Misdiagnosis and Dual Diagnoses of Gifted Children-article

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Counseling, Multiple Exceptionality, and Psychological Issues

Title: Misdiagnosis and dual diagnosis of gifted children Citation:

Abstracted from: Misdiagnosis and Dual Diagnoses of Gifted Children

and Adults: ADHD, bipolar, OCD, Asperger's, depression, and other

disorders. (2004) sdale: Great Potential Press. Available from

the publisher.

Author: T. Webb, R. Amend, Nadia E. Webb, Goerss,

Beljan, F. Olenchak

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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.

Internal Factors

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

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

Strengths Possible Problems

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 (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.

Common Mis-Diagnoses

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.

Dual Diagnoses

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. 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

(sen, 1999).

Conclusion

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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Ballantine.

Seagoe, M. (1974). Some learning characteristics of gifted children.

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