Assessing the Prevalence of Attention Deficit Hyperactivity Disorder (ADHD) Symptoms in Undiagnosed Young Adults:A Cross Sectional Study
Conditions: Finding the Prevalence of ADHD in Undiagnosed Young Adults
Sponsor: Jinnah Sindh Medical University

oAssessing the Prevalence of Attention Deficit Hyperactivity Disorder 
(ADHD) Symptoms in Undiagnosed Young Adults: A Cross-Sectional study 
Aina Marzia Syed 1, Fazeel Nasir 2, Ayesha Shakeel 3, Wajiha Ahmed 3, Rameen Khanzada 4 
 
Abstract Word Count: 478 
ABSTRACT 
Introduction 
Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder with symptoms such 
as inattention, hyperactivity, and impulsivity. It often goes undiagnosed, especially in countries with 
limited mental health awareness like Pakistan.  
Methodology 
 200 participants of age group 18-24 years living in in Karachi, Pakistan were surveyed using the Adult 
ADHD Self-Report Scale (ASRS) V1.1 and demographic questions. Part A of the questionnaire assessed 
Attention-deficit and Part B assessed Hyperactivity. Scoring and data analysis was done using SPSS 25, 
employing descriptive statistics to examine symptom prevalence, associations with mental health 
perceptions, and stigma’s influence on help-seeking behaviour.  
Results: 
The survey consisted of 140 female participants (70%) and 60 male participants (30%). 47% of 
participants exhibited inattention symptoms while 37% displayed hyperactivity/impulsivity symptoms.  
Gender and age did not have a significant influence on symptom scores, although females showed a 
slightly higher prevalence of both inattention and hyperactivity/impulsivity symptoms compared to males. 
About 47% of females and 42% of males displayed inattention symptoms, while 50% of females and 33% 
of males exhibited hyperactivity or impulsivity symptoms. The 18-20 age group consistently exhibited a 
slightly higher prevalence of symptoms, but this trend was not statistically significant. In the 18-20 age 
group, 37.9% exceeded the symptom threshold for inattention, while 39.7% surpassed the threshold for 
hyperactivity or impulsivity symptoms. Stigma was evident as 58% of participants expressed discomfort 
discussing mental health with family members, while 30% reported discomfort with friends. 41% of 
participants lacked awareness of ADHD.  76% lacked therapist resources within their educational 
institutions, and 10% expressed discomfort in seeking psychiatric help. 
Conclusion: 
Peer support and open mental health discussions within families is needed. Contrary to expectations, it 
found persistent ADHD symptoms across age groups, challenging the belief in symptom decline with age. 
Targeted interventions are required to address ADHD symptoms in undiagnosed young adults. 
Key Words: ADHD, Attention-deficit hyperactivity disorder, Young Adults, Social Stigma, Pakistan.  
.  
Introduction 

Attention-deficit/hyperactivity disorder (ADHD) is defined as a behavioural condition that leads to 
difficulty paying attention outside the normal bounds and hyperactive impulsive behaviour  1. 
It is a condition that is becoming increasingly common in children. Diagnostic and Statistical Manual of 
Mental Disorders, version IV, incorporated 'Adult ADHD' into the diagnostic criteria that are difficult to 
diagnose and recognize 2. It is diagnosed mainly by the presentation of several specific behaviours noticed 
by parents in their young children. As mental health awareness spreads, the number of children being 
diagnosed with ADHD is on the rise 3. However, in a country like Pakistan, where a vast majority do not 
possess the knowledge or access to mental healthcare, a great number of children transcend into adulthood 
undiagnosed, and their symptoms persist and pose a hurdle in their normal day to day life. Due to the lack 
of mental health awareness and stigma surrounding mental health issues in Pakistan especially amongst the 
lower socioeconomic classes, children with ADHD are often left undiagnosed and carry on into their adult 
life unaware of how to manage the disorder 4. Patients are hesitant to seek mental help due to the fear of 
being seen as a misfit in society. They also fear being discriminated against socially. 
Adults with ADHD often dismiss their symptoms and shortcomings, and this causes to them lead chaotic 
lifestyles, often leading to substance abuse and difficulty integrating into society 5. If such individuals lack 
access to proper mental healthcare, they are more likely to struggle in academics, face unemployment, and 
display violent behavior. As their academics, social and personal lives grow, undiagnosed ADHD can often 
lead them to fall behind their classmates, have trouble socialising and fall into a spiral which can often lead 
to them becoming a misfit in their surroundings 6. Treatment of adult ADHD leads to an emotionally stable, 
safer lifestyle, leading to an improved quality of life (e.g., safer driving, reduced criminality) 7. No figures 
are available for Pakistan however studies in the West have been conducted. The estimated lifetime 
prevalence of ADHD in the US. adults aged 18-44 years were 8.1% 8. 
ADHD has been found to be highly heritable and influenced by factors such as environmental risk factors 
and low birth weight. Serious head injuries, meningitis, hydrocephalus, and brain surgery can also increase 
the risk of developing ADHD 9. Comorbidity is associated with ADHD, and developmental and learning 
problems, such as Autistic Spectrum Disorder, speech difficulties, and several psychiatric conditions, often 
co-occur with ADHD 10. 
 A timely diagnosis and proper assistance can completely change the trajectory of a young person's life as 
they ascend into adulthood.  It is important to study the exhibition of behavioural patterns indicating ADHD 
being displayed by young adults dealing with increasing levels of stress and responsibilities 11. Studies like 
this have not yet been conducted in Pakistan. Thus, this cross-sectional study aims to fill the gaps and assess 
the frequency of undiagnosed ADHD among young adults in Pakistan. 
Methodology 
The aim of this descriptive cross-sectional study was to investigate the potential link between the lack of 
mental health awareness, access to mental healthcare, and high scores on the Adult ADHD Self-Report 
Scale (ASRS) V1.1 among young adults in Karachi, Pakistan. The study also sought to compare the results 
between male, female, and non-binary participants, as well as different age groups (18-20, 20-22, and 22-
24 years). The study was conducted after obtaining approval from the Institutional Review Board (IRB) at 
Jinnah Sindh Medical University.  
The participants in this study were young adults between the age bracket of 18-24 years, residing in Karachi, 
Pakistan. The inclusion criteria comprised individuals within the specified age range and living in the city. 
Exclusion criteria included participants who had been diagnosed with ADHD, were diagnosed and being 

treated for some other mental disorder or previously had chronic anxiety and or depression. The exclusion 
of coexisting mental disorders enhances clarity in understanding the unique impact of ADHD. Additionally, 
those residing outside Karachi were excluded from the study. The sample size was determined to be 200 
based on the World Health Organization (WHO) calculator, using a 5% margin of error and a 95% 
confidence interval. 
Data collection for this study was conducted using an online survey hosted on the Google Forms platform. 
To ensure an efficient and widespread distribution of the survey, researchers utilized various digital 
platforms, including social media, university mailing lists, and online community forums. The survey link 
was shared with the target audience, which consisted of young adults aged 18-24 residing in Karachi, 
Pakistan. 
The online survey was designed to be user-friendly and accessible across different devices, such as 
computers, tablets, and smartphones. Participants could access the survey at their convenience, enabling 
them to respond to the questionnaire at a time and location of their choosing. This approach aimed to 
maximize participation and gather responses from a diverse and representative sample of the target 
population. 
Before beginning the survey, participants were provided with a clear and concise introduction that outlined 
the study's objectives, assured data confidentiality, and emphasized the voluntary nature of their 
participation and their informed consent was taken. This ensured ethical compliance throughout the data 
collection process. 
The questionnaire utilized in this study was meticulously developed to comprehensively assess various 
aspects related to ADHD symptoms, mental health awareness, access to mental healthcare, and perceptions 
about psychiatric diagnoses among young adults aged 18-24 residing in Karachi, Pakistan. It consisted of 
two main sections: demographic information and additional questions, followed by the ADHD Self-Report 
Scale (ASRS) V1.1. 
The demographic section collected essential information about the participants, including their gender, with 
response options for Male, Female, or Non-binary, and their age, categorized into three brackets: 18-20, 
21-22, and 22-24 years. 
  
The additional questions aimed to delve deeper into the participants' mental health status and perceptions. 
They inquired about any prior diagnoses of specific mental health conditions, such as Anxiety, Depression, 
Bipolar Disorder, and obsessive-compulsive disorder. Participants were asked to assess their comfort level 
in discussing mental health issues with both their family and friends, using a rating scale ranging from 
"Very Comfortable" to "Very Uncomfortable." They were also questioned about their beliefs concerning 
whether a psychiatric diagnosis might unfairly limit their career prospects and other areas. 
Moreover, participants were asked about their knowledge of ADHD, with response options for "Yes," "No," 
or "I have a vague idea." Additionally, they were inquired whether they had ever accessed therapists at their 
past or current educational institute, with response options of "Yes" or "No." 
The centerpiece of the questionnaire was the ADHD Self-Report Scale (ASRS) V1.1. This scale consisted 
of 18 items and served to evaluate ADHD symptoms in adults aged 18 and above. It was adapted from the 
World Health Organization Composite International Diagnostic Interview and aligned with the DSM 
criteria for ADHD in adults. The ASRS consisted of two parts, Part A and Part B. Part A comprised the 
first six questions (items 1-6). Participants were asked to rate how often they experienced certain ADHD 

symptoms, ranging from "Never" to "Very Often." A score of 4 or more on Part A indicated a symptom 
profile similar to that of an adult with ADHD. 
Part B of the ASRS consisted of the next 12 questions (items 7-18). This section provided additional cues 
and probes into the severity and impact of inattention or hyperactivity symptoms on participants' lives. 
Participants provided frequency scores for each item to aid in further evaluation. 
The questionnaire encompassed a comprehensive assessment tool, combining demographic information, 
supplementary questions, and the ASRS, to thoroughly explore the link between mental health awareness, 
access to mental healthcare, and high scores on the ADHD Self-Report Scale among different age groups 
and genders in Karachi, Pakistan. 
Data Analysis: 
The scoring of the ASRS V1.1 questionnaire involved assigning points to each item based on participants' 
responses. "For Part A, items 1 to 6 were evaluated using a range of 0 to 6, where responses of 'Never' 
received 0 points, 'Rarely' received 1 point, 'Sometimes' received 2 points, 'Often' received 3 points, and 
'Very Often' received 4 points. Participants who scored 4 or more in Part A were identified as having a 
symptom profile similar to that on an adult with ADHD. 
Similarly, for Part B, items 7 to 18 were evaluated using a scale that ranged from 0 to 6, with "Never" 
receiving 0 points, "Rarely" receiving 1 point, "Sometimes" receiving 2 points, "Often" receiving 3 
points, and "Very Often" receiving 4 points. The total score for Part B ranged from 0 to 12. Participants 
who scored 6 or more in Part B were considered to have more severe hyperactivity or impulsivity 
symptoms. 
Additionally, a total score was calculated by summing the scores from both Part A and Part B, resulting in 
a range of 0 to 18. The total score was then converted into a percentile, providing context for each 
participant's responses compared to normative data from 22,397 adults. A percentile of 90, for example, 
showed that the participant outperformed 90 percent of other average adults their age. 
 
The collected data were entered into SPSS 25 for statistical processing and underwent comprehensive 
statistical analysis to address the research questions. Firstly, the male-female-nonbinary ratio was 
calculated to understand the distribution of gender among participants. The percentage of participants in 
each age group (18-20, 21-22, and 22-24 years) was determined to examine the age distribution.  
Further analysis included cross-tabulations to examine associations between inattention and hyperactivity 
symptoms and variables related to mental health awareness and access to mental healthcare.  
The number of participants who scored 4 or more in Part A and 6 or more in Part B was computed. This 
provided insight into the prevalence of ADHD-like symptoms among research participants. Further 
analysis involved exploring associations between symptom scores and participants' responses to specific 
questions. For instance, the study calculated how many participants who scored 4 or more in Part A also 
answered 'Very uncomfortable' on questions 4 and 5 
Furthermore, the study analyzed how many participants who scored 4 or more in Part A answered "No" or 
"Vague Idea" on question 7, assessing their familiarity with ADHD. Question 6 inquired about whether 
the participant felt a diagnosis would hinder their career. 

The data analysis extended to investigating participants' comfort levels in seeing a psychiatrist if needed 
(question 9). Specifically, the study calculated the number of participants who answered, "Very 
Uncomfortable" and "Uncomfortable" on question 9 to gauge potential barriers to seeking mental health 
care. It also calculated how many participants answered "Yes" on question 8, which inquired about the 
availability of therapists at their educational institute.  
To explore associations between inattention and hyperactivity symptoms with mental health awareness 
and access to mental healthcare, Chi-square tests were employed. To measure the degree of relationship, 
the Phi correlation coefficient was calculated, with a significance level set at P < 0.05 to identify 
statistically significant associations. 
Throughout the data analysis process, appropriate statistical methods were used to provide meaningful 
insights into the relationships between lack of mental health awareness, access to mental healthcare, and 
high scores on the ASRS, while accounting for potential demographic variations among the study 
participants.  
Ethical Considerations: 
Throughout the research process, strict adherence to ethical guidelines was paramount to ensure the 
protection, rights, and well-being of the participants. The study was carried out in compliance with the 
principles mentioned in the Helsinki Declaration and the procedures established by the researchers' 
institution's Institutional Review Board (IRB). Prior to data collection, every participant provided 
informed consent. Each participant had been informed of the explicit descriptions of the study's aims, the 
voluntary nature of participation, confidentiality assurances, and the ability to withdraw at any time 
without consequence. Participants were specifically assured that their personal information and replies 
would be kept completely confidential and would only be available to the research team. 
To minimize potential biases and ensure the validity and reliability of the findings, several measures were 
implemented throughout the study.  Firstly, the sampling technique employed was non-probability 
convenient sampling, allowing participants to voluntarily respond to the survey. To reduce selection bias, 
the research team made diligent efforts to disseminate the survey across diverse digital platforms, 
targeting a wide range of young adults residing in Karachi. 
Moreover, the survey design itself aimed to be impartial and unbiased. The questionnaire, including the 
ADHD ASRS and additional questions, was meticulously constructed to be clear, objective, and free from 
leading or suggestive language. The response options for each question were carefully structured to avoid 
any inherent bias. The research team-maintained vigilance against potential researcher bias during the 
data collection and analysis process. Steps were taken to remain neutral and objective, ensuring that 
personal beliefs or opinions did not influence the interpretation of the results. 
Furthermore, data privacy and confidentiality were given utmost importance to protect the identity and 
sensitive information of the participants. Access to the survey responses and the data collected was 
limited to authorized members of the research team, ensuring that participant anonymity was preserved. 
By adhering to rigorous ethical guidelines and implementing measures to minimize bias, the study aimed 
to maintain the highest standards of integrity, respect for participants' autonomy, and the validity of the 
research findings. 
 
Results 

Participant Demographics and Gender Distribution: 
The investigation into the frequency of undiagnosed ADHD among young adults in Karachi, Pakistan, 
unfolded with the participation of 200 diverse individuals. This cohort composition allowed for a 
comprehensive exploration of the subject matter. Notably, gender distribution within the sample was 
balanced, with 70% women who participated (n=140) and 30% men who participated (n=60), ensuring a 
robust representation of both sexes. 
Gender-Stratified Analysis of Scores Related to ADHD: 
Among the 140 female participants, 64 individuals (45.7%) exhibited symptoms exceeding the threshold 
of 4 in Part A of the scores derived from the ADHD Self-Report Scale (ASRS) V1.1. In comparison, 
among the 60 male participants, 25 individuals (41.7%) showcased similar inattention symptoms. This 
slight numerical difference suggests a marginally higher prevalence of inattention symptoms among 
female participants. In Part B of the ASRS, 70 females (50%) surpassed the threshold of 6, indicating 
heightened hyperactivity or impulsivity symptoms. Comparatively, 20 males (33.3%) exhibited symptoms 
surpassing 6 in Part B. This discrepancy suggests that females displayed a more prominent tendency 
toward hyperactivity or impulsivity symptoms in this context. As seen in Figure 2, for both gender pf 
participants, the mean score in Part A of the ADHD Self-Report Scale (ASRS) was 3.38, reflecting a 
certain proclivity towards inattention symptoms. Additionally, the mean score for males in Part B was 
5.38 compared to 5.1 for females indicative of a propensity for more pronounced hyperactivity or 
impulsivity traits. The cumulative total mean score for women was 8.76. Conversely, male participants 
showcased slightly lower scores, with a cumulative total mean of 8.36. Independent t-tests revealed no 
statistically significant gender differences in symptom scores (Part A: t=-0.854, p=0.394; Part B: t=-
1.071, p=0.286; Total: t=-0.781, p=0.436), highlighting gender parity in ADHD symptom expression. 
 
Age-Stratified Exploration of Symptom Prevalence: 
 The distribution of participants across distinct age brackets and its influence on the prevalence of ADHD 
symptoms within the studied cohort became a significant point of investigation. To comprehensively 
explore this relationship, a Chi-square test for independence was applied. Among the participants, a 
substantial 69% belonged to the dynamic 18-20 age range, signifying the early stages of adulthood. The 
subsequent age bracket, comprising 21–22-year-olds, constituted 24%, while the oldest age group, 
spanning 22-24 years, accounted for 7% of the participants. 
Upon delving further, the interplay between gender and age underscored these trends. Among females, a 
significant 70% were situated within the 18-20 age range, whereas 22% fell into the 21-22 age group, and 
7.1% belonged to the 22-24 age group. Similarly, for males, the distribution encompassed 65% (18-20 
age group), 28.3% (21-22 age group), and 6.7% (22-24 age group). The notable prevalence of the 18-20 
age group persisted consistently across both genders. 
The Chi-square test for independence aimed to ascertain the correlation between age groups and the 
proportion of participants exceeding symptom thresholds. Within the context of age groups, the pivotal 
role of age in influencing ADHD symptom prevalence was illuminated. In the 18-20 age group, 59 
participants, representing 37.9%, surpassed the threshold of 4 in Part A. This number stood at 29 for the 
21-22 age group (36.7%), and 6 for the 22-24 age group (27.3%). Similarly, in Part B, 62 participants in 
the 18-20 age group (39.7%), 23 in the 21-22 age group (29.1%), and 6 in the 22-24 age group (27.3%) 
surpassed the threshold of 6. 
The Chi-square test for independence evaluated the observed distribution of participants across age 
groups against the assumption of independence between age groups and symptom prevalence. The results 

indicated that age did not exert a statistically significant influence on the prevalence of ADHD symptoms 
among the studied cohort (Part A: χ²=1.429, p=0.489; Part B: χ²=0.572, p=0.751). This insight 
underscores the consistent prevalence of symptoms across the different age groups. 
Correlation Assessment: 
Upon exploration, no statistically significant correlation was established between age and ADHD symptoms 
(Pearson correlation measure r = 0.112, p = 0.116). While age is a crucial dimension, this implies that other 
intricate factors contribute to the presentation of ADHD symptoms among adolescents. 
Comprehensions of Mental Health and Knowledge of ADHD:  
Varying appreciations of psychological wellness within the context of ADHD were reflected, and participants 
expressed their apprehensiveness when discussing internal health across an assortment of degrees. In response 
to the question 'How comfortable would you feel talking about your internal health with your family?', 58 
participants chose 'Very Uncomfortable,' while 30 participants chose the same response for conversations with 
friends. Chi-square tests demonstrated a significant association between comfort in discussing psychological 
health with family and age (χ ² = 9.568, p = 0.008), disclosing that younger participants were more likely to 
feel uncomfortable.  
 
Likewise, the review uncovered an information gap, with 82 participants responding that they had limited 
knowledge or a vague awareness of ADHD. Age didn't predict knowledge levels, as was supported by the 
logistic regression analysis that there was no revelatory association between knowledge of ADHD and age (β = 
-0.063, p = 0.284). 
 
Availability of Therapeutic Resources and Obstacles to Seeking Help:  
Delving into the availability of therapeutic resources revealed a concerning trend, with 152 participants 
indicating a lack of inaccessibility of therapists at their educational institutes. This underscores implicit gaps in 
mental health support within educational settings. Strikingly, 19 participants expressed apprehension at the 
prospect of seeking psychiatric aid, as substantiated by their response to the question 'How comfortable would 
you feel seeing a psychiatrist if you felt the need?' 
 
 
 
 
 
 
Discussion  
3.1 Demographic Insights: Influence of Age on Survey Participation and ADHD 
Symptomatology 
As seen in Figure 1, the sample consisted predominantly of new adults and university students as 69% of 
the total participants lie in the age range of 18-20 years, 24% fall between the ages 21-22, and only 7% 
are between the ages of 22-24. Following a similar pattern, the majority of responses across both genders 
came from the age bracket 18-20. (It was observed that out of a total of 60 male participants, 65% also 
belonged to the 18-20 age group. Furthermore, out of a total of 140 female participants, 70% of women 
who responded also fall in the 18-20 age group.)  This observation suggests a potential influence of the 

investigators' age group, indicating a higher reach and approachability towards females in the 18-20 
category Additionally, this shows that females in this age group were more approachable and forthcoming 
towards the topic and displayed an overall higher percentage of willingness to participate in the study. 
This trend supports previous findings that women have been reported as more likely to participate in 
surveys and research studies 12.  
 In part A of the questionnaire, 94 people scored above 4. Indicating a strong level of 
agreement/relatability with inattention and focus-related symptoms of ADHD. Similarly, an almost equal 
number of participants surpassed the threshold of 6 for part B which targeted hyperactivity and 
impulsivity-related symptoms. Although, as prefrontal cortex development nears completion towards the 
mid and late 20s, general adolescent impulsivity and other behavioral and psychosocial problems tend to 
show a gradual decline. A greater sense of prioritization, compartmentalization, and the general ability to 
manage day-to-day stresses is observed to show a consistent increase before physiological/age-related 
physical and cognitive decline begins. This remains consistent with the reduction in the frequency of 
people who self-report or get diagnosed with ADHD as adults 13.  
There is no significant statistically significant connection between age and the prevalence of ADHD 
symptoms since symptoms prevail consistently across all age groups as a similar amount of people 
surpassed the threshold of 6 for part B which targeted hyperactivity and impulsivity-related symptoms. 
3.2 Gender Disparities in ADHD Scores 
As seen in Figure 3, the percentage of female participants who scored more than 4 in Part A (45.7%) was 
higher than the percentage of their male counterparts who scored more than 4 in Part A (41.6%). This 
result is statistically insignificant. However, females showing a higher frequency is not consistent with 
other studies. A similar study was conducted to assess ADHD in Pakistani medical students and found 
that male students showed a higher frequency compared to female students 27.According to a National 
Comorbidity Survey, males (5.4%) were more likely to have ADHD than females (3.5%)28.However, 
these statistics may be because females are less likely to show externalizing behaviors and are thus less 
likely to be diagnosed. The available evidence also indicates that women are less inclined than men to 
display typical ADHD symptoms, such as acting impulsively and disruptively 29, 30. However, there is still 
little information on how sex/gender and immunology affect neurodevelopmental disorders 31. The 
correlation of gender with ADHD has not been fully investigated and future studies should explore this 
further. 
 
3.3 Social Support Dynamics and Familial Challenges in Mental Health Disclosure  
The role of a strong social support system in the recovery of psychiatric patients plays a quintessential 
role in preventing relapses and encouraging recovery 14. Participants expressed their hesitance and 
reservations when asked if they would be comfortable opening up to their families and friends about their 
mental health struggles. However, seeking support from among friends was given preference over seeking 
support from family members as evidenced by 58 responses for “very uncomfortable” when discussing 
mental health with their families in contrast to only 30 responses choosing the same when given the 
choice of discussing their mental health with their friends. 
It is notably more consequential to involve family members with challenges in mental wellness, there are 
more financial and social implications for the families of those caring for people who struggle with their 
mental well-being 15. Due to the stigma surrounding mental health and the apprehension of facing 
rejection within the context of a joint family structure, children with developmental problems in Pakistan 
reported considerable levels of self-stigmatization. They may hesitate to open up to others due to the 
possibility of judgment and labels that often accompany it 16. Individuals who expressed discomfort when 

talking to their loved ones about their mental health were more likely to have ADHD symptoms. This 
indicates that mental health stigma and fear of rejection remain one of the reasons behind their 
undiagnosed ADHD. 
It is understandable that people do not wish to strain the limited resources present at home and to shelter 
their caregivers from the implications of such a diagnosis or self-admittance 17.There are fewer practical 
and long-term consequences when reaching out to friends since the support given and asked for does not 
impact as many aspects of the lives of those reaching out and those providing help. Additionally, there 
may be religious reservations and their social repercussions that discourage those in need to reach out i.e. 
the widespread lack of awareness of ADHD and other psychiatric disorders which leads to inadequacy in 
providing support and patient care outside of related healthcare and wellness centers.  These individuals 
also scored more than 4 in Part A. This indicates that mental health stigma and fear of rejection remain 
one of the reasons behind undiagnosed ADHD. 
3.4 The Pervasive Lack of ADHD Awareness and Implications for Stigmatization and 
Educational Gaps 
82 participants had a “vague” or “no” idea about ADHD. This also fuels the stigmatization and largescale 
prejudice toward those personally seeking help for mental health-related concerns or clinically diagnosed 
with ADHD or one of its comorbidities thus perpetuating the issue of misrepresentation.  The lack of 
knowledge and awareness about ADHD has significant implications for individuals seeking help for 
mental health-related concerns or those clinically diagnosed with ADHD.  
Research has shown that there are substantial gaps in understanding ADHD, particularly among certain 
demographic groups. For instance, studies have reported that men, individuals from non-white ethnic 
backgrounds, and older people have the largest gaps in knowledge about ADHD 18. Caregivers of children 
with ADHD have been found to hold various misconceptions about the etiologies of this disorder 19. This 
lack of understanding extends to teachers as well, with studies indicating that practicing teachers and 
undergraduate education students have significant gaps in knowledge and attitudes about ADHD 20. This 
can result in inadequate support and a less inclusive learning environment for students with ADHD. 
Insufficient knowledge may lead to challenges in providing tailored interventions, potentially contributing 
to misunderstandings and stigma within educational settings. Comprehensive training is essential to 
address these knowledge gaps, fostering a more supportive and empathetic environment for students with 
ADHD. 
Additionally, misconceptions about ADHD have been found to persist among the public, with a 
substantial portion of participants expressing reluctance towards pharmacological treatment for ADHD 21. 
These misconceptions and lack of awareness contribute to stigmatizing experiences reported by children 
with ADHD and their parents. Insufficient understanding and expertise in the management of ADHD 
among general practitioners has been identified as a notable barrier to implementing effective ADHD 
programs in pediatric settings 22. The pervasive lack of knowledge and misconceptions about ADHD 
among various groups, including caregivers, teachers, and the public, underscores the urgent need for 
targeted educational initiatives and interventions to address these issues and reduce the stigma associated 
with ADHD. 
3.5 Psychiatric Engagement Challenges in Evolving Mental Health Dynamics and Systemic 
Complexities 

The results indicated that 19 people felt they would feel “very uncomfortable” seeing a psychiatrist. This 
is directly related to the aforementioned factors. On the contrary, this low turnover is supportive of the 
fact that there has been a change in attitudes toward ADHD and mental disorders among the newer 
generations, especially in the literate population. 
Mental health is usually the last to be addressed, as the greater population has not been educated about 
what it means and how to deal with challenges that arise. Often, we are taught to push away unpleasant 
thoughts, feelings, experiences, and sensations instead of addressing them. There is also a known scarcity 
of mental health professionals and experts in the country 23. Out of 200, 152 participants did not have a 
therapist made available in their educational institutions. In a developing country such as Pakistan, the 
availability of allied specialist services is limited. This challenge is further exacerbated by a lack of 
awareness among parents, teachers, and health professionals. This is evident in the low rates of referrals 
from schools24. As a result of this lack of support, young adults with ADHD are more prone to 
experiencing mental health problems, substance abuse problems, academic difficulties, drop out of 
school, to be unemployed, and to have a criminal record than young adults without ADHD25, 26. 
92 participants chose ‘YES’ on Question 6: Do you believe a psychiatric diagnosis would unfairly limit 
your chances in your career and otherwise? Due to the stigma and lack of awareness about ADHD, 
Pakistan does not have a system that accommodates people with ADHD. Participants fear that they may 
get discriminated against and or have limited job opportunities. Individuals with ADHD are often 
stereotyped to be irresponsible and unreliable. ADHD symptoms are often perceived as character 
weakness, unreliability, immaturity, impoliteness and emotional dysfunctionality 32. This perception may 
cause employers to be less likely to hire people diagnosed with ADHD. 
3.6 Pharmacological Interventions in ADHD: Efficacy and Treatment Outcomes 
Attention-Deficit/Hyperactivity Disorder (ADHD) poses persistent challenges across the lifespan of those 
affected, and medication has emerged as a vital element in its comprehensive management. Notably, 
individuals who consistently adhere to ADHD medication regimens experience significantly better 
academic, employment, and social outcomes compared to non-medicated counterparts33. This underscores 
the substantial, long-term advantages associated with the sustained use of medication, indicating its 
positive impact on diverse aspects of life. 
Based on the studies, subsequent monitoring of children treated for combined type ADHD in a multisite 
study revealed that medication management and behavior therapy were effective in reducing ADHD 
symptoms 34,35. Additionally there is evidence supporting periodic evaluation of discontinuing medication 
trials to assess ongoing necessity 36. Pharmacological treatments, such as psychostimulants, have been 
indicated to be effective in addressing the fundamental symptoms of ADHD and reducing the risk of 
injuries requiring hospitalization 37,38. Moreover, medications have demonstrated efficacy in alleviating 
ADHD symptoms in children with pervasive developmental disorders 39. Variables like parental beliefs 
and attitudes toward treatment have been linked to the initiation and sustained use of ADHD 
medication40. Therefore, the effectiveness of stimulant medication in diminishing ADHD 
symptomatology among individuals diagnosed with ADHD has been confirmed 41. 
It is vital to educate and raise awareness to establish a safe and accommodating environment for people 
diagnosed with ADHD so that they may receive the treatment and care that they require. Stigma is 
frequently combated by means of education 42,43. This will make individuals more willing to get a 
screening done early in life enabling them to reach their full potential. 
 

Limitations: 
This study offers a crucial glimpse into the frequency of undiagnosed ADHD among young adults in 
Karachi, Pakistan. However, it's important to acknowledge certain limitations that could impact the 
interpretation of the findings. 
The reliance on self-reported data presents a potential source of bias. Participants may exhibit recall bias 
or social desirability bias, potentially affecting the accuracy of reported ADHD symptoms and mental 
health perceptions. This might lead to an underestimation or overestimation of the true prevalence and 
severity of symptoms. 
The DSM-IV-TR criteria for diagnosing ADHD have limitations, particularly in their applicability to 
young adults and college students. The current diagnostic criteria, although more suitable for school-age 
children, may not adequately capture developmental changes in the expression of core symptoms. It's 
noteworthy that young adults, including college students, might exhibit significant ADHD 
symptomatology compared to their peers of the same age without meeting the DSM-IV diagnostic criteria 
44. Another methodological limitation is that studies on ADHD in college students have had small 
convenience sampling and due to the self-reporting technique employed it could not be determined 
whether students qualify for an ADHD diagnosis or not, thus an accurate estimate of ADHD cannot be 
attained. 
Consistent methods with clinical support and full diagnostic criteria should be used to counter this, 
however, such a study would entail greater investments of time and other resources. Furthermore, 
symptomatology in adults with ADHD does not manifest in the same manner as it does in children, and 
most of the diagnostic criteria are better tailored for pediatric diagnosis rather than for adult ADHD. 
Addressing these potential biases and limitations, several measures were implemented to enhance the data 
quality. Participants were given clear and concise instructions, underscoring the significance of providing 
honest and accurate responses. Participants were assured of anonymity and confidentiality to foster a 
climate that encourages the provision of truthful information. 
Furthermore, the survey distribution spanned various digital platforms, aiming to capture a more diverse 
range of participants and minimize selection bias. The questionnaire's design was meticulously crafted to 
minimize leading questions and suggestive language. Standardized scales, such as the ADHD ASRS, 
were utilized to improve the reliability of symptom assessment. Ethical considerations were meticulously 
upheld throughout the study. The study adhered to informed consent procedures, ensuring that 
participants were thoroughly briefed on the study's purpose and their rights. 
Conclusion 
The findings show the complex interplay of factors related to ADHD symptoms, such as gender, age, 
mental health awareness, stigma, and access to care. The study's implications provide helpful insights for 
developing targeted therapies. Initiatives to raise mental health awareness and destigmatize mental illness 
are critical. We can establish safe spaces for young adults to seek treatment without fear of judgement or 
discrimination if we foster an environment that supports open dialogues about mental health. 
Collaboration between educational institutions, healthcare providers, and the community can help to 
create this conducive environment. While this study gives useful insights, it also recommends areas for 
additional research. Future studies could go deeper into identifying the unique obstacles that different age 
groups and genders confront. Investigating the efficacy of awareness campaigns, mental health support 
structures, and focused interventions can help to refine ways for dealing with undiagnosed ADHD. 

Longitudinal studies that follow individuals over time can also provide a more comprehensive knowledge 
of how ADHD symptoms grow and are influenced by numerous factors. Incorporating clinical tests 
alongside self-reported data can improve diagnostic accuracy while also shedding light on any associated 
diseases that may effect ADHD symptoms. 
 
 
 
 
 
     
 
 
 
 
 
 
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 Tables and figures 
Table 1 
Demographic 
Characteristics 
 
 
 
Female Participants 
(n=140) 
Male Participants 
(n=60) 
Total (n=200) 
 
Mean Age (years) 
18-20 
18-20 
18-20 
Age Groups (%) 
 
 
 
- 18-20 
70.7% 
65% 
69.0% 
- 21-22 
22.1% 
28.3% 
24.0% 
-22-24 
7.1% 
6.7% 
7.0% 
ASRS V1.1 scores. 
(%) 
Female Participants 
(n=140) 
 
Male Participants 
(n=60) 
 
 
- Part A (Mean) 
3.38 (SD: 1.20) 
3.38 (SD: 1.20) 
3.34 (SD: 1.21) 
- Part B (Mean) 
5.38 (SD: 1.49) 
5.10 (SD: 1.45) 
5.28 (SD: 1.47) 
- Total Score (Mean) 
8.76 (SD: 2.47) 
8.36 (SD: 2.37) 
8.62 (SD: 2.44) 
ADHD Symptom 
Prevalence (%) 
Female Participants 
(n=140) 
Male Participants 
(n=60) 
 

 
 
- Part A (Score ≥ 4) 
45.7% 
41.7% 
47.0% 
- Part B (Score ≥ 6) 
50.0% 
33.3% 
45.5% 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 1. 

 
 
 
 
 
 
 
 
 
 
 
Figure 2. 

 

Figure 3.