Misdiagnosis and Dual Diagnosis of Gifted Children
Authors: James T. Webb, Edward R. Amend, Nadia E. Webb, Jean Goerss, Paul Beljan, F. Richard Olenchak
Citation: Abstracted from Misdiagnosis and Dual Diagnoses of Gifted Children and Adults: ADHD, bipolar, OCD, Asperger’s, depression, and other disorders. (2004) Scottsdale: Great Potential Press. Available from the publisher.
Many gifted and talented children (and adults) are being mis-diagnosed by psychologists, psychiatrists, pediatricians, and other health care professionals. The most common mis-diagnoses are: Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (OD), Obsessive Compulsive Disorder (OCD), and Mood Disorders such as Cyclothymic Disorder, Dysthymic Disorder, Depression, and Bi-Polar Disorder. These common mis-diagnoses stem from an ignorance among professionals about specific social and emotional characteristics of gifted children which are then mistakenly assumed by these professionals to be signs of pathology.
In some situations where gifted children have received a correct diagnosis, giftedness is still a factor that must be considered in treatment, and should really generate a dual diagnosis. For example, existential depression or learning disability, when present in gifted children or adults, requires a different approach because new dimensions are added by the giftedness component. Yet the giftedness component typically is overlooked due to the lack of training and understanding by health care professionals (Webb & Kleine, 1993).
Despite prevalent myths to the contrary, gifted children and adults are at particular psychological risk due to both internal characteristics and situational factors. These internal and situational factors can lead to interpersonal and psychological difficulties for gifted children, and subsequently to mis-diagnoses and inadequate treatment.
First, let me mention the internal aspects (Webb, 1993). Historically, nearly all of the research on gifted individuals has focused on the intellectual aspects, particularly in an academic sense. Until recently, little attention has been given to personality factors which accompany high intellect and creativity. Even less attention has been given to the observation that these personality factors intensify and have greater life effects when intelligence level increases beyond IQ 130 (Silverman, 1993; Webb, 1993; Winner, 2000).
Perhaps the most universal, yet most often overlooked, characteristic of gifted children and adults is their intensity (Silverman, 1993; Webb, 1993). One mother described it succinctly when she said, “My child’s life motto is that anything worth doing is worth doing to excess.” Gifted children — and gifted adults– often are extremely intense, whether in their emotional response, intellectual pursuits, sibling rivalry, or power struggles with an authority figure. Impatience is also frequently present, both with oneself and with others. The intensity also often manifests itself in heightened motor activity and physical restlessness.
Along with intensity, one typically finds in gifted individuals an extreme sensitivity–to emotions, sounds, touch, taste, etc. These children may burst into tears while watching a sad event on the evening news, keenly hear fluorescent lights, react strongly to smells, insist on having the tags removed from their shirts, must touch everything, or are overly reactive to touch in a tactile-defensive manner.
The gifted individual’s drive to understand, to question, and to search for consistency is likewise inherent and intense, as is the ability to see possibilities and alternatives. All of these characteristics together result in an intense idealism and concern with social and moral issues, which can create anxiety, depression, and a sharp challenging of others who do not share their concerns.
Situational factors are highly relevant to the problem of mis-diagnosis (Webb, 1993). Intensity, sensitivity, idealism, impatience, questioning the status quo–none of these alone necessarily constitutes a problem. In fact, we generally value these characteristics and behaviors–unless they happen to occur in a tightly structured classroom, or in a highly organized business setting, or if they happen to challenge some cherished tradition, and gifted children are the very ones who challenge traditions or the status quo.
There is a substantial amount of research to indicate that gifted children spend at least one-fourth to one-half of the regular classroom time waiting for others to catch up. Boredom is rampant because of the age tracking in our public schools. Peer relations for gifted children are often difficult (Webb, Meckstroth and Tolan, 1982; Winner, 2000), all the more so because of the internal dyssynchrony (asynchronous development) shown by so many gifted children where their development is uneven across various academic, social, and developmental areas, and where their judgment often lags behind their intellect.
Clearly, there are possible (or even likely) problems that are associated with the characteristic strengths of gifted children. Some of these typical strengths and related problems are shown in Table 1.
Table 1: Possible Problems That May be Associated with Characteristic Strengths of Gifted Children
|Acquires and retains information quickly.||Impatient with slowness of others; dislikes routine and drill; may resist mastering foundational skills; may make concepts unduly complex.|
|Inquisitive attitude, intellectual curiosity; intrinsic motivation; searching for significance.||Asks embarrassing questions; strong-willed; resists direction; seems excessive in interests; expects same of others.|
|Ability to conceptualize, abstract, synthesize; enjoys problem-solving and intellectual activity.||Rejects or omits details; resists practice or drill; questions teaching procedures.|
|Can see cause–effect relations.||Difficulty accepting the illogical-such as feelings, traditions, or matters to be taken on faith.|
|Love of truth, equity, and fair play.||Difficulty in being practical; worry about humanitarian concerns.|
|Enjoys organizing things and people into structure and order; seeks to systematize.||Constructs complicated rules or systems; may be seen as bossy, rude, or domineering.|
|Large vocabulary and facile verbal proficiency; broad information in advanced areas.||May use words to escape or avoid situations; becomes bored with school and age-peers; seen by others as a “know it all.”|
|Thinks critically; has high expectancies; is self-critical and evaluates others.||Critical or intolerant toward others; may become discouraged or depressed; perfectionistic.|
|Keen observer; willing to consider the unusual; open to new experiences.||Overly intense focus; occasional gullibility.|
|Creative and inventive; likes new ways of doing things.||May disrupt plans or reject what is already known; seen by others as different and out of step.|
|Intense concentration; long attention span in areas of interest; goal-directed behavior; persistence.||Resists interruption; neglects duties or people during period of focused interests; stubbornness.|
|Sensitivity, empathy for others; desire to be accepted by others.||Sensitivity to criticism or peer rejection; expects others to have similar values; need for success and recognition; may feel different and alienated.|
|High energy, alertness, eagerness; periods of intense efforts.||Frustration with inactivity; eagerness may disrupt others’ schedules; needs continual stimulation; may be seen as hyperactive.|
|Independent; prefers individualized work; reliant on self.||May reject parent or peer input; non-conformity; may be unconventional.|
|Diverse interests and abilities; versatility.||May appear scattered and disorganized; frustrations over lack of time; others may expect continual competence.|
|Strong sense of humor.||Sees absurdities of situations; humor may not be understood by peers; may become “class clown” to gain attention.|
Adapted from Clark (1992) and Seagoe (1974)
Lack of understanding by parents, educators, and health professionals, combined with the problem situations (e.g., lack of appropriately differentiated education) leads to interpersonal problems which are then mis-labeled, and thus prompt the mis-diagnoses. The most common mis-diagnoses are as follows.
ADHD and Gifted. Many gifted children are being mis-diagnosed as Attention Deficit Hyperactivity Disorder (ADHD). The gifted child’s characteristics of intensity, sensitivity, impatience, and high motor activity can easily be mistaken for ADHD. Some gifted children surely do suffer from ADHD, and thus have a dual diagnosis of gifted and ADHD; but in my opinion, most are not. Few health care professionals give sufficient attention to the words about ADHD in DSM-IV(1994) that say “…inconsistent with developmental level….” The gifted child’s developmental level is different (asynchronous) when compared to other children, and health care professionals need to ask whether the child’s inattentiveness or impulsivity behaviors occur only in some situations but not in others (e.g., at school but not at home; at church, but not at scouts, etc.). If the problem behaviors are situational only, the child is likely not suffering from ADHD.
To further complicate matters, my own clinical observation suggests that about three percent of highly gifted children suffer from a functional borderline hypoglycemic condition. Silverman (1993) has suggested that perhaps the same percentage also suffer from allergies of various kinds. Physical reactions in these conditions, when combined with the intensity and sensitivity, result in behaviors that can mimic ADHD. However, the ADHD-like symptoms in such cases will vary with the time of day, length of time since last meal, type of foods eaten, or exposure to other environmental agents.
Oppositional Defiant Disorder and Gifted. The intensity, sensitivity, and idealism of gifted children often lead others to view them as “strong-willed.” Power struggles with parents and teachers are common, particularly when these children receive criticism, as they often do, for some of the very characteristics that make them gifted (e.g., “Why are you so sensitive, always questioning me, trying to do things a different way,” etc.).
Bi-Polar and other Mood Disorders and Gifted. Recently, I encountered a parent whose highly gifted child had been diagnosed with Bi-Polar Disorder. This intense child, whose parents were going through a bitter divorce, did indeed show extreme mood swings, but, in my view, the diagnosis of Bi-Polar Disorder was off the mark. In adolescence, or sometimes earlier, gifted children often do go through periods of depression related to their disappointed idealism, and their feelings of aloneness and alienation culminate in an existential depression. However, it is not at all clear that this kind of depression warrants such a major diagnosis.
Obsessive-Compulsive Disorder and Gifted. Even as preschoolers, gifted children love to organize people and things into complex frameworks, and get quite upset when others don’t follow their rules or don’t understand their schema. Many gifted first graders are seen as perfectionistic and “bossy” because they try to organize the other children, and sometimes even try to organize their family or the teacher. As they grow up, they continue to search intensely for the “rules of life” and for consistency. Their intellectualizing, sense of urgency, perfectionism, idealism, and intolerance for mistakes may be misunderstood to be signs of Obsessive-Compulsive Disorder or Obsessive-Compulsive Personality Disorder. In some sense, however, giftedness is a dual diagnosis with Obsessive-Compulsive Personality Disorder since intellectualization may be assumed to underlie many of the DSM-IV diagnostic criteria for this disorder.
Learning Disabilities and Giftedness. Giftedness is a coexisting factor, to be sure, in some diagnoses. One notable example is in diagnosis and treatment of learning disabilities. Few psychologists are aware that inter-subscale scatter on the Wechsler intelligence tests increases as a child’s overall IQ score exceeds 130. In children with a Full Scale IQ score of 140 or greater, it is not uncommon to find a difference of 20 or more points between Verbal IQ and Performance IQ (Silverman, 1993; Webb & Kleine, 1993; Winner, 2000). Most clinical psychologists are taught that such a discrepancy is serious cause for concern regarding possible serious brain dysfunction, including learning disabilities. For highly gifted children, such discrepancy is far less likely to be an indication of pathological brain dysfunction, though it certainly would suggest an unusual learning style and perhaps a relative learning disability.
Similarly, the difference between the highest and lowest scores on individual subscales within intelligence and achievement tests is often quite notable in gifted children. On the Wechsler Intelligence Scale for Children – III, it is not uncommon to find subscale differences greater than seven scale score points for gifted children, particularly those who are highly gifted. These score discrepancies are taken by most psychologists to indicate learning disabilities, and in a functional sense they do represent that. That is, the levels of ability do vary dramatically, though the range may be “only” from Very Superior to Average level of functioning. In this sense, gifted children may not “qualify” for a diagnosis of learning disability, and indeed some schools seem to have a policy of “only one label allowed per student,” and since this student is gifted, he/she can not also be considered learning disabled. However, it is important for psychologists to understand the concept of “asynchronous development” (Silverman, 1993), and to appreciate that most gifted children show such an appreciable, and often significant, scatter of abilities.
Poor handwriting is often used as one indicator of learning disabilities. However, many and perhaps most gifted children will show poor handwriting. Usually this simply represents that their thoughts go so much faster than their hands can move, and that they see little sense in making writing an art form when its primary purpose is to communicate (Webb & Kleine, 1993; Winner, 2000).
Psychologists must understand that, without intervention, self-esteem issues are almost a guarantee in gifted children with learning disabilities as well as those who simply have notable asynchronous development since they tend to evaluate themselves based more on what they cannot do rather than on what they are able to do. Sharing formal ability and achievement test results with gifted children about their particular abilities, combined with reassurance, can often help them develop a more appropriate sense of self-evaluation.
Sleep Disorders and Giftedness. Nightmare Disorder, Sleep Terror Disorder, and Sleepwalking Disorder appear to be more prevalent among gifted children, particularly boys. It is unclear whether this should be considered a mis-diagnosis or a dual diagnosis. Certainly, parents commonly report that their gifted children have dreams that are more vivid, intense, and more often in color, and that a substantial proportion of gifted boys are more prone to sleepwalking and bed wetting, apparently related to their dreams and to being more soundly (i.e., intensely) asleep. Such concordance would suggest that giftedness may need to be considered as a dual diagnosis in these cases, or at least a factor worthy of consideration since the child’s intellect and sense of understanding often can be used to help the child cope with nightmares.
A little known observation concerning sleep in gifted individuals is that about twenty percent of gifted children seem to need significantly less sleep than other children, while another twenty percent appear to need significantly more sleep than other children. Parents report that these sleep patterns show themselves very early in the child’s life, and long-term follow up suggests that the pattern continues into adulthood (Webb & Kleine, 1993; Winner, 2000). Some highly gifted adults appear to average comfortably as few as two or three hours sleep each night, and they have indicated to me that even in childhood they needed only four or five hours sleep.
Multiple Personality Disorders and Giftedness. Though there is little formal study of giftedness factors within MPD, there is anecdotal evidence that the two are related. The conclusion of professionals at the Menninger Foundation was that most MPD patients showed a history of childhood abuse, but also high intellectual abilities which allowed them to create and maintain their elaborate separate personalities (W. H. Smith personal communication, April 18, 1996).
Relational Problems and Giftedness. As one mother told me, “Having a gifted child in the family did not change our family’s lifestyle; it simply destroyed it!” These children can be both exhilarating and exhausting. But because parents often lack information about characteristics of gifted children, the relationship between parent and child can suffer. The child’s behaviors are seen as mischievous, impertinent, weird, or strong-willed, and the child often is criticized or punished for behaviors that really represent curiosity, intensity, sensitivity, or the lag of judgment behind intellect. Thus, intense power struggles, arguments, temper tantrums, sibling rivalry, withdrawal, underachievement, and open flaunting of family and societal traditions may occur within the family.
“Impaired communication” and “inadequate discipline” are specifically listed in the DSM-IV (1994) as areas of concern to be considered in a diagnosis of Parent-Child Relational Problems, and a diagnosis of Sibling Relational Problem is associated with significant impairment of functioning within the family or in one or more siblings. Not surprisingly, these are frequent concerns for parents of gifted children due to the intensity, impatience, asynchronous development, and lag of judgment behind intellect of gifted children.
Health care professionals could benefit from increased knowledge concerning the effects of a gifted child’s behaviors within a family, and thus often avoid mistaken notions about the causes of the problems. The characteristics inherent within gifted children have implications for diagnosis and treatment which could include therapy for the whole family, not in the sense of “treatment,” but to develop coping mechanisms for dealing with the intensity, sensitivity, and the situations which otherwise may cause them problems later (Jacobsen, 1999).
Many of our brightest and most creative minds are not only going unrecognized, but they also are often given diagnoses that indicate pathology. For decades, psychologists and other health care professionals have given great emphasis to the functioning of persons in the lower range of the intellectual spectrum. It is time that we trained health care professionals to give similar attention to our most gifted, talented, and creative children and adults. At the very least, it is imperative that these professionals gain sufficient understanding so that they no longer conclude that certain inherent characteristics of giftedness represent pathology.
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