these tools work best when informants receive proper instructions on how to complete them. Providing brief orientations or explanatory notes alongside rating scales can significantly improve the quality and reliability of the gathered information[21].

Furthermore, fostering ongoing communication between home and school, supported by behavior logs or digital tracking tools, can provide pediatricians with a long-term, context-specific view of the child’s functioning. When parents and teachers have the knowledge and tools to observe, document, and communicate effectively, their contributions to the diagnostic process become not only more accurate but also more helpful[106]. Empowering these stakeholders ultimately improves early detection, supports shared decision-making, and leads to more personalized and effective interventions for children with ADHD[107].

PATIENT AND FAMILY PERSPECTIVE

For many families, the journey to an ADHD diagnosis is marked by frustration, confusion, and emotional strain. Caregivers often report that their concerns are initially dismissed as parenting issues or normal developmental variation[108]. One mother shared, “I felt like I was failing as a parent – teachers said my son was disruptive, doctors told me to be stricter, but I knew something deeper was wrong”. This sense of being unheard is common, particularly in cultures where mental health carries stigma or where behavioral issues are attributed to discipline rather than neurodevelopmental causes[109]. The impact extends beyond the child; strained family relationships, academic struggles, and social isolation compound the stress. When a diagnosis is finally made, it often brings both relief and new challenges: (1) Navigating treatment options; (2) Managing school accommodations; and (3) Adjusting family routines[110]. Integrating caregiver voices into the diagnostic process not only affirms their role but also enhances the accuracy and cultural sensitivity of the assessment. Ultimately, listening to families is not just compassionate – it is clinically essential[111].

FUTURE DIRECTIONS

As understanding of ADHD continues to grow, future progress in neuroscience, genetics, and digital health could improve diagnostic accuracy. However, these innovations are mostly still in the research stage and should be approached with caution, scientific rigor, and ethical sensitivity. One area of ongoing research is the search for biological markers and neuroimaging indicators that might provide objective confirmation of ADHD. Techniques like functional magnetic resonance imaging, EEG, and other imaging methods have shown some structural and functional brain differences in people with ADHD, especially in areas related to executive function, attention control, and impulse regulation. Despite these findings, current neuroimaging tools lack the sensitivity, specificity, and reliability required for clinical use. They are costly, can vary between individuals, and pose ethical questions about labeling based on incomplete or poorly understood brain data. Currently, neuroimaging is primarily a research tool rather than a diagnostic standard.

Meanwhile, the use of AI and machine learning continues to grow in behavioral health. AI-based tools are being created to analyze behavioral data, rating scale responses, and electronic health records to identify patterns associated with ADHD. These tools may, in the future, aid in risk prediction, stratification, and even the planning of tailored interventions. However, their clinical application is currently limited by a lack of validation across diverse pediatric populations. Importantly, relying too heavily on AI-generated results without appropriate human oversight could introduce bias, hide clinical nuances, or lead to decisions that lack transparency. Ensuring fairness in algorithms, clear interpretability for clinicians, and data privacy are essential for responsible AI use. Another promising yet complex field involves genetic research. Genome-wide association studies have identified several genetic variants linked to increased ADHD risk, emphasizing its heritable nature. However, the predictive ability of these variants remains too weak for regular diagnostic purposes. There are also ethical concerns related to genetic labeling, including stigmatization, misuse of information, and impacts on family dynamics. Currently, genetic testing is not advised for ADHD diagnosis, though it might someday aid in risk assessment or personalized treatment within a broader clinical context.

Notably, while innovations in neuroscience, AI, and genetics might greatly influence the future of ADHD diagnostics, these tools are not yet ready to replace established clinical practices. Until they are fully validated and ethically implemented, diagnosing ADHD will still rely on clinical judgment, structured assessments, informant reports, and multidisciplinary teamwork. Responsible integration of new technologies should support – not substitute – the detailed expertise of pediatricians and mental health professionals.

Key clinical pearls for pediatricians diagnosing ADHD

Think broadly, act early: (1) ADHD symptoms often overlap with anxiety, ASD, learning disabilities, and sleep disorders; and (2) Use structured checklists and DSM-5/ICD-11 criteria to guide diagnostic reasoning.

Use validated tools thoughtfully: (1) Combine tools like Vanderbilt or conners scales with detailed history and behavioral observations; and (2) Educate informants (parents/teachers) on how to complete forms objectively.

Respect cultural contexts: (1) Be aware of local stigma and beliefs that may delay help-seeking or influence reporting; and (2) Use culturally validated tools where possible.

Communicate and collaborate: (1) Coordinate with school staff, psychologists, and families to gather multi-setting perspectives; and (2) Establish referral links to mental health services for complex cases.

Don’t delay intervention: Early diagnosis leads to better outcomes. Begin behavioral interventions and accommodations while awaiting formal evaluations if clinical suspicion is high.

Know when to refer: Refer when there is diagnostic uncertainty, comorbid psychiatric concerns, or limited progress despite interventions.

LIMITATIONS

While this review offers a comprehensive overview of the challenges pediatricians face when diagnosing ADHD and examines emerging solutions, several limitations need to be acknowledged. First, the review is narrative rather than systematic, which could introduce selection bias in source selection and potentially overlook relevant studies or alternative perspectives. The lack of a formal methodology also raises the risk of confirmation bias, particularly in a single-author review where interpretations might unintentionally reflect the author's preexisting views or clinical experiences.

Although efforts were made to include evidence from different regions, most of the referenced research and clinical guidelines come from high-income Western countries, which may limit the applicability of the findings to under-resourced or culturally different settings, including parts of the MENA and Arabian Gulf regions. Additionally, while focusing on the pediatrician’s perspective adds clinical value, it does not fully reflect the multidisciplinary viewpoints of psychologists, educators, and child psychiatrists involved in ADHD care. Equally important, the voices of children and caregivers – whose lived experiences, beliefs, and cultural interpretations greatly influence the diagnostic process – are not directly included in this review.

Furthermore, while emerging technologies such as AI-assisted diagnostics and neuroimaging are discussed as future directions, these fields are rapidly advancing, and some content may become outdated as new discoveries are made. The usefulness of digital screening tools and behavior-tracking platforms also varies widely and remains largely unstandardized, requiring more validation in diverse clinical settings. Finally, although this review addresses key diagnostic challenges, such as comorbidity, subjectivity, and systemic constraints, many of the proposed solutions remain conceptual or are in the early stages of implementation. More empirical research is necessary to evaluate their effectiveness, especially in primary care, where time, training, and support infrastructure are often limited. Despite these limitations, this review provides a practical and regionally informed overview of diagnostic barriers and new strategies, aiming to inform clinical practice and encourage further research in pediatric ADHD diagnosis.

CONCLUSION

Diagnosing ADHD remains a complicated and detailed process, especially in general pediatric practice. Although it is one of the most common neurodevelopmental disorders in children, correctly identifying it is often challenging due to several factors. These include significant symptom overlap with other developmental, psychiatric, and behavioral conditions; subjective differences in parent and teacher reports; cultural and societal influences that can skew perception and reporting of symptoms; and limited access to multidisciplinary evaluations caused by systemic, geographic, and financial barriers. Pediatricians, as the first contact for concerned families, are essential in managing these challenges; however, they often lack the time, specialized training, and support required for thorough assessments. This review highlights the vital role pediatricians play not only in recognizing ADHD but also in coordinating care, guiding families, and initiating interventions that can greatly influence a child's developmental course. To do this effectively, there is an urgent need for better diagnostic tools, including validated screening methods and technology-supported platforms; structured, accessible training during residency and ongoing medical education; and stronger systems of interdisciplinary collaboration connecting primary care with mental health, education, and community support services. Moving forward, health systems need to invest in solutions that empower pediatricians – through policy reforms, greater integration with behavioral specialists, and culturally sensitive resources – so they can provide timely, evidence-based ADHD diagnoses. Focusing on these strategic areas will not only improve diagnostic accuracy but will also enhance the care pathway for many children with ADHD, especially in underserved and culturally diverse regions.