Late, Overlooked, and Finally Diagnosed: The Truth About ADHD in Women

Written by Melissa Schenkman, MPH, MSJ

A Q&A with Licensed Mental Health Counselor Bailey Pilant

Bailey Pilant is a Licensed Mental Health Counselor in New York and Florida, a Certified ADHD Clinical Services Provider, and the founder of The Wave Counseling. She specializes in neurodivergent-affirming therapy for women navigating ADHD, autism, anxiety, PTSD, and trauma — and she brings a deeply personal lens to this work, having received a delayed diagnosis of both ADHD and autism herself. In this conversation, Bailey shares what she wishes more women knew about ADHD, from the biology behind symptoms to the realities of diagnosis, relationships, and daily life.

What drew you to specializing in ADHD, particularly in women?

Bailey Pilant: Anger, honestly. That's what fueled me — and I think it's a perfectly valid fuel.

Early in my career, I was working at an outpatient mental health clinic on the Upper West Side of Manhattan. I kept seeing the same pattern: young women coming in and out, all being labeled with anxiety, depression, or trauma. I remember going through one client's chart and noticing she actually had an original ADHD diagnosis. But nobody was treating it. Everyone had re-labeled her as anxious.

When I started asking these women deeper questions, I realized their so-called anxiety and depression were really executive dysfunction in disguise. When I shifted focus to executive functioning, I saw real improvement. But then I hit a wall — there was so much stigma around prescribing stimulant medications, and I had a medical director literally mansplain to me how anxiety shows up in ADHD. I had accurately documented everything. I was so mad. And it was my birthday.

That experience crystallized something for me: if someone had taught me about my own ADHD at 17 when I was first diagnosed, my 20s would have looked completely different. So many women have been mistreated for so long that they start to internalize the idea that their struggles are their fault — that they're not trying hard enough, that they're the reason therapy hasn't worked. When the real reason therapy hasn't worked is because it was never addressing the actual thing going on.

I was tired of women being missed, misdiagnosed, misunderstood, and mistreated. So I decided to do something about it.

What's the biggest misconception about ADHD that you run into?

The name itself. I genuinely think ADHD is mislabeled. We should be calling it an attention dysregulation disorder, not an attention deficit disorder — because it's not that we can't hold our attention. It's that we struggle to regulate where to put our attention and hold it there.

We have what I'd describe as emotionally motivated brains. When we're deeply interested in something, we can focus for hours. When we're not interested? It's a completely different story. That's not a deficit — it's dysregulation.

And then there's the hyperactivity piece, which is also wildly misleading. When most people hear ‘hyperactivity,’ they picture a little kid who can't sit still. But for adult women with ADHD, the picture looks very different:

• Many of us are exhausted — not bouncing off the walls.

• We can't sleep because our brain won't turn off.

• We feel like we're racing against a clock we can't even see.

• Our thoughts keep jumping from one thing to the next.

• There's a constant low-level agitation and tension we can't shake.

That's what I call internalized hyperactivity. It's real, it's exhausting, and it gets missed constantly because it doesn't look like what we were taught ADHD looks like.

The numbers around late diagnosis of ADHD in adult women are striking. What's driving them?

Before we even talk about why those numbers are high, let me give you a statistic that puts it all into perspective: Only 7% of people with ADHD will receive an accurate diagnosis in their lifetime. So yes, it feels like everyone is being diagnosed right now — but we are still missing an enormous number of people.

For women specifically, the gap comes from a few converging forces:

• ADHD research was historically done almost exclusively on boys and men, so the diagnostic criteria were built around male presentation.

• Girls are socialized to mask — to internalize, compensate, and hide symptoms in ways that look socially acceptable.

• Our executive functioning deficits get chalked up to personality traits ('she's so ditzy,' 'she's always late') rather than recognized as symptoms.

• Hormonal fluctuations across our lifespan make symptoms more pronounced at certain times and less at others, which creates an inconsistent picture that's easy to dismiss.

And then there's the misdiagnosis problem. A woman comes in describing what sounds like anxiety or depression — and yes, those are real and present — but they're often downstream of unaddressed ADHD. Treat the ADHD first, and a huge amount of that anxiety often resolves on its own. But most providers don't know to look for it that way.

Here's the stat that really should stop us cold: Those with ADHD who go untreated live, on average, 14 years less than those who do get treated. Fourteen years! That's not a small quality-of-life inconvenience. That's a public health issue!

How do ADHD symptoms change for women across their 20s, 30s, and 40s?

Here's the cruel irony: ADHD tends to get harder for women as we age, precisely because our demands increase as our hormonal support decreases.

In childhood, a lot of our executive functioning gets scaffolded by our parents and teachers. Then we go to college and suddenly we're expected to manage everything ourselves, with very little support. Some of us fall apart. Some of us barely hold it together. Some of us actually excel academically but feel like every other part of our life is a complete disaster. And we can never sit in our success, because something is always nagging us.

Then life compounds. We get a job. We get into a relationship. Maybe we get married, get a dog, or have children. Each of those steps adds another layer of executive functioning demand. We must hold the job, maintain the relationship, take care of the home, manage childcare, appointments, school schedules; and taking care of yourself…well that almost always ends up last on the list

And as those demands grow, the ADHD becomes more prominent. This is also why research historically suggested men ‘grew out of ADHD.’ They didn't. They just had wives who took on their executive functioning for them at home. Women don't get that luxury.

Then layer in hormones. Our estrogen levels are directly linked to how well our brain can use dopamine — which is the neurotransmitter at the center of ADHD. As estrogen declines through our 30s, 40s, and into perimenopause, ADHD symptoms become measurably harder to manage. It's not in our heads. It's in our hormones.

How does the menstrual cycle affect ADHD symptoms?

This is one of my favorite topics to talk about, because so few women realize how much their cycle is directly influencing how their ADHD feels day to day. Here's a simplified breakdown of what's happening across the phases:

• Follicular phase (after menstruation): Estrogen rises slowly. This is when ADHD symptoms tend to feel more manageable — your executive functioning is sharper, motivation is higher. The catch? Impulsivity also increases during this phase.

• Ovulation: Estrogen peaks. You might feel your most capable and energized.

• Luteal phase (pre-menstrual): Estrogen drops, progesterone rises. This is when the brain fog comes back hard. Your stimulant medication may feel less effective — or completely ineffective — because you've lost that estrogen priming for dopamine.

• Menstruation: The reset begins.

During the luteal phase especially, everything becomes harder:

• Task initiation feels 10 times more difficult

• Working memory takes a hit

• Planning and organizing feel nearly impossible

• Time management goes out the window

And all of our executive functioning skills work in tandem — they're puzzle pieces that have to fit together. When one is struggling, it impacts all the others. So a rough luteal phase isn't just "PMS." For women with ADHD, it can feel like the floor has dropped out.

It's worth noting that hormonal birth control doesn't necessarily level this out. It uses synthetic hormones, not an exact match for your body's natural production, so fluctuations can still happen even when you're on it.

What should women with ADHD know about pregnancy and the postpartum period?

I'll be honest with you: the research here is frustratingly limited. Clinical trials on pregnancy are ethically complicated, so we haven't been able to study this nearly as much as we need to. But here's what we do know from experience and the studies that have been done:

ADHD symptoms don't take a break during pregnancy — they're actually exacerbated by it. And postpartum can be even harder, because your hormones are going through a seismic shift while your demands are at an all-time high. You know how people talk about "mom brain"? For a woman with ADHD, it's mom brain times five.

Think about what pregnancy requires in terms of executive functioning alone. You have to remember to consistently take vitamins daily, eat well, exercise, sleep, hold down a job while your body is going through enormous changes, and plan for the baby’s arrival. 

That's a massive executive functioning load on a brain that was already struggling. And then the baby arrives, and the demand doesn't decrease — it multiplies.

On the question of medication during pregnancy: The message I want people to hear is that for many women, it can be done safely. The key is individual assessment, the lowest effective dose, and close collaboration with a provider who understands both ADHD and perinatal care. 

And critically important — a pregnant woman's mental health matters too. An untreated mental health condition during pregnancy is not without risk to the baby either. These decisions are nuanced, case by case, and require a compassionate, informed conversation with your care team.

What about perimenopause?

I have some news that surprises a lot of women: Recent studies suggest that women with ADHD are more likely to enter perimenopause in their 30s rather than their 40s. That matters because perimenopause is when your body starts dialing down estrogen production — and estrogen, as we've established, is a critical neuro-primer for dopamine.

The symptoms to watch for:

• Chronic fatigue — not laziness, but a bone-deep exhaustion coupled with an inability to switch the brain off

• Increased brain fog

• Worsening working memory deficits

• Greater difficulty with task initiation and time management

Here's something I tell my clients that I want everyone to hear: Women with ADHD have a higher risk of developing dementia and Alzheimer's later in life, connected to working memory deficits. I'm not saying this to frighten anyone — I'm saying it because there are things we can do about it. 

Hormone replacement therapy (starting as early as safely possible) and stimulant medication have both been studied repeatedly and consistently shown to reduce that risk. If your working memory is noticeably worsening, please go get your hormones tested. Go get assessed. This is an area where early action genuinely matters.

How should someone go about getting an ADHD evaluation? Who do they see?

It sounds simple in theory. The reality is harder — but it's absolutely doable. Here are the main routes:

• Neuropsychological evaluation with a psychologist: The most comprehensive option. They'll look at your full cognitive profile, rule out other conditions, and can identify co-occurring diagnoses like autism, OCD, or CPTSD. These can be expensive, and they often ask for things like old report cards and input from someone who knew you in childhood and in adulthood.

• A therapist who specializes in adult female ADHD: This is my path. I do in-depth intake assessments, but the key piece — and I cannot emphasize this enough — is that "specializes in ADHD" means very different things to different therapists. You want someone who specializes specifically in the adult female presentation.

• A psychiatrist or psychiatric nurse practitioner: Another valid route, particularly for those seeking medication management alongside evaluation.

The most important variable across all of these is finding someone who actually understands how ADHD presents in women. Here's how you can suss that out on a consultation call:

• Ask: "What's your take on ADHD in women? How does it tend to present differently?"

• Notice how they reflect your experience back to you. Are they really listening, or are they already reaching for a more familiar label like anxiety or depression?

• Pay attention to whether they ask clarifying questions — a good clinician will probe the specifics of how your symptoms show up, not just tick boxes on a checklist

One thing that trips women up frequently: We tend to describe our racing thoughts as a symptom, and most providers immediately hear ‘anxiety.’ But there's a crucial difference. Anxious racing thoughts loop on the same fear or worry — they won't let go. ADHD racing thoughts jump from thing to thing to thing. ‘I forgot to water the plants. I need to re-pot them. I need soil. Should I propagate them? Is it the right time?’ A skilled provider knows to ask which type you're experiencing. If they don't, that tells you something.

What does neurodivergent-affirming therapy look like in practice?

At its core, it means helping someone build a relationship with their diagnosis that is empowering rather than shameful — while being honest that the challenges are real and not going away.

There's a lot of rhetoric on both ends of the spectrum around ADHD: doom and despair on one side, and toxic positivity on the other. "It's a superpower!" Well — sometimes. But the hard days are also really hard, and I never want to minimize that. What I try to do instead is help clients find the space in between: radical self-acceptance without needing to slap a positive spin on everything.

Practically, this looks like:

• Using identity-first language that helps clients see their ADHD as part of who they are, not a character flaw

• Identifying executive functioning strengths — because everyone has them — and using those as a foundation to shore up weaker areas

• Designing systems, accommodations, and supports that are built around how that individual's brain actually works, not how a neurotypical brain works

• Reducing demand — questioning the idea that things "have to" be done a certain way, and finding approaches that genuinely work for that person

• Building tools for managing the symptoms that cause the most friction in daily life

A big part of how I measure progress isn't whether every new system is working perfectly all the time — nothing works 100% of the time. It's about how clients talk about themselves, how they handle hard things, and whether they've developed more trust in their own capacity to navigate challenges.

How does ADHD affect romantic relationships, and what helps?

My husband and I both have ADHD. We're celebrating 10 years together and four years married. And yes, the research on ADHD and relationships tends to be pretty bleak — which I think is deeply unhelpful and often overstated.

The impact ADHD has on a relationship is hugely dependent on how both partners approach it. The questions thatI think matter the most are:

• Does your partner understand and accept the ADHD, or do they pathologize it and use it against you?

• Are you working with your combined executive functioning strengths, or are you both fighting over the same deficits?

• Can you both hold space for the fact that ADHD will impact you more on some days than others — and that that's not a moral failing?

What my husband and I have found is that our different executive functioning profiles actually complement each other. We lean into what we're each good at. We communicate. And yes, our ADHD also makes us pretty fun to be around — there's a creativity and spontaneity that comes with neurodivergent brains that can genuinely enrich a relationship when it's working with you instead of against you.

What about managing symptoms at work and at home?

Let me give you the two pieces of advice that reliably get an eye roll — and that I also reliably stand behind.

First: time blocking. I know. I know you're cringing. I was too. But hear me out. The version of time blocking I'm talking about isn't the rigid color-coded calendar of your nightmares. It's about finding a structure that works for your specific brain. When I figured out a system that actually worked for me, it was genuinely a life changer. The key is adapting it to you — not following the rules about how it's supposed to be done.

Second: routine. Again — I know. But routine is particularly important for ADHD brains because without it, we tend to let the whole week's housework accumulate until the weekend, then feel too exhausted to do it, then feel overwhelmed by the pile, then avoid it more, then start a new work week in a house that feels like chaos. 

The fix isn't to white-knuckle your way through a chore day. It's to break tasks down and spread them out like dust on Monday’s, vacuum on Tuesday’s and wipe down the mirrors on Wednesday’s.Small, manageable, built into the week. Boring? Yes. Effective? Genuinely, yes.

For work specifically, my biggest advice is: Don't overcommit early. This is such a common trap. Someone with ADHD comes into a new job wanting to prove themselves, goes all in, sets an unsustainable pace, and then burns out — while also having set expectations they can't maintain long term. The healthier approach is slow, steady, and honest. Communicate your capacity. Set clear boundaries. Identify early whether your workplace is going to be supportive of neurodivergent employees — and if you're in the interview process, you're allowed to ask that directly.

What's the one thing you most want women with ADHD to hear?

There's nothing wrong with you.

Not having a diagnosis doesn't mean you're imagining it. Having one doesn't mean your life is defined by it. The challenges are real — I will never minimize them — but they are workable. There is support that actually helps. There is therapy that actually addresses the right thing. There are medications that can genuinely change your experience. And there are communities of people who understand.

You don't have to frame your ADHD as a superpower to accept it. And you don't have to frame it as a tragedy to take it seriously. You can just... have it. Learn how your brain works. Build a life that works with that brain. And trust that a really beautiful, successful life — in whatever form that means to you — is still available to you.

Even with ADHD. Maybe even partly because of it.

Want to hear more from therapist Bailey Pilant? Check out the YMyHealth Podcast on our YouTube channel or on your favorite streaming platform!