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 wellbeing.
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. 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 often ends.
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. 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. Intellectual ability doesn’t protect from illness or injury. Gifted children are not immune from any disorder.
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 and experienced cognitive decline yet continued important scientific work. 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. Learning about the twice-exceptional is often the unlearning of suppositions.
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.
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. ADD and 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, yet many children are labeled after a brief appointment and a rating scale. Inattention can arise from depression, anxiety, fatigue, under-challenge, learning disabilities, hearing or vision impairment, head injury, illness, or other causes. Children who have attention problems in one setting or with one teacher often have a problem of fit, not a medication deficiency.
A diagnosis should help drive good treatment decisions and be part of a whole-child perspective. Forty percent of children correctly identified as having ADD also have learning disabilities. 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 tend to present in many different ways and the complexity can flummox parents as well as professionals. Families often arrive with conflicting advice and multiple possible diagnoses. The range of problems that could explain a child’s difficulties is large.
Emotional Health
There are no precise statistics on how many gifted children carry psychological diagnoses, but estimates suggest a meaningful minority may suffer mental health problems. Depression and anxiety can dramatically undermine cognitive performance, 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 language disorders, including expressive or written language problems. Some struggle with reading, grappling with the relationship between sounds and symbols or with tracking and sequencing text. A substantial proportion have a dyslexic parent. Most children with dyslexia also have broader language problems that may be overlooked once the label is applied.
Auditory Processing
Central Auditory Processing Deficits (CAPD) are a listening problem not detected by routine hearing screens. Children with CAPD can seem inattentive because they fatigue and tune out when trying to follow speech amid background noise. They experience school much like attending a loud, crowded party and expend energy simply trying to follow instruction.
Learning and Memory
Children with learning or memory problems may have strong auditory recall but poor visual recall, or vice versa. Useful assessment questions include:
- Does repetition help?
- Is recall accurate or distorted?
- Is recognition memory intact?
- Does this child group information meaningfully or learn it at random?
- Is short-term or long-term recall compromised?
- Do cues help or make no difference?
Attention
The average gifted child enters the classroom knowing much of the material to be taught. Boredom can be mistaken for attention problems when it is a poor academic fit. Inattention is problematic when it interferes with peer interaction, learning, or demonstrating knowledge. Children may pay attention, but not to the task adults expect.
Executive Functioning
Executive functioning includes planning, judgment, delaying gratification, self-monitoring, and impulse control. Problems in these areas can stem from compromised neurological systems and are common after head injury. Most children with ADD also have executive functioning issues that may go unaddressed.
Sensory and Motor
Fine motor delays can frustrate bright children whose ideas exceed their motor execution. Some children with neurological issues have apraxia or other specific motor-planning difficulties. The brain produces remarkably narrow and specific patterns of difficulty.
Social Concerns
Academically misplaced or isolated gifted children are at greater risk for depression, anxiety, and adjustment difficulties. Extreme ability can contribute to isolation, peer labeling, and difficulty interacting. Misunderstanding giftedness can lead to perfectionism, sadness, and avoidance of growth opportunities.
Intervening: Why we fail
Understanding a problem is the first step toward intervention, yet many interventions fail. IEPs often focus on deficits without highlighting strengths, which undermines motivation. Effective support emphasizes effort, learning processes, strategies, and opportunities to develop talents without fear of looking foolish.
Bibliography
Selected references include the DSM-IV-TR, research on gifted learning-disabled students, and works on assessment, creativity, and neuropsychological case studies.
