Gifted Homeschoolers Forum

Misdiagnosis and Missed Diagnosis: Giftedness and Disorders

by Linda Kreger Silverman, Ph.D.

Psychology recognizes retardation as an organizing principle - a unique trajectory of development with atypical characteristics. Giftedness needs to be recognized as the mirror image of retardation, and training needs to be provided to clinicians in working with this exceptionality. Few expect developmentally delayed individuals to behave exactly like everyone else. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which establishes the criteria used to determine various mental disorders, provides ample demonstration of this. The criteria for many of the psychiatric diagnoses bear the exclusionary clause, "If Mental Retardation is present, the difficulties are in excess of those usually associated with these problems"(American Psychiatric Association [APA], 1994, p. 58). Certain behaviors that would appear abnormal in an average person are part of the syndrome of retardation; therefore, they are attributed to retardation rather than to other categories. The diagnostic emphasis is on comparing the developmentally disabled with their own group rather than with societal norms.

This same principle needs to be applied in diagnosing problems in gifted individuals. However, since gifted individuals look like everyone else and can pretend to be like everyone else, they are usually judged by a set of standards based on norms for the general population rather than compared with their own group. Some behaviors that would signify disorder in the rest of the population are typical characteristics for the gifted.

Some Typical Characteristics of the Gifted

Emotional highs and lows, for example, are part of the creative process, but they may be mistaken for signs of manic depression. Gifted individuals are often empathic and feel the weight of the world on their shoulders. As teenagers, they can become depressed at the realization of their inability to make a difference in the condition of the world. This could be confused with endogenous depression, which is usually treated with medication.

Perfectionism is one of the most frequently misunderstood qualities of the gifted. Therapists often assume that perfectionism needs to be cured, since it appears to be a factor in several conditions, such as obsessive-compulsive personality disorder, anxiety, depression, anorexia, bulimia, sexual compulsions and dysfunctions, and psychosomatic disorders. However, perfectionism in the gifted has an entirely different significance. It is a component of the drive for self-actualization (Maslow, 1971).

Self-actualization means experiencing fully, vividly, selflessly, with full concentration and total absorption. It means experiencing without the self-consciousness of the adolescent. At this moment of experiencing, the person is wholly and fully human. This is a self-actualizing moment. This is a moment when the self is actualizing itself. As individuals, we all experience such moments occasionally. As counselors, we can help clients to experience them more often. We can encourage them to become totally absorbed in something and to forget their poses and their defenses and their shyness to go at it whole-hog. (p. 45)

Maslow invites counselors to encourage what others might discourage: perfectionistic zeal.

In a recent large-scale study of gifted and talented sixth graders, Parker (1997) found perfectionism to be correlated with conscientiousness rather than neurosis; he argued for appreciation of a healthy form of perfectionism. Therapists need to be able to distinguish between an unreachable, punitive set of standards of an average client and a level of excellence within the grasp of a gifted one. Robinson (1996) also regards perfectionism in the gifted as a potentially healthy trait, and exhorts counselors to support what she calls 'positive perfectionism':

Some therapists would label as neurotic those characteristics that are quite typical of bright youngsters. Indeed, therapists are trained to look for psychopathy rather than health in people who are different. Counselors tend, in particular, to see perfectionism as a neurotic trait. Although, in general, high degrees of perfectionism may be associated with lower degrees of self-confidence (Flett, Hewitt, & Davidson, 1990), supportive adults can enable students to practice 'positive perfectionism' (i.e., setting high standards for oneself, working to meet those standards, and taking joy in their attainment). Passionate pursuit of one's own interests, even esoteric ones, to the exclusion of a well-rounded life may be seen by counselors as peculiar and socially isolating. (pp. 133-134)

Atypical Symptoms of Dysfunction

Misdiagnosis can occur in both directions. It is possible to miss subtle signs of serious disorders because the gifted may exhibit atypical manifestations rather than textbook symptoms. For example, a highly able adult may experience only the lows without the highs and still have bipolar disorder. The manic phase may consist of periods of enthusiasm, less need for sleep, enormous creative energy, and the motivation to begin new projects. Then the depression sets in and the person is unable to complete the projects begun. And the cycle repeats itself. Or one manic episode can end a life that could have been saved with lithium.

It is easier to extract the symptoms of disorder from the symptoms of giftedness when the gifted are compared with their own group. Currently, therapists receive no training in giftedness that would enable them to sort out these complex variables. Gifted people suffer when their gifts are distorted into defects, and lives can be lost when serious disorders are masked by giftedness.

AD/HD and Giftedness

The question of misdiagnosis of the gifted has come to the forefront because of the disconcerting numbers of gifted children who have been diagnosed as having Attention Deficit/Hyperactivity Disorder (AD/HD). Though many hypotheses have been offered, the reason for the high number of gifted children labeled AD/HD remains a mystery. Gifted children may exhibit AD/HD-like symptoms without actually having this disorder. Roedell (1988) refers to these children as “gifted but wiggly” (p. 9). The gifted absorb more information, process rapidly on many levels, have unusual energy, and often can do many things at once. Attention focused elsewhere—exploring the effects of a sunbeam or a mathematical relation or a fantasy world—may appear as inattention in an unchallenging classroom. The DSM-IV indicates that “inattention in the classroom may also occur when children with high intelligence are placed in academically understimulating environments” (p. 83, emphasis in original).

Some children are highly active, extraverted, exuberant learners who talk rapidly and are always on the go, but their behaviors do not interfere with learning or social interaction. Acceptance of these traits is in part culturally determined. Behavior that might brand a child as AD/HD in Billings, Montana, could be the norm in Brooklyn.

However, separating out those behaviors related to giftedness from those associated with AD/HD has proven to be a daunting task. In their popular book, Driven to Distraction, Hallowell and Ratey (1994) explain the creativity of individuals with AD/HD in a manner uncomfortably descriptive of most gifted people:

A third element that favors creativity among people with ADD is the ability to intensely focus or hyperfocus at times. The term 'attention deficit' is a misnomer. It is a matter of attention inconsistency. While it is true that the ADD mind wanders when not engaged, it is also the case that the ADD mind fastens on to its subject fiercely when it is engaged. A child with ADD may sit for hours meticulously putting together a model airplane. An adult may work with amazing concentration when faced with a deadline. (p. 177) This ability to hyperfocus heats up the furnace in the brain. The intensity of the furnace when it heats up may help explain why it needs to cool down, to be distracted, when it is not heated up. A fourth element contributing to creativity is what Russell Barkley has called the hyperreactivity of the ADD mind. Cousin to the traditional symptom of hyperactivity, hyperreactivity is more common among people with ADD than hyperactivity is. People with ADD are always reacting. Even when they look calm and sedate, they are usually churning inside, taking this piece of data and moving it there, pushing this thought through their emotional network, putting that idea on the fire to burn, exploding or subsiding, but always in motion. Such hyperreactivity enhances creativity because it increases the number of collisions in the brain. Each collision has the potential to emit new light, new matter, as when subatomic particles collide. (p. 178)

Inconsistent attention, the ability to hyperfocus, and hyperreactivity of the mind, are just three of the many traits shared by both the gifted and AD/HD population. When do such traits become problems and when are they simply the experience of being a typical 'gifted but wiggly' child? (1) When problems appear at home as well as at school, such as engaging in dangerous activities, hurting others, destroying property, frequent uncontrollable outbursts; (2) when inattention or lack of impulse control seriously interferes with learning, social interaction, and family dynamics; (3) when the child is unhappy, it is important to determine the source of the problem. While AD/HD may seem to be the likely culprit, a complex array of emotional factors could cause the same symptoms. A thorough diagnosis is in order by a mental health professional who has worked with numerous gifted individuals. Sometimes a team approach is best: one who specializes in giftedness and another who specializes in AD/HD?to sort through the overlapping symptoms.

While overdiagnosis of AD/HD is a serious problem in some communities, lack of appropriate diagnosis of AD/HD among the gifted also occurs. Too many professionals dismiss the symptoms of AD/HD if a child can concentrate for long periods of time in areas of interest. Hallowell and Ratey?s (1994) description of the hyperfocusing ability of individuals with AD/HD needs to heeded. Creative children and adults who have AD/HD can focus exquisitely for long periods of time on their own interest areas, but lack the ability to focus when they are not interested. This is important information for differential diagnosis.

One way to determine if a child's behavior is a function of giftedness or AD/HD is to observe the child in a situation in which his or her level of giftedness is being appropriately challenged. A child whose activity and distractibility level are beyond the norm of a group of gifted children in a special setting is more likely to be truly AD/HD than a child who exhibits symptoms of AD/HD within a heterogeneous classroom.

Conclusion

Giftedness is a ground of experience that differs significantly from the norm. Just as developmental delay produces lifelong effects on social and emotional development, developmental advancement permeates all facets of a person?s life in childhood and adulthood. Diagnosticians, school psychologists, therapists and educators need to be aware of the characteristics of giftedness in order to recognize what is atypical for this population, rather than comparing gifted individuals with the general population. The caveat in the DSM-IV, "If Mental Retardation [etc.] is present" the difficulties are in excess of those usually associated with these problems" (p. 58) should be applied to the gifted population as well. Traits that might be perceived by untrained practitioners as dysfunctional, such as emotional intensity, sensitivity, perfectionism, excessive energy, are understood as typical manifestations of the gifted.

References.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (Fourth edition). Washington, DC: Author.

Hallowell, E. M., & Ratey, J. J. (1994). Driven to distraction. New York: Pantheon.

Maslow, A. H. (1971). The farther reaches of human nature. New York: Viking Press.

Parker, W. D. (1997). An empirical typology of perfectionism in academically talented children. American Educational Research Journal, 34, 545-562.

Robinson, N. M. (1996). Counseling agendas for gifted young people: A commentary. Journal for the Education of the Gifted, 20, 128-137.

Roedell, W. C. (1988). “I just want my child to be happy”: Social development and young gifted children. Understanding Our Gifted, 1(1), 1, 7, 9-11.

Linda Kreger Silverman, PhD, is a licensed psychologist. She directs the Institute for the Study of Advanced Development, and its subsidiary, the Gifted Development Center, in Denver, Colorado. Her textbook,Counseling the Gifted and Talented, is the most popular text in this area. Dr. Silverman is also the author of the Upside-Down Brilliance: The Visual-Spatial Learner, a book which is rapidly becoming a classic in the field of gifted education.