Attention Deficit Disorders and Gifted Students: What do we really know?

By Felice Kaufmann, M. Layne Kalbfleisch. and F. Xavier Castellanos

Few current topics in education have engendered as much attention, concern, and passion as Attention-Deficit/Hyperactivity Disorder (ADHD), particularly in gifted children. We recognize that giftedness is multifaceted and can be assessed in many ways other than a standardized IQ test. We will summarize and differentiate between what is known and what is assumed about ADHD in gifted students. (See our NRC/GT monograph for a complete analysis of this topic.)

ADHD: History, Definition, and Etiology Attention-Deficit/Hyperactivity Disorder (ADHD) is a “syndrome,” i.e., a grouping of symptoms that typically occur together. The core symptoms of ADHD are impulsivity, inattention, and hyperactivity (American Psychiatric Association, 1994). Estimates of the prevalence of ADHD among school age children vary but the median estimate across all definitions of ADHD and all types of studies is 2% in boys and girls combined (Lahey, Miller, Gordon, & Riley, 1999).

Family, adoption, and twin studies demonstrate that genetic factors are very important in ADHD, but environmental factors also play a significant role since heritability is less than 100%. Environmental factors, including premature birth, head injury, fetal alcohol syndrome, prenatal exposure to drugs of abuse, such as cocaine, lead toxicity, prenatal maternal smoking, and rare endocrine abnormalities can all cause the ADHD syndrome.

How Is ADHD Assessed and Diagnosed? Four subtypes of Attention-Deficit/Hyperactivity Disorder (ADHD) are recognized in the DSM-IV: Predominantly Hyperactive/Impulsive, Predominantly Inattentive, Combined, and Not Otherwise Specified (American Psychiatric Association, 1994). To meet the criteria for one of the specific subtypes, at least 6 of the 9 symptoms of hyperactivity/impulsivity, or at least 6 criteria from the 9 symptoms of inattention must be present. (Combined type means both sets of criteria are met.) The symptoms must occur in more than one setting, must persist for at least 6 months, and must affect the individual “to a degree that is maladaptive and inconsistent with developmental level” (American Psychiatric Association, 1994, p. 83).

Under optimal circumstances, a team, including a qualified clinician, such as a pediatrician, family physician, psychiatrist, neurologist, or psychologist should make the diagnosis of ADHD because only these types of specialists can assess the physical and psychological problems that mimic ADHD. Information about these conditions is rarely available to school personnel, no matter how observant, experienced, or well trained.

For the majority of children with ADHD, symptoms become clear-cut when their behavior can be observed regularly and compared to other children over a sustained period. The classroom teacher, therefore, is typically the best person to make such comparisons, especially when systematic behavioral checklists or rating scales are employed. When the child in question is gifted, an individual who specializes in giftedness should also be included in the process to provide information about the child’s behavior in comparison to other children of similar abilities (Silverman, 1998).

ADHD or Gifted: Either or Both? In recent years, several authors (Baum, Olenchak, & Owen, 1998; Cramond, 1995; Freed & Parsons, 1997; Lind, 1993; Tucker & Hafenstein, 1997; Webb & Latimer, 1993) have expressed concern that giftedness is often misconstrued as ADHD and that the diagnosis of ADHD among the gifted population has run amok. We acknowledge for the purposes of this discussion that there are cases of mistaken diagnosis, although as of this writing, we have found no empirical data in the medical, educational, or psychological literature to substantiate the extent of this concern.

The lack of scientific data heightens our dismay over the wave of skepticism that appears to prevail about the existence of ADHD in gifted children. Specifically, we are concerned that the question “ADHD or gifted?” dismisses the possibility that the two conditions may coexist. Prudent attempts to avoid over-diagnosis must be balanced against a child’s need for evaluation and treatment in the context of inevitable uncertainty when medical diagnoses are invoked.

In this context, Silverman (1998) notes that some professionals erroneously assume that a child who demonstrates sustained attention, such as a gifted child engaged in a high-interest activity, cannot have ADHD. It is understandable that an observer might discount the possibility of ADHD because from all appearances the child is so absorbed in a task that other stimuli fade into oblivion. While this state of rapt attention is often described as “flow” (Csikszentmihalyi, 1990), it can also be ascribed to “hyperfocus,” which is a similar condition that individuals with ADHD frequently experience (Hallowell & Ratey, 1994).

Activities that are continuously reinforcing and “automatic,” such as video or computer games or reading for pleasure, do not distinguish children who have ADHD from children who do not have ADHD, whereas effortful tasks do (Borcherding et al., 1988; Douglas & Parry, 1994; Wigal et al., 1998). By virtue of their giftedness, the range of tasks that are perceived as “effortless” is broader for gifted children, which is why their ADHD may be less apparent than in children who struggle more obviously and to lesser effect.

Recent work (Kalbfleisch, 2000) suggests that the gifted child with ADHD is particularly predisposed to exhibit this state of “flow” or “hyperfocus.” While this can be a positive aspect of task commitment and a sign of motivation, it becomes a problem when the child is asked to shift from one task to another. Therefore, while cognitively this state can have positive aspects, behaviorally it can also cause problems (Moon, Zentall, Grskovic, Hall, & Stormont, in press). Furthermore, ADHD is not characterized by an inability to sustain attention, but rather by the inability to appropriately regulate the application of attention to tasks that are not intrinsically rewarding and/or that require effort. Such tasks are, sadly, characteristic of much of the work that is typically required in school, even in programs for gifted students.