Gendered school expectations and ADHD recognition in an Ultra-Orthodox Jewish community: a qualitative study of parents, educators, and therapists

Abstract

Background

Attention Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental condition that manifests differently in boys and girls, often leading to disparities in diagnosis and treatment. In the Ultra-Orthodox Jewish (UOJ) community, where gender-segregated education is the norm, these differences may be further influenced by cultural and educational expectations. This study explores how gendered educational environments impact the recognition and treatment of ADHD in UOJ schools.

Methods

This qualitative descriptive study utilized a secondary analysis of previously collected focus group data. Four homogeneous focus groups were conducted (n = 25) with UOJ mothers and fathers of children with ADHD, educators, and occupational therapists. Conventional content analysis was used to identify key themes related to gender, ADHD recognition, school expectations, medication use, and parental advocacy.

Results

Four central themes emerged: (1) Gatekeeping of recognition; (2) Institutional fit/misfit; (3) Pharmacological compliance vs. personality preservation; and (4) Gendered care work. Despite challenges reported, participants noted a growing awareness of ADHD and increased acceptance of accommodations in some UOJ schools.

Conclusions

Findings highlight the complex interplay between gender, education, and ADHD recognition within a religiously structured community. While systemic barriers persist, evolving school practices and increased parental advocacy suggest gradual shifts toward more inclusive ADHD support. These insights underscore the need for culturally sensitive interventions, increased teacher training on ADHD, and expanded learning models to accommodate neurodiverse students. Future research should further explore gendered ADHD experiences in other religious and traditional educational settings.

Background

Attention Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental condition characterized by persistent patterns of inattention, hyperactivity, and impulsivity that interfere with daily functioning and development [1]. It is among the most frequently diagnosed childhood conditions, with a global prevalence of 5–7% [2]. Despite its widespread recognition, ADHD may manifest differently in boys and girls, often leading to disparities in diagnosis, intervention, and educational experiences [3].

Gender differences in ADHD recognition and treatment have been well-documented [4]. Boys are diagnosed at significantly higher rates than girls, with estimates suggesting a 2:1 or even 3:1 ratio in clinical settings [3, 5]. However, this disparity may likely reflect differences in symptom presentation rather than true prevalence. Boys are more likely to exhibit externalizing behaviors, such as hyperactivity and impulsivity, which are disruptive in classroom settings and more easily recognized by educators and healthcare professionals [5]. In contrast, girls tend to display internalizing symptoms, including inattentiveness and emotional dysregulation, which are often misinterpreted as anxiety, immaturity, or a lack of motivation rather than ADHD [5]. As a result, many girls remain undiagnosed or receive a diagnosis later in life, missing critical early interventions that could improve their long-term outcomes [3].

While gendered patterns of ADHD presentation have been observed across different countries and developmental stages [6, 7], research on these patterns within traditional or religiously segregated educational systems remains limited. These patterns of ADHD presentation may have implications for children’s educational trajectories [5] and self-perceptions [8]. Societal norms may influence ADHD recognition and treatment, particularly through gendered expectations in education. Across cultures, boys and girls are often socialized into distinct roles that shape how their behaviors are perceived and addressed within schools. Understanding these cultural variations is essential for informing ADHD diagnosis and treatment practices [9].

The Ultra-Orthodox Jewish (UOJ) community may provide a unique context in which to examine these dynamics. As a gender-segregated society with distinct educational structures, the UOJ community offers insight into how cultural traditions and gender norms may shape ADHD recognition and management. Boys and girls attend separate schools with curricula aligned with traditional gender roles [10]. Boys typically study in yeshivot or cheders (UOJ religious schools for boys only), where intensive religious learning, particularly Talmudic study, demands prolonged attention and discipline [11]. Conversely, girls attend religious schools such as Bais Yaakov (UOJ religious schools for girls only), with shorter school days and a curriculum that includes both religious and secular subjects [12]. This separation in educational experiences may contribute to gender-specific disparities in ADHD recognition and treatment. Unfortunately, there is limited data on the prevalence of ADHD in the UOJ population. This lack of prevalence research may also support the importance of examining how ADHD is recognized and addressed in UOJ schools, where gendered expectations and educational norms strongly shape children’s experiences.

Beyond the school setting, traditional gender roles in the UOJ community often shape expectations for both children and parents. Boys are often encouraged to pursue extended religious study, while girls are socialized toward diligence, organization, and modesty, with an implicit expectation of future roles as wives and mothers [10, 12]. In family life, fathers’ roles are frequently tied to scholarship [11], whereas mothers carry the main responsibility for childrearing, household management, and navigating educational or health-related services [12]. These social arrangements often influence how children’s behaviors are interpreted, who advocates for them in schools, and how ADHD is ultimately recognized and managed [9]. Understanding these cultural and educational influences is important for developing effective, culturally sensitive approaches that address the unique needs of boys and girls with ADHD in this cultural setting [9].

Given that ADHD diagnosis and treatment occur within multiple social and institutional settings [6, 7], the perspectives of key stakeholders, including parents, educators, and healthcare professionals, are essential. Parents play a critical role in navigating the diagnosis and treatment process, advocating for accommodations, and managing their child’s daily functioning [13]. Educators, as primary observers of children’s academic and behavioral challenges, often initiate referrals for evaluation [14]. Occupational therapists contribute specialized expertise in ADHD-related functional difficulties, executive function interventions, and school-based accommodations [15, 16].

In approaching these perspectives, this study adopts a social-constructionist lens, which views gender and culture as contextually shaped social processes rather than fixed attributes. Gender is understood not as a biological attribute but as the socially constructed roles, norms, and expectations that shape how children’s behaviors are perceived and valued within schools, while sex refers to biological characteristics. Likewise, culture is viewed as the shared values, practices, and social arrangements that organize community and educational life. Framing the study in this way may underscore how gender and culture may function as contextual forces that influence the recognition and treatment of ADHD in the UOJ community [3, 5, 9].

Thus, the present study explores how gendered educational expectations in the UOJ community influence the recognition and treatment of ADHD. The study aims to identify cultural challenges and opportunities for gender-sensitive support structures within educational settings by drawing on the perspectives of parents, educators, and occupational therapists. Within this manuscript, gendered educational expectations are defined as the cultural and institutional norms in UOJ schools that shape how children’s behaviors are interpreted, evaluated, and managed [9]. In contrast, the term experiences refers to the perspectives reported by stakeholders as they navigate ADHD within this context [9].

Methods

Study design

This qualitative descriptive study, which utilized focus groups as the primary data collection method, is a secondary analysis of previously collected data. The original study examined the experiences of mothering a child with ADHD in the Ultra- Orthodox Jewish (UOJ) community [17]. The secondary analysis, conducted with a distinct aim, explores how gendered educational expectations influence the recognition and treatment of ADHD within UOJ schools.

Secondary analysis of qualitative data is a valuable approach for maximizing data utility, particularly when working with hard-to-reach populations such as UOJ families, where participant recruitment can be challenging due to cultural sensitivities [18, 19]. Because qualitative research requires significant resources, secondary analysis provides an efficient and cost-effective method to examine the role of gender in ADHD experiences without the need for additional data collection. By leveraging rich existing datasets, this study provides new insights into the intersection of gender, education, and cultural influences on ADHD without requiring further data collection, ensuring that the full potential of previously gathered data is realized [18, 19].

While secondary analysis is not always appropriate, such as when research questions are unrelated or when too much time has elapsed since the original study, this approach was well-suited for the current study for several reasons. During the original data collection and analysis, it became evident that gender played a crucial role in shaping how ADHD was perceived, recognized, and managed within segregated UOJ educational settings [17]. This realization informed the research questions for the secondary analysis, ensuring that the new inquiry remained closely aligned with the original study [18]. By re-analyzing the data with a specific focus on gendered educational expectations, this study extends previous findings while providing new insights into the intersection of gender, education, and ADHD within a religious-cultural context. Furthermore, because the secondary analysis was conducted by the same research team following the original analysis, continuity in interpretation and methodological rigor was maintained. The findings generated here may serve as a foundation for future in-depth studies on gender, ADHD, and educational interventions in religious communities, further advancing knowledge in this under-researched area [18, 19].

Participants

Four homogeneous focus groups were conducted separately with UOJ mothers of children with ADHD, UOJ fathers of children with ADHD, educators, and occupational therapists. Inclusion criteria for participation varied by group to ensure relevance to the study’s objectives. For mothers and fathers, eligibility required having a child diagnosed with ADHD between the ages of six and 18 and self-identifying as UOJ in their religious affiliation. Parents were excluded from the study if they reported a major health condition (beyond ADHD) affecting themselves or a family member. Such conditions could significantly impact daily functioning and shift the focus away from the study’s primary aim. Educators were required to have experience working with children diagnosed with ADHD in UOJ schools. Occupational therapists were included in the study if they provided therapy services to children with ADHD and their families within the UOJ community.

Recruitment and procedure

Following approval from the university’s ethics board (#15112022), recruitment was conducted through social media groups, child development centers in UOJ neighborhoods (with permission from clinic administrators), and snowball sampling. The study advertisement outlined the research objectives and provided the author’s credentials and contact details. As an academic and occupational therapist from the UOJ community, the author conducted initial phone screenings to confirm participants’ eligibility.

One week prior to the focus groups, the participants received a consent form via email, which they reviewed and signed before participation. Upon providing consent, they completed a demographic questionnaire. Mothers were requested to provide information regarding their age, marital status, education level, employment status, number of children, and ADHD history (self and family). Fathers, occupational therapists and educators were requested information regarding their age, if they had themselves or had family members with ADHD, years of work experience, place of employment, and title of position (educators only). Once questionnaires were received, the first author coordinated focus group scheduling, ensuring availability and convenience for all participants. To maximize accessibility, focus groups were conducted via Zoom between December 2022 and February 2023. Each session, lasting 80 to 90 min, followed a semi-structured format, allowing guided discussions while encouraging open participant sharing.

Sample size

The number of focus groups and participants was determined based on established guidelines for qualitative research [20]. The sample size fell within the acceptable range of at least three focus groups with 4–12 participants in each group [20]. All sessions were recorded and transcribed verbatim, with anonymization procedures in place to protect participant confidentiality.

Data analysis

Conventional content analysis was used to examine the focus group qualitative data [21]. Given that this study is a secondary analysis, the transcripts of all focus group sessions, which originally focused on the development of an intervention, were systematically re-examined to extract only the discussions related to ADHD symptom expression and its impact within educational settings. This ensured that the analysis remained focused on the secondary research aim, rather than the broader intervention development discussed in the original study. All relevant excerpts were re-read multiple times to gain an in-depth understanding of the data. An inductive coding approach was applied, allowing themes to emerge directly from the data rather than being predetermined. The first stage of analysis involved initial coding, where key phrases, recurring concepts, and notable patterns were identified by the author across transcripts. These codes were then clustered into broader categories, reflecting common experiences and perspectives among participants regarding ADHD recognition, management, and school expectations. The coding framework was developed with explicit attention to gender and culture as analytical categories. This involved examining how school norms, parental roles, and community expectations influenced recognition of ADHD in boys and girls. Analytic memos were used to capture how cultural values (e.g., emphasis on religious study, maternal advocacy roles) shaped stakeholder accounts.

Investigator triangulation [22, 23] was employed to ensure multiple perspectives in the data interpretation. Collaboration with additional researchers allowed for diverse observations and conclusions, enhancing both the confirmation of findings and the exploration of different viewpoints. To strengthen the analysis, an additional researcher with expertise in neurodevelopmental conditions reviewed the transcripts and coding framework developed by the primary author. This process ensured that only data relevant to ADHD symptomatology and educational experiences were included. Any discrepancies in coding and theme identification were discussed and refined to improve coherence and clarity. The final themes were selected based on their relevance and frequency, capturing the lived experiences of children with ADHD as reported by parents, educators, and occupational therapists in the UOJ educational system.

Results

A total of 25 participants took part in four homogeneous focus groups: mothers (n = 6), fathers (n = 6), educators (n = 7), and occupational therapists (n = 6). Several mothers and fathers reported personal or family histories of ADHD. The mothers’ and fathers’ groups consisted of different individuals; the fathers were not married to the mothers who participated in the study. Educators included teachers, principals, and supervisors from both boys’ and girls’ schools, with 10–17 years of experience; some also had a child or sibling with ADHD. Occupational therapists were all female, with 3–24 years of experience across community, educational, and clinical settings, and several reported family or personal experiences with ADHD. See Table 1 for participant demographics.

Table 1.

Participant demographics (N = 25).

Participant group	n	Gender	Age range (Years)	Key characteristics
Mothers	6	All female	31–48	4–8 children each; 5 with bachelor’s degrees; 4 employed full-time; 2 diagnosed with ADHD; 2 suspected ADHD.
Fathers	6	All male	Not reported	All with ≥ 1 child with ADHD; 4 with other family members with ADHD; 1 diagnosed with ADHD; 1 suspected ADHD.
Educators	7	3 males; 4 female	Not reported	3 teachers, 2 principals, 2 supervisors; 3 from boys’ schools, 4 from girls’ schools; 10–17 years’ experience; 5 had child with ADHD; 1 had sibling with ADHD.
Occupational Therapists	6	All female	Not reported	3–24 years’ experience; workplaces: child development clinics (n = 4), private practice (n = 3), primary schools (n = 3), special ed preschools (n = 1), mental health clinics (n = 1); 2 had sibling with ADHD; 1 had child with ADHD; 1 diagnosed with ADHD.

Mothers and fathers participated in separate focus groups. The fathers were not married to the mothers in the sample; groups were recruited independently

Content analysis of focus group discussions with mothers, fathers, educators, and occupational therapists revealed four key themes: (1) Diagnosis and recognition of ADHD, (2) School expectations, (3) Medication, and (4) Parental roles and advocacy. See Table 2 for a summary of the gendered and cultural dynamics across the four themes.

Table 2.

Gendered and cultural dynamics across themes

Theme	Boys	Girls	Cultural factors shaping both
Gatekeeping of recognition	Disruptive behaviors flagged early; boys referred for diagnosis at young ages	Inattentive or organizational struggles overlooked or reframed as lack of effort, leading to delayed diagnosis	Cultural reluctance to “label” children delays recognition; recent increase in awareness, especially for girls
Institutional fit/misfit	Struggled with prolonged Talmud study, rigid schedules, and risk of exclusion	Expected to be naturally organized and self-reliant; struggles seen as personal failings	Educational structures reinforce gendered roles; some schools adopting adaptations (learning in pairs, project-based learning)
Pharmacological compliance vs. personality preservation	Strong pressure to medicate to sustain study loads and classroom discipline	Reluctance to medicate due to fears of “dulling” personality or changing identity	Medication attitudes influenced by cultural values around scholarship, modesty, and family roles
Gendered care work and advocacy	Fathers are more involved in boys’ religious learning and behavior issues	Mothers bear primary responsibility for advocacy, school communication, and therapy	Division of parental roles reflects broader community gender norms; growing maternal peer networks and advocacy

Theme 1: gatekeeping of recognition

Boys flagged early through disruption

Most participants noted that boys were more likely to be referred for ADHD evaluation at an early age because their disruptive behaviors drew attention in the classroom. Educators, parents, and therapists all described boys as “unable to sit still” or “in trouble,” which prompted early recognition and intervention:

“Boys get flagged early because they can’t sit still in class; they’re disruptive” (OT 1, 15 years of experience).

“My son was diagnosed at age five because he was running around and getting in trouble” (Mother 3, 42 years old).

Girls overlooked or reframed as ‘not trying’

In contrast, participants explained that girls’ ADHD symptoms were frequently misinterpreted or overlooked. Rather than being recognized as inattentive, girls were often described as “spacey,” “lazy,” or “not applying themselves.” This reframing delayed diagnosis and denied girls timely intervention:

“Girls? They’re often just seen as ‘spacey’ or struggling with organization, but no one thinks of ADHD right away” (OT 1, 15 years of experience).​.

“My daughter, on the other hand, was struggling in school for years, but the teachers just kept saying she was ‘not applying herself.’ She only got a diagnosis when she was 12” (Mother 3, 42 years old).​.

“We don’t usually see girls causing trouble in the classroom, so their struggles get ignored. If a girl is failing the material, the assumption is that she’s just not trying hard enough” (Educator 2, 12 years of experience in girls’ schools).

Cultural reluctance to label boys

Interestingly, one father noted that his son took longer to receive a diagnosis because of a cultural reluctance to label children with neurodevelopmental disorders in his son’s school:

“In our community, if a boy can’t focus, they just say he needs ‘more discipline.’ It took years before they agreed that my son needed an evaluation” (Father 5, 37 years old).​.

Emerging awareness for girls

Several participants also described recent shifts in awareness, noting that teachers are beginning to recognize inattentive presentations in girls and make more referrals than in the past:

“I’ve seen more teachers questioning why certain girls struggle in class, rather than just assuming they are lazy or unfocused” (Occupational Therapist 3, 8 years of experience).

“It used to be that only the most severe cases of ADHD in girls were identified. Now, we are starting to see more referrals, which is progress” (Educator 5, 17 years of experience in girls’ schools).​.

Theme 2: institutional fit/misfit

Rigid study demands in boys’ schools

Participants described how boys with ADHD struggled to meet the intensive expectations of yeshiva learning. The long, lecture-based lessons with minimal breaks were especially challenging, often resulting in exclusion or transfer to lower-tier schools. Parents and educators noted that these rigid structures left boys feeling like failures:

“He was constantly being told he wasn’t ‘serious enough’ for learning. The teacher would send him out of class every day because he couldn’t sit through the lessons. It made him feel like a failure” (Father 2, 45 years old).​.

“The structure is rigid—long lessons, minimal breaks. A child with ADHD who needs movement, or an alternative approach has nowhere to turn.” (Educator 3, 10 years of experience in boys’ schools).

“My son was told, ‘If you can’t sit and learn, you don’t belong here.’ But how can a child with ADHD focus for 10 hours straight without any support?” (Mother 1, 38 years old)​

“If a boy can’t keep up with the pace of Talmud study, he’s at risk of being asked to leave or transferred to a lower-tier yeshiva (school).” (Father 4, 40 years old)​

Organizational expectations in girls’ schools

In contrast, girls were expected to manage organizational and academic demands independently. Rather than being disruptive, their difficulties often remained hidden, and teachers interpreted them as personal shortcomings. As a result, girls were pressured to “push through” without support:

“There’s an assumption that girls are naturally organized. If a girl can’t keep up, she’s expected to work harder instead of getting support.” (Educator 7, 15 years of experience in girls’ schools)​

“Girls don’t usually disrupt the class, so their challenges stay hidden. Teachers expect them to follow the rules, keep their materials in order, and just figure things out.” (Occupational Therapist 4, 12 years of experience)​

“A girl with ADHD who is disorganized or inattentive isn’t seen as having a problem that needs intervention—she’s just seen as ‘messy’ or ‘unfocused’ and is expected to fix it herself.” (Mother 2, 35 years old)​

“If a girl is struggling with focus, she’s expected to just push through.” (Mother 6, 44 years old)

Impact on self-perception

One occupational therapist noted how these gendered expectations affect girls’ self-perception:

“Boys with ADHD are seen as ‘challenging.’ Girls? They just feel like they’re not good enough. They internalize it and blame themselves.” (Occupational Therapist 5, 10 years of experience)​

Emerging school adaptations

Despite these challenges, some participants described how schools have begun introducing adaptations that better fit the needs of children with ADHD. Boys benefited from chevruta (paired study) or active learning methods, while girls thrived when given opportunities for leadership and hands-on activities:

“Some schools are starting to see that boys with ADHD do much better in paired learning than just sitting through lectures” (Educator 1, 13 years of experience in boys’ schools).​

“My son’s yeshiva finally allowed him to study in chevruta instead of listening to long shiurim (frontal lessons), and it made a huge difference. He’s more engaged and actually enjoys learning now” (Father 3, 42 years old).​

“We’ve found that when girls with ADHD are given leadership roles in school projects, they thrive. They just need teachers to recognize their strengths” (Educator 6, 11 years of experience in girls’ schools).​

“My daughter’s teacher gave her more hands-on activities in class, and she’s thriving. Instead of struggling with focus, she’s leading activities and feeling capable” (Mother 4, 36 years old).​

Theme 3: pharmacological compliance vs. personality preservation

Pressure to medicate boys

Participants described expectations that boys with ADHD would be medicated in order to meet the rigorous study demands of yeshiva. Teachers and school administrators often framed medication as the only viable option to ensure compliance with long hours of study. Parents reported feeling pressured to comply with these expectations:

“For boys, the expectation is that they will sit and study all day. If a boy can’t, the school tells the parents to ‘fix it’, and that usually means medication” (Educator 4, 14 years of experience in boys’ schools).​

“The teacher told me bluntly, either he takes Ritalin, or he can’t stay in school. There was no discussion about other options” (Mother 2, 38 years old).​

Hesitancy to medicate girls

In contrast, participants reported a reluctance to medicate girls due to fears that it would alter their personalities or suppress valued traits such as energy, expressiveness, and sociability. Parents and teachers expressed concern that medication might “dull” girls’ spark:

“Some parents refuse to medicate their daughters because they’re afraid it will make them ‘too quiet’ or change who they are” (Educator 2, 12 years of experience in girls’ schools).

“We had no problem getting medication for our son. But when it came to my daughter, my wife and her teachers were hesitant, they didn’t want to ‘flatten her spark’” (Father 1, 39 years old).​

“I see so many mothers struggling with their daughters, but they still hesitate to medicate them because they don’t want them (the child) to lose their energy or become someone they’re not.” (Occupational Therapist 3, 8 years of experience)

Shifting attitudes over time

Despite initial resistance, most participants noted that attitudes toward ADHD and medication are shifting, particularly as more families discuss ADHD openly and schools become more familiar with the condition:

“Years ago, people didn’t believe in ADHD at all. Now, at least we have the option to get help, and educators are more open to listening” (Father 6, 48 years old).​

“Even within my school, I see a change. A decade ago, no one talked about ADHD. Now, we have meetings about it and try to support these kids instead of just labeling them as troublemakers” (Educator 4, 14 years of experience in boys’ schools).​

Theme 4: gendered care, work, and advocacy

Mothers as primary advocates

Across the focus groups, participants emphasized that mothers carried the primary responsibility for securing school accommodations, pursuing therapy, and educating themselves about ADHD. Mothers described being the ones who met with teachers, pushed for services, and managed the daily impact of ADHD in both sons and daughters:

“When my son was struggling, I was the one going to meetings, pushing for support, reading about ADHD. My husband would say, ‘Just listen to the teacher,’ but the teacher wasn’t the one dealing with my son’s meltdowns” (Mother 3, 42 years old)​.

“I was the one meeting with teachers, explaining my daughter’s challenges, and trying to get her extra help. My husband was supportive, but it was clear that dealing with school accommodations was ‘my job.’” (Mother 5, 41 years old)​

“I almost never see fathers in therapy sessions. It’s always the mothers who take the initiative” (Occupational Therapist 6, 8 years of experience)​.

Fathers focused on boys’ religious study

By contrast, fathers were often portrayed as more engaged in supporting their sons’ religious learning, rather than in advocating for ADHD-related educational or therapeutic needs. Their involvement was tied closely to expectations of boys’ success in Talmud (religious texts) study:

“It’s my job to help him with his Gemara (Talmud) learning. If he can’t keep up, I need to find a tutor, not an ADHD specialist” (Father 2, 45 years old).​

Division of parental roles

Educators and parents described a gendered division in advocacy: fathers were more likely to be called about boys’ behavior, while mothers were expected to address academic or organizational difficulties, especially for daughters:

“When it comes to my son, my husband makes sure he’s doing well in yeshiva, but for my daughter, her education needs are more my responsibility.” (Mother 2, 38 years old)​

“When we call a parent about a boy’s behavior, we speak to the father. When we talk about academic struggles, it’s the mother who comes in” (Educator 3, 10 years of experience in boys’ schools).​

“A father will go to the school if his son is struggling with learning, but when it’s a daughter, it’s usually the mother who handles it.” (Educator 5, 17 years of experience in girls’ schools)​

Growing peer and community support

Despite entrenched gendered patterns, several participants did note that parental advocacy is becoming stronger, and community support networks are growing, making it easier for families to navigate ADHD-related challenges in the school:

“There’s more awareness now. Schools aren’t perfect, but they are starting to listen when parents push for accommodations” (Mother 5, 41 years old).​

“Once I started talking about my son’s ADHD, I found other mothers going through the same thing. We support each other, share advice, and even go to school meetings together” (Mother 6, 44 years old).​

Discussion

This study explored how gendered educational expectations in the Ultra-Orthodox Jewish (UOJ) community influence the recognition and treatment of ADHD. By analyzing perspectives from parents, educators, and occupational therapists, four key themes were identified: (1) Gatekeeping of recognition, (2) Institutional fit/misfit, (3) Pharmacological compliance vs. personality preservation, and (4) Gendered care, work, and advocacy. These findings suggest that cultural norms, gendered educational expectations, and school structures may interact to shape ADHD recognition and management in the UOJ community. While these intersections revealed barriers to timely identification and support, they also pointed to gradual shifts in awareness and emerging practices that may better address the needs of both boys and girls.

Consistent with previous research on ADHD diagnostic gaps [3, 5], participants reported that boys were more likely to be identified at an early age because their disruptive behaviors attracted attention. In contrast, girls’ inattentive or organizational difficulties were often overlooked or reframed as a lack of effort, resulting in delayed diagnosis and missed interventions. Within the UOJ educational system, these disparities were reinforced by cultural and structural factors: boys who struggled with focus were sometimes described as “not serious enough” about their studies, prompting earlier referrals and, in many cases, pressure to use medication to sustain long hours of Talmud study [22]. Girls, by contrast, were expected to manage their difficulties independently and conform to organizational expectations, with parents and educators expressing reluctance to use medication for fear of diminishing valued traits such as energy or sociability.

These patterns resonate with broader literature on gender and ADHD. Prior studies have shown that inattentive presentations in girls are frequently overlooked or misattributed to immaturity or lack of effort, leading to delayed diagnosis and unmet needs in educational contexts [6]. Research further demonstrates how gendered expectations shape recognition and limit access to support for young women [24], while systematic reviews highlight the persistence of unmet needs across genders and call for more responsive practices [25]. By situating these dynamics in the culturally specific environment of the UOJ community, this study extends existing knowledge by illustrating how gendered and religious expectations converge to shape recognition and treatment trajectories [9, 26–28].

Although these findings echo patterns reported in broader populations, this study contributes by situating these patterns within the distinctive cultural and educational environment of the UOJ community. Educational structures are strongly gender-segregated, with boys engaged in prolonged Talmud study and girls expected to demonstrate organization and self-management [11]. These expectations may intensify the gendered pathways of ADHD recognition and treatment: boys were subject to strong academic pressure and encouraged to use medication, while girls’ inattentive symptoms were more often overlooked or reframed as lack of effort. Parental roles also emerged as closely tied to religious norms, with mothers primarily responsible for advocacy and fathers focusing on boys’ religious study [22]. By examining these dynamics in a traditionally underrepresented community, the study underscores how cultural and religious contexts may shape ADHD recognition and management in ways that extend beyond what has been documented in mainstream samples [9, 27].

Interpreting these findings within the cultural and educational context of the UOJ community may help explain how ADHD is understood and managed in ways that are inseparable from broader communal values. For boys, religious study is central to identity and future prospects, which may amplify both recognition of disruptive behaviors and pressure to pursue interventions, particularly medication, to sustain long study hours [11, 22]. For girls, modesty, organization, and self-management are emphasized as cultural ideals, leading teachers and parents to view inattentive behaviors as personal shortcomings rather than symptoms warranting evaluation [9, 28]. Parental roles similarly may reflect communal structures: mothers are primarily responsible for navigating educational systems and therapeutic support, while fathers’ involvement is often framed through boys’ progress in Talmud study [22]. These cultural expectations seemed to shape not only how ADHD was identified but also which interventions were considered acceptable, underscoring the importance to interpret ADHD experiences through the lens of the UOJ community’s social and educational frameworks [26, 27].

Across cultures, boys and girls are socialized into distinct roles that shape how their behaviors are perceived and addressed within schools [26, 27]​. Boys are often encouraged toward academic or religious scholarship, requiring sustained attention and discipline [11], while girls are expected to develop self-regulation, organization, and caregiving abilities [28]​. These expectations often influence how ADHD behaviors are considered in that a behavior that is problematic in boys may be tolerated or misattributed in girls [17]​. Understanding these cultural variations is essential for informing ADHD diagnosis and intervention practices [29]​.

Encouragingly, some UOJ schools are beginning to explore alternative learning approaches to support students with ADHD. Educators and parents highlighted successful implementations of paired (chevruta) learning, active engagement strategies, and leadership roles that enable children to build on their strengths rather than be hindered by classroom demands that highlight their difficulties. For boys, paired learning offers a structured yet interactive way to engage with religious studies, allowing for movement, discussion, and peer support [30]. This format may be especially beneficial for children with ADHD, as it can reduce the strain of prolonged passive listening, encourage active participation, and provide a socially engaging environment that can support focus and comprehension [30]. Traditional lecture-based learning, which requires sustained attention for extended periods [31], often challenges children with ADHD, leading to frustration, disengagement, and behavioral difficulties. In contrast, paired learning may allow them to interact dynamically with their peers and receive immediate feedback, which may support them processing information more effectively [30, 32]. Similarly, for girls, providing active roles in classroom activities, such as projects, may support their focus, ability to stay on task, and help them stay and engaged [30, 32].

These alternative educational approaches not only accommodate the unique challenges of students with ADHD but also may leverage their strengths, providing opportunities for engagement and success rather than focusing solely on deficits. They align with best practices in ADHD education, which emphasize interactive, strength-based learning, and individualized support [31]. This suggests that, rather than conflicting with traditional religious education, thoughtful adaptations within existing frameworks may create more inclusive environments where children with ADHD may thrive.

The school expectations are not unique to the UOJ community alone. Similar patterns of gendered educational expectations exist in other traditional and religious education systems [33]. In some Islamic madrasas, students engage in long hours of Quranic memorization and recitation, much like Talmudic study in UOJ yeshivas. Those with learning disabilities and other challenges often face difficulties maintaining focus, sometimes resulting in disciplinary actions rather than accommodations. However, some Islamic schools have begun adopting small group learning models and adaptive study techniques, recognizing that flexible approaches can improve engagement without compromising religious education [34].

Likewise, in Confucian-based education systems, such as those in China and South Korea, students are expected to conform to strict academic and behavioral norms [35], which may be particularly challenging for children with ADHD. The heavy emphasis on rote memorization and long study hours often leads to academic burnout and self-esteem issues [36]. In response, some schools have introduced collaborative and project-based learning models, which offer greater engagement and flexibility for neurodiverse students [35–37].

These cross-cultural comparisons may highlight a common challenge in traditional education systems, the tension between structured learning environments and the need to support neurodiverse students. The UOJ community’s gradual shift toward alternative educational approaches may reflect a broader global trend where educators and families seek to balance religious and academic expectations with a growing understanding of inclusive learning [17, 34, 35]. By adopting interactive, student-centered learning strategies, these communities are making progress toward inclusive education that respects both tradition and individual learning needs. While cultural and religious values remain central, flexible adaptations may enhance educational outcomes for students with ADHD without compromising the integrity of traditional learning frameworks.

Consistent with gendered caregiving norms, this study found that mothers assumed the primary responsibility for ADHD advocacy and intervention, while fathers focused more on religious education and discipline. Mothers frequently attended school meetings, researched ADHD, and pushed for accommodations, while fathers were more involved in ensuring their sons’ success in Talmudic studies. This division of responsibilities aligns with prior research indicating that mothers of children with ADHD frequently bear the emotional and logistical burden of care, including the emotional toll of navigating the complex ADHD diagnosis and treatment process [17, 38].

However, there is evidence of growing parental advocacy within the UOJ community [17]. Participants described a shift toward more supportive community networks, where they share resources, experiences, and strategies to navigate the complex school systems and identify treatment options. These networks often provide emotional support and practical advice, empowering mothers to advocate more effectively for their children [17, 36].

Moreover, educators observed a shift in school attitudes toward parental advocacy. Schools that once dismissed ADHD-related concerns are now becoming more receptive to parent-led initiatives​ [17]. This may reflect a potential shift toward greater collaboration between families and schools, suggesting that, as parental advocacy increases, schools may begin to adapt and incorporate ADHD-specific interventions into their educational practices. This positive development offers hope for a future where parents and educators work more collaboratively, reducing the strain on families and improving outcomes for children with ADHD in the UOJ community.

Implications for policy and practice

Findings from this study suggest several key recommendations for improving ADHD recognition and treatment within the Ultra-Orthodox Jewish (UOJ) community education system. First, increased teacher training on ADHD and gender differences is needed. Educators should be equipped to recognize how ADHD presents differently in boys and girls, ensuring that inattentive symptoms in girls are identified rather than overlooked and that hyperactive boys receive support without punitive measures. Additionally, expanding alternative learning models may provide more inclusive educational opportunities. Schools can integrate chevruta (paired) learning and active learning strategies to better accommodate students with ADHD, allowing them to engage with the curriculum in ways that align with their strengths. Another important recommendation is reducing stigma around ADHD and medication through discussions that normalize ADHD as a legitimate neurodevelopmental condition. These discussions may help address concerns about medication use for both boys and girls, shifting the focus from stigma to informed decision-making. Lastly, enhancing parental advocacy support may further empower families to navigate ADHD-related challenges effectively. Strengthening parent networks may provide parents with the knowledge and tools necessary to advocate for their children’s needs within schools and broader community settings. By implementing these recommendations, the UOJ community may create a more supportive and inclusive environment for children with ADHD, supporting both boys and girls in receiving the recognition and accommodations they need to thrive.

Limitations

While this study provides valuable insights into gendered educational expectations and ADHD recognition within the UOJ community, several limitations should be acknowledged. First, as a qualitative study, findings are not generalizable beyond the specific cultural and religious context of this community. The results provide in-depth perspectives from parents, educators, and occupational therapists, but they may not fully capture the experiences of all individuals within this population or in other traditional religious communities. Further research with larger and more diverse samples could help validate and expand upon these findings. Second, the study relied on secondary analysis of existing focus group data, originally collected for a broader study on mothers’ experiences raising children with ADHD. While re-examining the data with a specific focus on gendered educational expectations, the original focus group discussions were not designed explicitly to explore this topic. Some perspectives may have been underrepresented due to the nature of the original discussions. Third, socioeconomic diversity within the sample was somewhat limited, as most participants were employed and had at least some level of higher education. In addition, the analysis was conducted through a binary gender lens, reflecting the structure of the UOJ educational system. While this framing was appropriate for the current study, it limits consideration of gender diversity and variation within groups of boys and girls. Furthermore, the study reports adult stakeholder perspectives but did not include the voices of children themselves. Given that ADHD directly shapes children’s daily experiences, future research should prioritize integrating their perspectives alongside those of parents, educators, and therapists. Despite these limitations, this study provides important contributions to understanding how gender norms influence ADHD recognition and intervention in religiously structured educational settings. Future research should continue to examine these dynamics across different cultural and religious contexts.

Conclusion

This study highlights the complex interplay between gender, culture, and ADHD diagnosis and treatment in the UOJ community educational settings. While challenges remain, particularly in diagnosis disparities, school expectations, and gendered medication attitudes there is growing awareness and adaptation within schools and families. By fostering teacher training, alternative learning approaches, and open conversations about ADHD, there is an opportunity to create a more supportive educational environment for boys and girls alike. Future research should further explore this interplay in more diverse religious communities and identify best practices for culturally sensitive ADHD interventions in gender-segregated educational systems.

Appendix 1

Coding framework, key terms and definitions

Theme/Category	Definition	Inclusion criteria	Exclusion criteria	Example quotation
Gatekeeping of recognition	How ADHD symptoms are identified, interpreted, or overlooked, often shaped by gendered expectations	Mentions of boys flagged early for disruption; girls’ inattentive behaviors reframed as lack of effort	General symptom descriptions without reference to recognition or school response	“For my son, they called right away when he couldn’t sit still. My daughter was just told she wasn’t trying hard enough.”
Institutional fit/misfit	How school structures and demands align (or conflict) with children’s attentional capacities	Descriptions of boys struggling with long Talmud study sessions; girls facing heavy organizational demands	Non-school settings (e.g., home chores, friendships)	“In yeshiva the boys sit for hours, so if he can’t, it’s a problem.”
Pharmacological compliance vs. personality preservation	Stakeholder beliefs and practices regarding ADHD medication, framed differently for boys and girls	Statements about pressure to medicate boys for academic survival; hesitancy to medicate girls due to fears of dulling personality	Non-medication interventions (therapy, tutoring)	“For boys it’s expected, otherwise they can’t keep up. For my daughter, I was scared it would change who she is.”
Gendered care, work, and advocacy	The division of parental roles in navigating schools, treatment, and accommodations	Mothers advocating at school; fathers focusing on religious study or boys’ progress	General parental stress unrelated to advocacy	“It’s always me going to the meetings. My husband deals with the Gemara tutors, not the ADHD.”

Abbreviations

ADHD

Attention Deficit Hyperactivity Disorder

UOJ

Ultra-Orthodox Jewish

Author’s contributions

J.B. wrote the main manuscript text and reviewed the manuscript.

Funding

No funding to declare.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study was approved from the Hebrew University’s ethics board (#15112022) on December 20, 2020.

Consent for publication

All participants provided signed consent for publication. Copy of form available upon request.

Competing interests

The authors declare no competing interests.