When we think of ADHD, we often picture a child bouncing off the walls, calling out impulsively in class, or struggling to sit still. These images reflect the stereotypical “boy” presentation of ADHD—high energy, impulsive, loud, and disruptive. However, this stereOType has contributed to generations of neurodivergent girls being overlooked, misunderstood, and misdiagnosed. Many girls, particularly those with the inattentive presentation of ADHD, fly under the radar, quietly struggling in ways that rarely get flagged by teachers, parents, or clinicians.
In Occupational Therapy (OT), we pride ourselves on taking a holistic, functional approach to support children across their daily environments. But when it comes to girls with Quiet ADHD, our standard assessments and tools often fall short. We may miss the internal distress, mental fatigue, executive function challenges, and sensory processing differences because the child isn’t “causing problems.” The result? These girls are often identified late—if at all—by the time they hit burnout, anxiety, or complete academic disengagement.
This blog explores how ‘quiet ADHD’ presents in neurodivergent girls, why it is so often missed in OT assessments, and how we can do better. It also offers practical assessment strategies, red flags to watch for, and suggestions for a more neuroaffirming OT approach.
Table of Contents
What Is Quiet ADHD?
While not a clinical term, ‘quiet ADHD’ typically refers to the predominantly inattentive presentation of Attention-Deficit/Hyperactivity Disorder. These children, most often girls, don’t fit the disruptive, hyperactive mold. Instead, they may:
- Drift off during lessons
- Appear disorganised or forgetful
- Seem shy, anxious, or socially withdrawn
- Avoid eye contact or group participation
- Struggle with sustained attention, but mask well in structured environments
- Internalise their struggles rather than acting out
These behaviours are frequently misattributed to personality traits—“She’s just a bit dreamy,” “She’s shy,” or “She just needs to try harder.” The reality is that these children are often using immense cognitive and emotional effort to stay afloat.
Why Girls with ADHD Are Missed
1. Diagnostic Bias and Gender Norms
Historically, ADHD research and diagnostic criteria have been based predominantly on boys. Most rating scales, symptom thresholds, and classroom observation protocols focus on externalising behaviours—hyperactivity, impulsivity, and defiance. Girls who are quiet, internalising, and avoidant don’t raise the same red flags.
Compounding this issue are gendered social expectations: girls are often socialised to be compliant, helpful, and emotionally regulated, and many girls with ADHD overcompensate by becoming perfectionistic or people-pleasing. This masking behaviour conceals their distress from adults and peers.
2. Overlap with other Diagnoses
Girls with ADHD are frequently misdiagnosed with anxiety, depression, or learning disorders—conditions that may coexist with ADHD but are often seen as primary. A girl who is emotionally overwhelmed, avoids tasks, and forgets her homework may be seen as anxious rather than struggling with attention, working memory, and executive function.
There’s also significant diagnostic overlap with autism, particularly in girls who mask their social challenges. Many girls with both ADHD and ASD go undiagnosed for years because their masking strategies are effective enough to appear superficially typical.
3. Teachers and Parents May Miss the Signs
If a child is well-behaved in the classroom, doesn’t act out, and achieves average or above-average grades, there may be no perceived need for referral. But what we don’t see are the after-school meltdowns, the hours spent re-doing work to perfection, the mental exhaustion, or the growing sense of failure and shame these girls carry.
Parents may also feel confused. They might describe their daughter as “lazy” or “unmotivated” one moment, and “a perfectionist who never stops working” the next. Without a framework for understanding ADHD in girls, the internal inconsistency seems inexplicable—and OTs may overlook it too.
What OT Assessments Miss
OTs have a unique opportunity to detect subtle neurodivergent traits in the children we see. However, our standard assessment tools are often insufficient when it comes to detecting the internal struggles of girls with inattentive ADHD.
Here are key areas where assessments fall short:
1. Focus on Externalised Behaviours
Standardised OT assessments often rely on observable behaviours and checklists completed by adults. If a child is quiet, compliant, and appears to follow instructions, she may receive a “within normal limits” result—even if she is struggling with every step of the task.
Girls with quiet ADHD might:
- Sit still but not retain what they’re hearing
- Copy from the board but not understand the material
- Appear to finish tasks but rely on scaffolding from peers or parents
- Perform well on tests but fall apart under stress or change
These inconsistencies are hard to measure without functional and context-rich observation.
2. Executive Functioning Gaps Are NOT Always Tested Functionally
Tools like the BRIEF-2 are helpful, especially when used across environments (home and school). But executive function deficits may not show up clearly unless we observe how the child plans, initiates, monitors, and adapts during tasks in real time.
A child may have:
- Difficulty beginning a writing task without support
- Trouble holding multiple steps in mind
- Poor time perception and slow task completion
- Difficulty shifting between tasks or managing interruptions
Yet unless we structure our assessments to look at these components in real-world contexts, they may be missed.
3. Sensory Processing Differences Look Different in Girls
Girls with ADHD may not be sensory-seeking in obvious ways, but many experience hypersensitivity to noise, touch, or visual input. Rather than acting out, they may withdraw, zone out, or experience internal panic. Sensory questionnaires often fail to detect this if adults aren’t observing the behaviours or the child isn’t aware enough to articulate their discomfort.
We also miss signs of interoceptive challenges—difficulty noticing hunger, thirst, fatigue, or emotional cues. This is crucial for understanding regulation, emotional outbursts, and shutdowns.
4. Masking and Social Camouflaging
Many neurodivergent girls become experts at masking. In the OT clinic, they may mimic what they think is expected, echo phrases used by adults, or rely heavily on routine. Standard social skills checklists may mark them as “appropriate,” even when:
- They struggle with social nuance and reciprocity
- They script conversations or use echolalia
- They don’t initiate friendships or play
- They feel unsafe to be themselves
Without a trauma-informed, neuroaffirming lens, these coping strategies can be misread as competence.
A Better Way Forward: Rethinking OT Assessment
It’s time to reframe how we assess and understand neurodivergent girls with quiet ADHD. This doesn’t mean throwing out our current tools—but it does mean adapting how we use them, and what questions we ask alongside them.
1. Use Functional, Contextual Assessment
Observe the child doing tasks that matter in real-life settings:
- How do they plan and organise getting ready in the morning?
- How do they manage transitions at school or between therapy tasks?
- What scaffolding do they rely on to finish a worksheet or project?
Assess not just the outcome of the task, but the cognitive and emotional load required to complete it.
2. Gather Diverse Perspectives
Involve:
- Parents (who see emotional fallout at home)
- Teachers (who observe academic and social patterns)
- The child themselves, using developmentally appropriate methods like drawing, sentence completion, or visual supports
Use open-ended questions such as:
- “When is school the hardest for you?”
- “What helps you stay calm when you’re feeling frustrated?”
- “What happens in your body when you’re about to cry?”
This helps identify internal experiences that aren’t reflected in checklists.
3. Be Interoception-Informed
Girls with ADHD may be constantly dysregulated but unaware. Incorporate interoceptive awareness assessments or informal strategies like:
- Body mapping
- Emotion journaling
“Check-in” visuals (e.g., What’s my heart doing? My tummy?) - Helping them link physical cues to emotional states
This builds emotional literacy, but also helps with transitions, toileting, sleep, and regulation.
4. Look for Patterns Over Time
A single session may show little. But over time, you may notice:
- Fatigue or disengagement by the end of sessions
- Meltdowns after school or after busy days
- Inconsistencies between “good days” and “bad days” that don’t align with effort
- High anxiety around making mistakes or changing plans
These patterns are often more telling than any single checklist result.
5. Validate the Internal World
Let girls know you believe them—even if they can’t yet name or explain their experiences. Say:
- “That sounds really hard.”
- “Lots of kids try really hard but still feel stuck.”
- “I believe you, even if I can’t see it.”
For many girls, having their struggle validated is the first step toward self-understanding and healing.
OT’s Role in Early Identification and Support
OTs are in a powerful position to identify quiet ADHD early, before it turns into anxiety, depression, or burnout. We can advocate, educate, and empower families by:
- Demystifying executive function: Teach parents and schools that these are brain-based challenges, not laziness or lack of effort.
- Normalising scaffolding: Use visuals, prompts, and predictable routines to reduce load, not to “train independence” through stress.
- Designing regulation strategies that are not punitive: Move away from behaviourist token systems and toward nervous system supports like sensory breaks, co-regulation, and emotional expression.
- Teaching self-advocacy and strengths-based identity: Help girls build the language to talk about their brains and advocate for their needs with pride—not shame.
Final Thoughts: Seeing Beyond the Mask
‘Quiet ADHD’ is anything but quiet when you know what to look for. Behind the mask of the well-behaved, polite girl may be a child working 10 times harder than her peers to function—and blaming herself for struggling.
As OTs, we must look beneath the surface, adjust our lens, and validate lived experience even when it’s not “disruptive.” Neurodivergent girls deserve to be seen, heard, and supported before they burn out trying to meet invisible expectations.
Let’s make sure we don’t miss them.
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