A neuropsychologist is not the first professional a family consults. I still spend time correcting people when they ask if I am a “Nurse/Psychologist.” Neuropsychologists work with neurologically-based behavior concerns such as problems with inattention, memory, planning, judgment, emotional regulation, and the like. Disorders of cognition and emotion are intertwined with neurobiology. Sometimes problems are acquired through an illness or injury; sometimes they are the expression of a genetic vulnerability. The gifted are not immune, although they may present a more complicated picture.
Mind and brain are inseparable in sickness and in health. The nervous system responds and adapts to the demands we place on it. Every skill we learn and every memory we form lasts because of changes in the brain; it is stored as a chemical and electrical trace. A whole child approach to the twice-exceptional child should include a child’s social context (such as family, school, and friendships); it will also include mental health and neurobiological well being.
Neuropsychologists tend to see a wider range of issues, and the profession is less perplexed by the idea the great ability and inability can sit side-by-side. It is routine, and very few neuropsychologists doubt the idea of twice exceptionality. We see physicians, artists, judges, and professors who have suffered small strokes or brain injuries from low impact automobile accidents. We see brilliance and deficits in combination as our profession. A gifted child with an attention deficit, dyslexia or an auditory processing problem is another variant. Not only do we find it plausible that a child can be twice exceptional, we find it logical. This is not a common perspective; despite thirty-plus years of documentation that gifted children can be learning disabled or otherwise neurologically compromised (Baum and Owen, 1988; Fox, Brody, and Tobin, 1983; Whitmore, 1980). One of the greatest difficulties in working with twice-exceptional children is helping school personnel move beyond the “One Label per Customer” model. Because of this mode of thinking, children tend to be defined by their gifts or their deficits, but not both. Once one label has been applied to a child, the quest for answers ends. The child identified as gifted receives little support even when learning disabilities are identified. The child identified as learning disabled is given remedial services, but rarely challenged or offered acceleration. In fact, teachers usually lower standards for children identified as learning disabled, even when they are intellectually advanced (Richey & Ysseldyke, 1983).
Often the twice-exceptional child is identified as neither because an inferior or mediocre performance in a bright child can seem “average.” They tend to drift through classes underachieving, but blending in. Their difficulties remain unaddressed and their potential undeveloped. They receive nothing. However, because they get by, the resources go elsewhere. The cumulative effect is slower academic gains and falling further behind in expressing their potential.
Being gifted may allow you to compensate more gracefully, but it doesn’t buffer us from the neurological vagaries of life. We tend to frame the question of the twice-exceptional backwards, which contributes to our collective myopia. Instead of asking why gifted children should have learning disabilities, we should be asking, “Why shouldn’t they?” Giftedness provides no immunity against genetic vulnerabilities or injuries. We are all susceptible to tiny chromosomal variants and genetic repeats. Intellectual ability doesn’t protect from cancer, diabetes or toxin exposure, nor does it cushion impact in a car accident. Gifted children are not immune from any disorder. Michael Pyryt (2005) suggests it would be reasonable to consider that gifted children would have at least the same incidence of these disorders as would children in general, unless we find good evidence to the contrary.
Anyone who has seen a brilliant colleague recover from a small stroke or concussion has seen deficits and brilliance co-exist. Newton suffered from mercury poisoning in 1677 and in 1692 as a consequence of his scientific experimentation. Colleagues and friends noted progressive cognitive decline and psychotic thinking after each episode – with only partial recovery (Klawans, 1990). Only Newton’s research on optics predated his first exposure. Although impaired, he went on to reckon the movement of the planets, provide a foundation for physics and the understanding of gravity, and independently derive calculus. Newton himself observed that he lacked his “former consistency of mind.”
We are only marginally comfortable with the idea that the psyche dwells within an internal organ. What we see is shaped by what we know, and we are blindest to the disabilities that do not fit our preconceptions. Most of us have a narrow perspective on the range of neurological “faults” in the wiring. For example, few of us know that learning disabilities and psychiatric disorders can be acquired. Learning about the twice-exceptional is often the unlearning of suppositions. A gifted mind is housed in a delicate structure that has the consistency of Jell-O. The long cables connecting one neuron to another have the texture of wet spaghetti. A car accident at seven miles per hour can send this soft mass careening around in the skull. The soft spaghetti-like strands are pulled, twisted, and compressed – shearing and damaging many of them in the process. The gelatinous brain slides and pivots across the knifelike ridges that line basin of the skull, often bruising against the hard surface of the skull as it ricochets.
As a neuropsychologist, I know that I am one blow away from being a janitor with three advanced degrees. We can protect our child’s gifts by requiring sports helmets and teaching that seat belts are not optional. We can also acknowledge that high fevers, anoxia from asthma, mild head injuries, seizures, and the like may have surprisingly significant consequences. The brain can have precisely located skills as well as more complex systems. Recently, researchers found neurons in the visual area of the cortex that fire only to pictures of Jennifer Anniston (Quiroga, Reddy, Kreiman, Koch, & Fried, 2005). While the loss of a Jennifer Anniston neuron might not be a complete tragedy, the idea that some of our skills hang by such a fragile tether is justifiably unnerving.
It does not make it easier to identify learning disabilities and similar neurologically-based issues when they arrive in a variety of strange permutations. When someone says they have dyslexia, the correct response should be “which one?” There are nine identified subtypes of dyslexia, as well as five identified kinds of attention problems, each of which responds best to a different intervention. These subtypes have been identified in a normal population, on and for whom the tests were developed. Gifted children can be even more challenging to identify because their coping strategies can help or hinder identification.
We are blind to the disabilities we are unfamiliar with or those we think that we understand. Preconceptions shape what we observe. For example, we have no difficulty imagining a brilliant child with a speech impediment but we struggle to imagine a brilliant child with a reading impediment. Listening involves hearing and blending sounds into words; speaking involves making and blending sounds into words. Reading is correctly perceiving and sequencing visual marks that stand in for sounds that can be blended into words. Reading is the more complicated task.
Identifying the problem
Given all of this, the challenge is how to provide a practical, whole-person understanding. Most twice-exceptional children would respond well to minor accommodations and a better understanding of their relative strengths and weaknesses. Ironically, the assessment process itself can sometimes hinder understanding a child because it is usually superficial. It is based on limited time, limited resources, and limited insurance reimbursement rather than the actual requirements needed to make the diagnosis.
Attention Deficit Disorder
Attention Deficit Disorders are the “poster children” for the problem of misidentification and misdiagnosis. Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD) are the most commonly diagnosed childhood disorders; it is rare that a child comes through my door who does not have someone championing the diagnosis. ADD is supposed to be a “diagnosis of exclusion,” meaning physicians and psychologists are supposed to rule out every other disorder or problem that might disrupt attention before making the diagnosis. Yet most children are given the diagnosis after a 15-minute appointment with the pediatrician and a behavior rating scale. Inattention is easily disrupted by any number of other core problems. It is difficult to attend when a child is depressed, anxious, fatigued, under-challenged, learning disabled, hearing or vision impaired, preoccupied with problems at home, head injured, madly in love, hungry, ill, or otherwise compromised. There is only one mention of gifted in the entire Diagnostic and Statistical Manual (DSM-IV TR), the book used to codify and guide the diagnostic process. The listing is under the ADD section and specifically mentions assessing the fit between a child of high ability and an under-challenging classroom. Children who have attention problem in one setting or with one teacher have a problem of fit, not a Ritalin deficiency.
A diagnosis should help drive good treatment decisions and should be part of a whole-child perspective. Often, because of the “one label per customer” thinking, the inquiry often stops once a child is identified with a disorder. However, children are complex little people. Forty percent of children correctly identified as having ADD also have learning disabilities. Even more of them have problems with conduct, oppositional behavior and depression. A correct diagnosis is not a solution or a treatment; it is a start.
Understanding Behaviors
Parents bring children to be assessed, not disorders. Gifted children, being their own quirky selves, tend to present in any manner by the classic presentation of anything. They are complicated little people, usually being cared for by thoughtful, intelligent parents. These parents have usually spoken with teachers, friends, pediatricians, and relatives long before they come to see me. Yet the complexity of the gifted children often flummoxes parents as well as professionals. Often the starting point for understanding a child’s difficulties begins something like this:
“We were asked to come in for a parent teacher conference. Our son’s teacher said his book report was awful. He did half the required number of pages. What he handed in was chaotic and disorganized, and he didn’t seem to care about doing it. The school counselor suggested he might be ADD because he just doesn’t seem to focus when he is asked to do in-class assignments. He doesn’t do them, does them badly, or just makes up his own assignment and does that instead. Getting him to do homework is a struggle. Do you think he has ADD? Or is he in the wrong place in a GT program? Are we asking too much from him or does he need a kick in the rear?”
Although it is a deviation back to my roots as a family therapist, parents tend to come in with a difference in opinion. Usually the father is the one who thinks he needs to buck up and the mother thinks he would do better with more support. Both parents are usually bright, dedicated parents who have read several advice books and talked to several professionals before walking through my door. When they walk in, they bring conflicting advice and opinions, and often several possible diagnoses (formal and informal). Inevitably someone thinks he has ADD. But the range of problems that could explain this child’s difficulties would fill a shopping list.
Emotional Health
As with the issue of misdiagnosis, there are no precise statistics on the number of children who are gifted and carry a psychological diagnosis, even though some advocates for gifted children have estimated that between 4.5% and 20% of gifted students may suffer mental health problems. Depression and anxiety can dramatically undermine cognitive performance on standardized IQ tests; they also disrupt motivation, focus, and creativity. In children, depression can present as irritability, which often alienates those who care most.
Language
Children can have a wide range of disorders, including problems in understanding and using expressive language or problems with written expression (the articulate child who becomes plodding and tongue-tied when asked to write the same ideas). Some wrestle with reading, struggling to grasp the relationship between sounds and symbols or tracking and sequencing the information in the line of text. Twenty-five to fifty percent of these children have a dyslexic parent (DSM-IV TR). A parent may watch his daughter struggle with the same problems that he did in school, which often evokes painful memories and resentment that can color interactions with teachers and administrators. Most children with dyslexia also have broader language problems, which may not be identified once the label “dyslexia” has been applied.
Other children have “prosody” problems: they seem to have the words but not the music of a conversation. Tone of voice and nuances of body language are lost on them. Imagine being the teenager who misses all the cues that it is time to go. His friend looks at his watch and says, “It’s been great talking to you.” He stands up and walks towards the door. All of this is opaque, until the friend finally becomes exasperated and says, “You really need to go!” This child lives in a world where others seem clumsy, abrupt and perplexing. Often this kind of problem is associated with Autistic Spectrum Disorders or Non-Verbal Learning Disabilities, but it is not unique to them. Prosody problems can stand alone.
Auditory Processing
Central Auditory Processing Deficits (CAPD) have become a popular concern in the gifted community, but few people understand the definition or how it is distinct from a hearing loss. CAPD is a listening problem that is not measured by the hearing test at school. Children with CAPD can seem like they have attention problems because they eventually fatigue and tune out. These children are, experientially, trying to go to school at a cocktail party. It results in fatigue, disinterest and avoidance that mirrors the adult experience in such settings.
Learning and Memory
Children with learning or memory problems may have superb auditory recall and poor recall of visual information (or vice versa). It is helpful to know which channels of communication are strengths and to use these when the goal is learning content. Basic questions that an assessment can illuminate include:
- Does repetition help?
- Is recall accurate or distorted?
- Is recognition memory intact?
- Does this child group information meaningfully or try to learn it in random fashion?
- Is short-term or long-term recall compromised?
- Do cues help or do they make no difference?
Attention
The average gifted child enters the classroom knowing two-thirds of the material that will be taught in the coming year. Few seven year olds use their free time constructively when they are bored. This is easily misunderstood as a behavior or attention problem, when it is a problem of poor academic fit. Inattention is a problem if it interferes with a child’s ability to interact with peers, learn, and demonstrate what he knows. Inattention can include problems with simple focus, sustaining attention over time, sustaining attention under distraction, shifting attention between tasks, or allocating attention wisely.
Executive Functioning
Executive functioning or complex attention includes planning, judgment, delaying gratification, self-monitoring, and impulse control. Most children with ADD will also have problems with executive functioning, although it is often not addressed as a specific problem. It is also a particularly common consequence of car accidents, particularly those in which the child or teenager is unbelted.
Sensory and Motor
Can the fingers do what the mind can imagine? Bright minds are often housed in the bodies of young children. For children with fine motor delays or poor dexterity, frustration can be pronounced and interfere with written work and projects. Children with head injuries or neurological issues may have esoteric problems such as apraxia, where the connection between the idea and the motor pattern has been severed.
Social Concerns
While most gifted children are well adjusted, academically misplaced or isolated gifted children are at greater risk for depression, anxiety and other mental health concerns. Students scoring in highest IQ ranges may experience greater adjustment difficulties, possibly because extreme abilities contribute to isolation and worsen fit with their environment. The twice-exceptional child is more likely to be misplaced and isolated from peers, which can lead to dissatisfaction and abandonment of abilities.
Intervening: Why we fail
Understanding the problem is a basic step toward designing an intervention, yet we often fail at the second step. An Individualized Education Plan (IEP) tends to focus on deficits rather than strengths. Effective support should focus on effort, learning processes, and strategies, emphasizing practice, mentorship, and a willingness to risk failure in the service of learning.
Bibliography
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision). American Psychiatric Association.
Baum, S. & Owen, S. (1988). High Ability/Learning Disabled Students: How are they different? Gifted Child Quarterly, 32, 321-326.
Buescher, T. M. (1985). A framework for understanding the social and emotional development of gifted and talented adolescents. Roeper Review, 8(1), 10-15.
Selected other references include works by Boodoo et al.; Coleman & Gallagher; Davis & Rimm; Fox, Brody & Tobin; Jenkins-Friedman & Murphy; Klawans; Minner; Nickerson; Pyryt; Quiroga et al.; Richey & Ysseldyke; Ruban & Reis; Simonton; Terman; Tallent-Runnels & Sigler; Webb et al.; Whitmore.
