Why Were So Many Girls and Women Missed for ADHD and Autism Diagnoses?
The diagnostic language changed. Our understanding changed. And many girls learned to look “fine” even when they were struggling.
“Why weren’t you diagnosed when you were a kid?”
I’m 54, and I’ve heard versions of this question more than once. The simplest answer is that the labels and frameworks used today were different when I was growing up. Some diagnoses did not yet exist in their current form. Others were defined in ways that made many girls’ and women’s experiences easier to miss.
That history does not explain every late diagnosis. It does help explain why a person can look back at childhood and recognize longstanding patterns that the adults around her did not identify at the time.
The names and criteria changed
In the United States, autism was described before it became a separate diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM). DSM-II, published in 1968, classified severe early developmental differences under childhood schizophrenia. DSM-III introduced “infantile autism” as a distinct diagnosis in 1980. DSM-III-R later changed the term to “autistic disorder” and used criteria intended to apply across a wider range of ages and developmental levels (Rosen et al., 2021).
The diagnostic language for ADHD also developed over time. DSM-II used “Hyperkinetic Reaction of Childhood.” In 1980, DSM-III introduced “Attention Deficit Disorder,” with or without hyperactivity. DSM-III-R adopted the name “Attention-Deficit Hyperactivity Disorder” in 1987 (Lange et al., 2010).
These timelines matter when someone asks why a diagnosis was not made in childhood. For much of my childhood, the autism diagnosis now used in clinical practice was not yet available in the DSM. ADHD-related diagnoses existed, but the terminology and criteria were different from what clinicians use today.
Autism became a spectrum diagnosis
DSM-IV, published in 1994, included several diagnoses within the Pervasive Developmental Disorders category. These included Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder–Not Otherwise Specified (PDD-NOS).
DSM-5, published in 2013, brought several earlier diagnoses together under one diagnosis: Autism Spectrum Disorder (ASD). It also changed the diagnostic criteria. The categories were not simply renamed; the way clinicians determine whether someone meets criteria changed as well.
That shift has had practical consequences. In studies that reapplied DSM-5 criteria to people who had received earlier diagnoses, a portion—especially some people previously diagnosed with Asperger’s Disorder or PDD-NOS—did not meet the newer threshold. At the same time, DSM-5-TR says that people with a well-established DSM-IV diagnosis of Autistic Disorder, Asperger’s Disorder, or PDD-NOS should be given an ASD diagnosis (American Speech-Language-Hearing Association, n.d.; Smith et al., 2015).
So when people say that an earlier Asperger’s diagnosis does not always map neatly onto the current criteria, there is a real history behind that concern. It is also important to distinguish research re-evaluation from the DSM-5-TR guidance for people with an established prior diagnosis.
Why girls and women could be overlooked
A diagnostic framework is only useful if clinicians recognize the different ways people may show the traits it describes. Research reviews identify several barriers that can delay or obscure autism identification in girls and women, including differences in how traits are expressed, camouflaging, and other mental health concerns overshadowing autistic traits (Cook et al., 2024).
Social expectations can matter, too. Girls may be encouraged to be agreeable, attentive, organized, and socially responsive. Some learn to watch other people closely, imitate their behavior, rehearse what to say, or hide visible signs of discomfort. These strategies can make differences less apparent to a casual observer, even when the person is using significant effort to get through social situations.
Masking and camouflaging are not exclusive to women, and no single presentation applies to everyone. The point is that an assessment based only on what is easiest to observe may miss internal effort, sensory strain, confusion, or the cost of keeping up appearances.
ADHD can also be overlooked when difficulties are less disruptive or more internalized. A girl who is daydreamy, overwhelmed, disorganized, forgetful, or trying hard to compensate may draw less attention than a child whose behavior is visibly disruptive. Anxiety or depression may become the focus of care while ADHD-related difficulties remain unrecognized (Quinn & Madhoo, 2014).
And what if she gets good grades? Grades can tell us something about performance. They do not tell us how much time, stress, support, perfectionism, or recovery it took to achieve that performance. A child can be academically successful and still be struggling.
If a girl is quiet, compliant, or doing well on paper, adults may conclude that she is fine. That conclusion can miss the effort behind the outcome.
Rising diagnoses do not prove it is a fad
Diagnoses of ADHD and autism are more common now than they were in earlier decades. That increase is real in the data. But diagnosis rates alone cannot tell us how much reflects changes in underlying prevalence and how much reflects changes in awareness, diagnostic practice, or access to assessment.
For ADHD, the CDC notes that national estimates of parent-reported diagnoses have increased over time, but the data cannot establish whether that increase reflects a change in how many children have ADHD or a change in how many are diagnosed. For autism, the CDC identifies multiple factors that may influence differences in observed prevalence, including diagnostic practices and access to services (Centers for Disease Control and Prevention, 2024, n.d.).
A rise in identification does not, by itself, mean that being autistic or ADHD has become a trend. It can also reflect people who were previously missed finally recognizing themselves in a clearer description—or finally finding a clinician who understands what to look for.
That does not mean every person who wonders about ADHD or autism meets diagnostic criteria. It means that “more people are being identified” and “people are following a fad” are not the same claim.
Sometimes the framework was limited
When someone asks, “Why didn’t anyone notice?” the answer is not always that there was nothing to notice. The diagnostic language may not have existed yet. The criteria may have changed. A girl may have learned to mask. Her grades or behavior may have reassured the adults around her. Her distress may have been attributed to anxiety, mood, personality, or lack of effort.
A late diagnosis does not mean the traits suddenly appeared. Sometimes it means our understanding finally caught up with a life that had been there all along.
We have made progress in recognizing ADHD and autism across the lifespan. We still need diagnostic practices that account for different presentations, ask about internal effort and developmental history, and take the perspectives of girls and women seriously.
Sometimes there was plenty to notice. The signs simply did not match what people expected to see.
Darcy Stephens, LPCC
References
American Speech-Language-Hearing Association. (n.d.). Autism and autism spectrum disorder [Practice Portal]. Retrieved September 30, 2026, from https://www.asha.org/practice-portal/clinical-topics/autism/
Centers for Disease Control and Prevention. (2024, May 15). Facts about ADHD throughout the years. https://www.cdc.gov/adhd/data/adhd-throughout-the-years.html
Centers for Disease Control and Prevention. (n.d.). Frequently asked questions about autism spectrum disorder. https://www.cdc.gov/autism/faq/index.html
Cook, J., Hull, L., & Mandy, W. (2024). Improving diagnostic procedures in autism for girls and women: A narrative review. Neuropsychiatric Disease and Treatment, 20, 505–514. https://doi.org/10.2147/NDT.S372723
Lange, K. W., Reichl, S., Lange, K. M., Tucha, L., & Tucha, O. (2010). The history of attention deficit hyperactivity disorder. ADHD Attention Deficit and Hyperactivity Disorders, 2(4), 241–255. https://doi.org/10.1007/s12402-010-0045-8
Quinn, P. O., & Madhoo, M. (2014). A review of attention-deficit/hyperactivity disorder in women and girls: Uncovering this hidden diagnosis. The Primary Care Companion for CNS Disorders, 16(3), PCC.13r01596. https://doi.org/10.4088/PCC.13r01596
Rosen, N. E., Lord, C., & Volkmar, F. R. (2021). The diagnosis of autism: From Kanner to DSM-III to DSM-5 and beyond. Journal of Autism and Developmental Disorders, 51(12), 4253–4270. https://doi.org/10.1007/s10803-021-04904-1
Smith, I. C., Reichow, B., & Volkmar, F. R. (2015). The effects of DSM-5 criteria on number of individuals diagnosed with autism spectrum disorder: A systematic review. Journal of Autism and Developmental Disorders, 45(8), 2541–2552. https://doi.org/10.1007/s10803-015-2423-8
