A conversation with Dr. Yath Ramesh, a psychiatrist specializing in ADHD
A personal note before we begin
I have been working with adults for many years, and like any clinician who follows the literature, I have experienced a significant change in the way we understand ADHD in the last decade. It is not just about updating diagnostic criteria. It is about a reconfiguration of the entire picture : who receives the diagnosis, at what age, in what context, and with what delay. Integrating the current international consensus has meant, for me as a professional, reconsidering things that I thought were already consolidated.
But there is a second level, just as important. As an adult woman, I understand firsthand what it means to go through the stages of life that Dr. Ramesh describes: the transitions, the overlapping responsibilities, the way the body and mind change, and how everything that was once manageable can suddenly become complicated. This dual perspective, clinical and personal, is why I believe that the interview with Dr. Yath Ramesh deserves more than a summary. It is worth a close read.
There are few clinicians who can speak about ADHD with the experience of a psychiatrist who has treated patients from 18 to over 80. Dr. Yath Ramesh is one of them. Dually specializing in general adult psychiatry and geriatric psychiatry, he has observed something that rarely makes it into specialist textbooks: that ADHD looks different at 25 than it does at 55 or 75, and that for women, the path from initial difficulties to a correct diagnosis is often long, winding, and fraught with misinterpretations.
The summary below follows the main ideas from the interview given to the ADHD Chat podcast , with a focus on the aspects most relevant to adult women.
What will you find in this article?
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- How ADHD changes throughout life: the stages everyone goes through
- Why women get diagnosed later (and what’s lost in the meantime)
- Masking as a survival mechanism and its long-term cost
- Menopause and ADHD: An Often Ignored Combination
- The grieving process after diagnosis, regardless of age
- Is it too late at 73 or 80? What the clinician says
ADHD does not remain the same throughout life.
Dr. Ramesh describes the evolution of ADHD through four stages:
Dependent stage (childhood). Symptoms become visible when a child requires more support than his peers. If masking works well or there is another context that explains the behavior (a sibling with louder symptoms, a divorce in the family), ADHD can go unnoticed.
Independent stage (young adulthood). The person tries to become autonomous, but the external structure that supported them disappears. Those who have been successful academically may suddenly fail in college or at their first jobs, without understanding why .
Integrative stage (maturity). Responsibilities overlap: children, elderly parents, leadership roles. The space for recovery disappears, as does the possibility of preparing for anxiety-provoking situations. ADHD now manifests itself not necessarily through classic symptoms, but through a difficulty in managing the complexity of life.
The retirement stage. A stage with its specific challenges related to the loss of professional structure and identity.
The central idea: the ability to cope with symptoms depends on the ratio of available resources to life’s demands. When demands increase faster than resources, ADHD becomes visible, even in a person who has been doing “well” for decades.
Why women receive the diagnosis later
UK data (2024-2025) shows that in the 0-18 age group, two boys are diagnosed with ADHD for every girl diagnosed. The difference narrows with age, and after the age of 65, more women than men receive a new diagnosis.
Dr. Ramesh identifies three mechanisms that explain this inequality:
Masking is more effective in girls. Girls tend to develop emotional maturity earlier and conform to social norms, which allows them to hide their difficulties. The girl who rechecked her homework four times before handing it in, or who studied twice as much at home as her classmates to make up for what she didn’t understand in class, didn’t seem like a problem to anyone. That’s why she went undiagnosed.
Misdiagnosis. The symptomatic overlap between ADHD (emotional dysregulation, sensitivity to rejection) and borderline personality disorder or bipolar disorder is significant. When treatments for these diagnoses do not work, the conclusion is not necessarily that the diagnosis was wrong, but that the patient is “treatment resistant.” This only reinforces the belief that something is deeply wrong with her.
Impersonalized support. Even when the diagnosis is correct, treatment does not take into account the complexity of the situation, including the menstrual cycle, menopause, history of trauma, or overlap with other conditions.
Masking and its price
Masking is not a conscious choice. It is an adaptation that begins early, often in childhood, in response to repeated messages about being “different,” “disorganized,” “not concentrating.” The person constructs a narrative about themselves: that there is something fundamentally wrong or deficient about them. From that narrative, social anxiety, withdrawal, depression, or difficulties with emotional regulation arise.
One clinical detail that Dr. Ramesh points out: Many older adults don’t know they’re masking, because they’ve come to believe that ADHD traits are simply their personality. The woman who needs time alone before a social gathering doesn’t know that she’s actually mentally rehearsing conversations and trying to remember details so she doesn’t seem indifferent. She calls it introversion. Aging adds another layer: executive difficulties are blamed on age, which in turn becomes a socially acceptable form of masking.
Menopause and ADHD: an often ignored combination
The fluctuations in estrogen during perimenopause, followed by its decline during menopause, can exacerbate existing ADHD symptoms and add new cognitive difficulties: working memory deficits, difficulty processing multiple information at once. If a woman has not previously received an ADHD diagnosis, these symptoms may seem like unexplained cognitive decline.
The danger, which Dr. Ramesh explicitly highlights, is that of oversimplification: the tendency to attribute everything to menopause or everything to ADHD, without recognizing that the two influence each other and that their interaction requires an integrated approach.
The grieving process after diagnosis
No matter how much a person has prepared for a diagnosis, the first response is usually shock. There is always an internal voice, often fueled by sensitivity to rejection, that says: maybe it’s not you, maybe everyone else is doing well and you’re not.
After the shock, relief usually comes: past behaviors and difficulties gain a coherent explanation. It wasn’t a character flaw, it was a brain that works differently.
The process is more complex in older age, because it involves reinterpreting a greater number of years and the decisions made in those years. The question that often arises: what would my life have looked like if I had known earlier? Dr. Ramesh suggests a practical technique: identify three concrete priorities that you want to improve now, as a starting point for moving forward, not just reflecting on the past.
Is it too late at 73 or 80?
Dr. Ramesh’s short answer: no.
He illustrates with the story of a man in his 80s with a terminal cancer diagnosis who requested an advance appointment, fearing he would miss his evaluation. The ADHD diagnosis allowed him to coherently reinterpret his biography, forgive himself for the failures of the first chapter of his life, and reconnect with people he had estranged from. His daughter described this as one of the most meaningful things he did before he died.
Some practical recommendations for late assessment: involving people who have known the patient at different stages of life (for the longitudinal history necessary for diagnosis), prior exclusion of reversible medical causes that may mimic ADHD symptoms, and openness to an individualized plan, which does not necessarily follow the classic route.
A personal perspective
There is one thing I particularly appreciate about Dr. Ramesh’s honest clinical discussions: the fact that he explicitly acknowledges that it has been a learning process for him too, that he has come to understand women’s experiences better by listening to women. This honesty seems more valuable to me than certainty.
As a mental health professional, I have witnessed a real shift in the way we understand adult ADHD in recent years. The international consensus has refined considerably: we now know better what ADHD looks like in its mildest form, how masking works, how ADHD interacts with anxiety, depression, and trauma accumulated over time. It is no small feat to integrate these changes into practice, especially when they contradict things you thought were solid.
As an adult woman, I understand from the inside that life stages are not just neutral contexts in which symptoms unfold. They are moments of change that reconfigure what is visible, what is manageable, and what surfaces precisely because you no longer have the resources to keep it under control. Hormonal transitions, overlapping responsibilities, loss of structure: none of these are “stressors” added to ADHD. They are part of the clinical picture.
That’s why I believe that a good assessment cannot be separated from the person’s life history and that understanding ADHD in women still requires more attention than we have given it as a field so far.
Source (youtube): interview with Dr. Yath Ramesh, ADHD psychiatrist, ADHD Chat podcast.
I support the work of the AboutADHD Romania community . As a professional and as a woman, I have seen too many times how the lack of a safe space and accurate information leaves people to fend for themselves with questions that deserve good answers.
References:
Young, S., & all (2020). Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/hyperactivity disorder in girls and women. BMC Psychiatry, 20, Article 404. https://doi.org/10.1186/s12888-020-02707-9