Observations from a paediatric emergency department

Between September 2021 and July 2023 we implemented a systematic ADHD screening protocol for all adolescent patients presenting to the emergency department of ASUFC Udine (northern Italy) with DSH and/or suicidal ideation. Diagnostic interviews were conducted for those who screened positive. Through this protocol, we identified 58 adolescent females (mean age 14.9 years) presenting with DSH or suicidal ideation. Of these, 41 (70.7%) had never undergone any prior neuropsychiatric evaluation and 9 (15.5%) met the diagnostic criteria for ADHD. Remarkably, 8 out of 9 (88.9%) received their first-ever ADHD diagnosis during this presentation due to our active screening protocol. Every participant underwent a comprehensive psychodiagnostic assessment: (a) Columbia Suicide Severity Rating Scale (C-SSRS); (b) Motivational Interview for Suicidality (MIS); (c) Kiddie-Schedule for Affective Disorders and Schizophrenia (KSADS) interview; (d) Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD); and (e) Personality Inventory for DSM-5 questionnaire. In cases of suspected ADHD, additional assessments were conducted using tests from the Nepsy-II battery (A Developmental Neuropsychological Assessment, 2nd ed.). The diagnosis of ADHD was formulated according to DSM-5 criteria.

The comparative analysis revealed that females with ADHD (ADHD+) differed significantly from those without ADHD (ADHD–) across several domains. The ADHD+ group presented with greater impulsivity scores (p = 0.003) on MIS, and increased lethality of suicide attempts (p = 0.011) and elevated suicidal behaviour scores (p = 0.038) on C-SSRS. They also exhibited higher rates of conduct disorder (p < 0.001) on KSADS. Moreover, these patients showed more pronounced antisocial personality traits (p = 0.001) on SCID-5-PD.

The emergency department as a critical setting for ADHD screening and diagnosis

The prevalence of inattentive symptoms in females with ADHD, such as daydreaming, forgetfulness and organisational difficulties, makes the presentations less disruptive in school and home environments. Unlike the hyperactive–impulsive phenotype more commonly seen in males, the inattentive presentation does not usually lead to referrals in primary care or educational settings. ^{Reference Martin2,Reference Ward and Curran3} Additionally, females with ADHD are more prone to internalising problems such as anxiety, low self-esteem and depression, which can mask the underlying ADHD and lead to misdiagnosis as primary mood or anxiety disorders. ^{Reference Martin2,Reference Todzia-Kornaś, Szczegielniak and Gondek4}

Martin et al identified maternal depression, anxiety and early educational challenges as childhood antecedents in females with ADHD receiving a late diagnosis. ^{Reference Martin, Rouquette, Langley, Cooper, Sayal and Ford1} Data from our cohort indicate that early warning signs often remain under-recognised until an acute episode prompts urgent psychiatric evaluation. Consequently, the emergency department becomes a crucial diagnostic setting for identifying those patients who were missed by school-based screenings or primary care assessments.

Impulsivity as a critical mediator of risk

Impulsivity emerged as a key discriminator in our cohort, with ADHD+ females showing markedly elevated scores across several validated instruments. This finding has important clinical implications: impulsivity in the context of DSH and suicidality is particularly dangerous, because it may drive the selection of highly lethal methods and reduce the time available for clinical intervention, thereby increasing the risk of death by suicide. Impulsivity is also a well-established driver of suicide attempts, particularly when combined with emotional dysregulation. ^{Reference Lee, Gilbert, Waldman, Zarate and Ballard5} The significantly higher lethality scores identified in our ADHD+ group suggest that such attempts may be more dangerous, with less planning and fewer opportunities for intervention.

Martin et al reported odds ratios of 7.69 for DSH among later-diagnosed ADHD+ females compared with their ADHD– counterparts. ^{Reference Martin, Rouquette, Langley, Cooper, Sayal and Ford1} Our data suggest that this increased risk might be influenced by trait impulsivity and its interaction with acute emotional distress. Consistent with these observations, the pooled clinical prevalence of ADHD in paediatric populations presenting with DSH has been estimated at approximately 40%, ^{Reference Johnson, Lim, Jacoby, Faraone, Su and Solmi6} underscoring the importance of systematic screening in acute settings.

Implications for clinical practice and training

Several strategies must be implemented to improve the recognition of ADHD in females.

First, emergency department clinicians should be trained to screen for and evaluate ADHD as a differential diagnosis in adolescent females presenting with DSH, particularly when impulsivity and externalising traits are present. ^{Reference Chen and Taylor7,Reference Mowlem, Rosenqvist, Martin, Lichtenstein, Asherson and Larsson8}

Second, the finding that most of our cohort had never received prior neuropsychiatric evaluation indicates systemic failures in early detection. Teachers, school counsellors and primary care physicians require dedicated training on recognising the inattentive and combined presentations of ADHD with internalising symptoms in girls. ^{Reference Swanson, Owens and Hinshaw9} Poor academic performance, difficulties in relationships with peers and emerging mood disorders in school-aged girls should prompt an evaluation for ADHD, rather than attributing symptoms solely to anxiety or depression. ^{Reference Martin2}

Third, given that early diagnosis can serve as a protective factor against subsequent DSH and death by suicide, ^{Reference Martin, Rouquette, Langley, Cooper, Sayal and Ford1,Reference Chen and Taylor7} improving the identification of ADHD in females may prevent many adverse outcomes observed in those diagnosed later. Gender-sensitive assessment tools that accurately capture inattentive symptoms, emotional dysregulation and internalising comorbidities are urgently needed. ^{Reference Ward and Curran3,Reference Swanson, Owens and Hinshaw9}

Fourth, clinicians should be aware of the frequent misclassification of females with ADHD as having borderline personality disorder, given the considerable symptom overlap including emotional dysregulation, impulsivity and unstable interpersonal relationships. ^{Reference Todzia-Kornaś, Szczegielniak and Gondek4,Reference Swanson, Owens and Hinshaw9} Moreover, comorbid premenstrual dysphoric disorder and psychological trauma are probable additional contributing factors to DSH and suicidality in adolescent females with ADHD, and should be systematically assessed in emergency settings. ^{Reference Chen and Taylor7}

Martin et al have provided robust evidence that delayed ADHD diagnosis in females leads to poorer long-term outcomes. ^{Reference Martin, Rouquette, Langley, Cooper, Sayal and Ford1} Our observations complement their population-level findings suggesting that, for many female patients, the emergency department represents a critically important service contact for diagnosing ADHD and initiating treatment.

Coordinated, multi-level structural interventions are required to reduce diagnostic delays. The emergency department should serve as a safety net, rather than the primary point of identification for these patients. Further details are provided in the Supplementary Material available at https://doi.org/10.1192/bjp.2026.10875.