When diagnosing ADHD, consider possibility of giftedness in some children
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Author Erik von Hahn, MD, FAAP Citation Reprinted with permission from AAP News, July 2012 issue, copyright American Academy of Pediatrics

When diagnosing ADHD, consider possibility of giftedness in some children

by Erik von Hahn, M.D., FAAP

Reprinted with permission from AAP News, July 2012 issue, copyright American Academy of Pediatrics.

Parents and teachers often ask whether a child might have attention deficit/hyperactivity disorder (ADHD). But when a child is gifted, a diagnosis is not always clearcut.

Although gifted children generally do well, they may show behaviors that mimic ADHD. For example, they may appear hyperactive because they ask many questions and are so excited about learning. Or, they may fail to participate in age-expected activities because of their over-focus on an area of interest. Finally, boredom can lead to inattention as well as feelings of depression.

In such cases, the child does not have ADHD or another disability, and the appropriate intervention is to provide needed stimulation. Otherwise, the child is at risk for academic and social failure despite superior potential.

‘Twice-exceptional’ children

Although atypical behaviors in gifted children do not necessarily indicate the presence of a disability, gifted children can have ADHD or another behavioral or mental health condition even when they are provided with appropriate levels of stimulation.

This concept of dual diagnosis, or twice-exceptional children, can be difficult for parents, teachers and clinicians to accept. Adults who work with children often seek one explanation for the child’s behaviors and may not accept that a student can be gifted and have a disability.

Identifying giftedness and an accompanying disability such as ADHD is not hard to do if pediatricians consider the possibility that both might be present in the same child. As is the case for any child who may have ADHD, criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) must be fulfilled to make the diagnosis. The pediatrician also needs to consider whether the symptoms listed in the DSM-IV are due to giftedness (and the result of excitement, boredom or over-focus on other interests); if they are due to the executive dysfunctions believed to cause ADHD; or if they are due to a combination of the two.

Ask these questions

The following questions can help pediatricians identify a gifted child:

• Do the parents believe the child might be gifted? Most of the time, parents are accurate in their assessment of their child’s giftedness. They will give a good description of their child’s advanced skills and will state that their child complains of boredom or completes his/her work much more quickly than peers, etc.

• Does the child have strong academic or cognitive skills, unexpected for his or her age? These are identified through formal intelligence measures but also should be evident from the student’s school performance (past or present). Examples include advanced reading, writing or math skills. Detailed questioning may be needed to identify advanced academic skills in students who may also show academic failure due to boredom.

• Does the child show non-academic abilities unexpected for his or her peer group? Exceptional skills are those valued by society, such as advanced skills in drawing, dance, sports or music.

• Does inattention occur in only one setting or with certain types of tasks? Can the child explain why she or he is not paying attention? More importantly, is the child attentive, focused and productive when engaged in his or her area of interest?

The following questions might help pediatricians identify a gifted child who also might have ADHD:

• Do symptoms of inattention persist even though the gifted student participates in classroom and other activities that provide the appropriate level of stimulation (i.e., enrichment activities and/or activities with similarly abled peers)?

• Does the child complain of not being able to focus successfully or of being forgetful? These complaints are especially pertinent if they interfere with the tasks that the child wishes to complete.

• Does the inattention interfere with academic and social success, and also with managing daily routines? The child has to show symptoms of inattention during different types of tasks and across settings, and has to require significant adult supervision/supports to manage routines of the day.

Although these lists are not complete, the take-home message is that giftedness can look like ADHD and can co-exist with ADHD. If pediatricians consider both conditions, they will be able to gather the necessary information or make the appropriate referrals to establish an accurate diagnostic picture.

RESOURCES

• Webb JT, et al. Misdiagnosis and Dual Diagnoses of Gifted Children and Adults. Great Potential Press, 2005

• National Association for Gifted Children, www.nagc.org

• Supporting the Emotional Needs of the Gifted, www.sengifted.org

• The Association for the Gifted, Division of the Council for Exceptional Children, www.cectag.org

• Davidson Institute for Talent Development, www.ditd.org

 

Erik von HahnDr. von Hahn is a developmental and behavioral pediatrician. He works at the Floating Hospital for Children at Tufts Medical Center in Boston.

 

 

 

9 Comments »

  1. This article would be more comprehensive, if it also mentioned how dyslexia iappears in intellectually gifted children/students. Not only is ADHD misdiagnosed in gifted, but doubly so in 2e kids who are both intellectually gifted and also have dyslexia. (See the Eides’ work, book, website and article on stealth dyslexia). Schools often provide nothing for the gifted or the dyslexic child, and because they develop compensatory strategies early on and their intelligence permits them to function at grade level in younger grades (grade level being all anyone is interested in these days), both gifts often go unnoticed/ unaddressed and pure exhaustion from functioning in such a contrary environment gets mislabeled ADD or ADHD. ADD/ADHD diagnoses are highly suspect, due to the diagnosis being so subjective, the solution being solely meds, and this label alleviating schools from any responsibility to educate these children properly/ provide appropriate differentiated instruction. Dyslexic children are often highly creative, plus require multi sensory instruction. Gifted children are often highly creative and require depth, breadth, etc. Our schools now only offer rote grade level test-focused desk work to be memorized and spit out for one-right-answer bubble tests–undeserving the gifted, the dyslexic, the creative thinkers, and most of all the 2e child who is all three– intellectually gifted, creative with dyslexia. Drugging our brightest, most creative minds, rather than nurturing them is ian approach that is running rampant in our public schools.

    Comment by Pam — July 16, 2012 @ 7:19 am

  2. WHY “PAYING ATTENTION TO ATTENTION” IS VITAL

    Superb article. My experience at Columbia University (NYC) helped me understand that ADHD Symptoms and Gifted Multitasking are Identical Twins. I always used time/orginising strategies and even (I know a terrible word) self-discipline (students waiting a few seconds before impulsively responding to stimuli.

    Diagnosis by treatment (response)
    We used diagnosis by treatment. If giving stimulants calmed, then the child may be hardwired for over-reacting. In our decision tree we always tried to sort out if it’s a Won’t or Can’t Problem (won’t control own impulsivity, distractibility vs. Can’t control). If the person CAN’T control attention/impulsivity perhaps they should consider “event planning” or other highly stimulating careers.

    “I WANT TO BE ADHD” (The new mantra)
    Another very complicating issue is many teenagers WANT to be diagnosed as ADHD (status symbol, access to stimulant drugs, excuses for underachievement).

    BOTTOM LINE: PAY ATTENTION or at least DO NO HARM.
    Every student’s success is my goal. The world does not care why a surgeon might leave an operation in the middle
    of a procedure, to go run to his bank to make a deposit (a true life case.) The world doesn’t care why, while performing surgery, the surgeon is thinking about his golf game, what he’s going to have for dinner that evening
    If he makes a mistake because he’s not focused, there are serious consequences.

    ATTENTION: GATEWAY SKILL
    Gifted kids must understand that focusing on task is premiere, no matter how hard it might be. When I taught “A course in common sense for the Gifted” while interning at Columbia, I tried to get kids to focus on their breathing for at least a minute, rarely with success at first.

    It doesn’t matter Why a person does or does not pay attention, all that matters is that they DO PAY ATTENTION.
    Attention is the Gateway MetaSkill. Gifted children are architects of the future. It is our job to equip children with qualities (e.g patience) which will improve everyone’s quality of life

    A race care with no steering wheel.
    It matters not whether a person is hardwired with 100 Terabytes of information (ordinary PC has ONE Terabyte of info), without the ability to steer into curves and slow down mentally, the student may not even finish the “rat race”. The first US President to Graduate from Columbia (1983), centerpieced “finding his focus” as THE LEADING skill he acquired. I would imagine if learning how to focus is good enough to lead about a hundred million people, it’s good enough to pack in everyone child’s packback in his back to school journey.

    A concerned educator
    Dr. Ron Rubenzer EDD, MA, MPH, MSE
    Author – How the best handle stress

    Comment by Dr. Ron Rubenzer — July 16, 2012 @ 10:04 am

  3. Thank you, Pam, for your comments about dyslexia. The topic of dyslexia is a huge one in and of itself which may explain why it was not specifically included in this article about ADHD. Your concerns about the disorder are valid. The Eides, members of SENG’s Professional Advisory Board, have done enormous amounts to bring awareness to the issue of dyslexia in gifted populations. Their most recent book, “The Dyslexic Advantage” is excellent. How the DSM-V will eventually handle the diagnosis of dyslexia is at the point unclear, as it is currently expected to be included under the umbrella term of SLD (specific learning disorder). Dyslexia is a term which is recognized both legally and educationally, and the outcome of the DSM-V is one many are anxiously awaiting.

    Comment by Marianne Kuzujanakis — July 20, 2012 @ 12:40 pm

  4. As one who serves the very, very young population or )-36 months, and assists parents with decisions for early school entry, there seems to be a void in the literature regards assessing inattention vs giftedness and the possible overlap for these children. Any advice, suggestions? Typically I have one to two families per year with bright speech delayed children who are already chronically driving their families/caregivers to concern, due to possible inattention but probable extreme understimulation. I note that when provided sufficient challenge & novelty, these younsters show lengthy concentration periods, also that they have unusually accurate longer term detailed memory for age.

    Comment by T Burns — July 29, 2012 @ 8:00 am

  5. Very nice article Dr. von Hahn –one of the best I have read on gifted and ADHD. I appreciate the balanced approach. While there may be certain overlapping traits between some gifted kids (certainly not all) and ADHD the gifted component does need to be considered when seeking an evaluation. I think most ADHD specialists are cognizant of the gifted piece and are sensitive to the possible overlap. I would like to mention that many gifted kids with ADHD fall through the cracks as they may not fit a typical ADHD profile. Dr. Thomas Brown has 2 studies on the gifted child and gifted adult. EF issues are discussed as well as how a high IQ can mask the ADHD and lead to a missed diagnosis. I love the all too common mantra of these ADHD High IQ kids “ I work best under pressure”. It is interesting to note that many of these kids do fairly well until high school or later where the EF impairments significantly interfere with their academics and even life (i.e driving ) but the real downside to a missed diagnosis is that they may not be capable of actualizing their full potential. Niehart wrote: (2003) “Until systematic studies are conducted, we should be cautious about rejecting ADHD diagnosis in gifted children out of hand because there are serious, long-term negative consequences for undertreating the disorder (Barkley, 1998). The available research on ADHD children indicates that nationally, there is a good deal of undertreatment as well as some overtreatment of ADHD children.”
    Horrigan suggests that high IQ can compensate and delay the diagnosis of ADHD. This graph http://www.medscape.org/viewarticle/713528_2 shows that the higher the IQ the older one is when eventually diagnosed. And then there is the added dimension of gifted girls with ADHD …so many are missed. Your readers may be interested in reading the work of Nadeau and Quinn as it relates to Gifted Girls and ADHD.
    With so much emphasis on the mis-diagnosis of adhd in gifted kids in the US I see very little being done to address the social and emotional impact of ADHD on gifted kids. The self-esteem issues are horrendous. There is virtually nothing on educational strategies for the gifted ADHD student and it is especially problematic, since many do not receive the needed early intervention. What I have read focuses on behavioral issues, which is usually not the problem with the inattentive subset so common among the gifted ADHD.. Moon (2002) even suggested that recommended interventions for ADHD may actually be worse for gifted ADHD kids.

    Comment by Kristine — August 9, 2012 @ 12:35 am

  6. After carefully reading the information above it seems to me that some kids are diagnosed wrongfully of havng ADHD. I know a kid that has been described as having ADHD and does not fit the criteria of the above. I am not diminishing anybody’s diagnosis or being horrible in anyway, but in my experience of kids the one that I know is no different to any other kids who throws their dolls out if they cannot get their own way, trantrums etc.

    Comment by no 2 parent — August 10, 2012 @ 5:07 pm

  7. One disturbing detail that’s never addressed: What if a child shows “exceptional skills” in an area NOT valued by society? Are they just unlucky? Unidentifiable because we can’t id an unvalued skill? Born in the wrong age?
    Unfairly ignored? A successful cat burgler? spy? safe cracker? con artist?
    Is there a potential societal problem if these kids are ignored?

    For all the greed allowed and in control of everything, I guess it makes sense that “special education” is funded despite the unlikelyhood of these kids making a big economic contribution because if gifted kids were equally funded, they might have influence with their higher sense of morality, equality, and skills.

    Comment by Twrl33 — September 12, 2012 @ 10:00 pm

  8. It took a while to get my son diagnosed because his giftedness masked his ADHD. At the time he was diagnosed it was unclear if he also had ODD and Mood Disorder (depression). I note that the latter has disappeared since we have attended his needs (environmental, medical) better. This reminds me that these labels help us know what to read about, research, and give us a framework, but the bottom line — which is inconvenient in today’s big classrooms and with busy adults — is that no matter what the identified label (or not), some children learns differently, and that is not wrong simply if it isn’t average. I have really had to change my perspective on what is important, and be willing to change plans to meet my son’s needs. Exhausting, sometimes; but I’m happy to report he is in a much better place. I read everything (gifted, ADHD, visual-spatial, 2E, LD, EF), but go with what works for him.

    Comment by Dawn — October 18, 2012 @ 3:27 pm

  9. Thanks for raising the issue Dawn. As the parent of a son who has tested as profoundly gifted and who may or may not have ADHD or dsylexia or both, I’m in a similar place. I understand the need for clear guidelines for diagnosis and the value of a diagnosis in getting attention from schools and others – and I don’t want to downplay those needs. But they are not my needs. I don’t need a label. I don’t really need a “diagnosis”. What I need is a set of possible coping strategies that we can experiment with to figure out exactly what’s going to work for my son. Right now all I can find are tests to diagnose the problem. Has anybody put together a list of the “possible coping strategies to try (short of medication) if your gifted child appears to have some combination of ADHD/dyslexia”?

    Comment by Kris — October 20, 2012 @ 6:48 am

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