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