Attention-Deficit/Hyperactivity Disorder With Family Relational Challenges and Persistent Gender-Nonconforming Expression in a Preadolescent Girl: A Case Report

Attention-deficit/hyperactivity disorder (ADHD) in girls may be overlooked or diagnosed late because symptoms can be influenced by emotional dysregulation, compensatory behavior, and family or social context. We describe a 10-year-old girl who was referred for impaired concentration, impulsivity, academic disruption, and aggressive peer interactions. A comprehensive behavioral assessment supported a diagnosis of ADHD, combined presentation. Clinical evaluation also identified substantial conflict involving her parents, twin sister, and grandmother, together with a longstanding pattern of gender-nonconforming expression. Treatment consisted of individual psychotherapy, behavioral parent training, school accommodations, and family-based interventions targeting emotional regulation, executive functioning, and relational conflict. After six months, caregivers and teachers reported fewer aggressive incidents, improved classroom participation, and better emotional regulation, although attentional difficulties persisted. This case illustrates the importance of evaluating ADHD within the child's developmental, educational, and family contexts while distinguishing gender expression from gender identity. Individualized, nonjudgmental, and developmentally appropriate care can address neurodevelopmental impairment without pathologizing a child's personal expression.