Attention Deficit Disorders and Gifted Students: What Do We Really = Know?=20

By: Felice Kaufmann, M. Layne Kalbfleisch, and F. Xavier Castellanos=20 (2000)

Few current topics in education have engendered as much attention, = concern,=20 and passion as Attention-Deficit/Hyperactivity Disorder (ADHD), = particularly in=20 gifted children. We recognize that giftedness is multifaceted and can be = assessed in many ways other than a standardized IQ test. We will = summarize and=20 differentiate between what is known and what is assumed about ADHD in = gifted=20 students.

ADHD: History, Definition, and Etiology = Attention-Deficit/Hyperactivity=20 Disorder (ADHD) is a "syndrome," i.e., a grouping of symptoms that = typically=20 occur together. The core symptoms of ADHD are impulsivity, inattention, = and=20 hyperactivity. Estimates of the prevalence of ADHD among school age = children=20 vary but the median estimate across all definitions of ADHD and all = types of=20 studies is 2% in boys and girls combined.

Family, adoption, and twin studies demonstrate that genetic factors = are very=20 important in ADHD, but environmental factors also play a significant = role since=20 heritability is less than100%. Environmental factors, including = premature birth,=20 head injury, fetal alcohol syndrome, prenatal exposure to drugs of = abuse, such=20 as cocaine, lead toxicity, prenatal maternal smoking, and rare endocrine = abnormalities can all cause the ADHD syndrome.

How is ADHD assessed and diagnosed?

Four subtypes of Attention-Deficit/Hyperactivity Disorder (ADHD) are=20 recognized in the DSM-IV: Predominantly Hyperactive/Impulsive, = Predominantly=20 Inattentive, Combined, and Not Otherwise Specified. To meet the criteria = for one=20 of the specific subtypes, at least 6 of the 9 symptoms of=20 hyperactivity/impulsivity, or at least 6 criteria from the 9 symptoms of = inattention must be present. (Combined type means both sets of criteria = are=20 met.) The symptoms must occur in more than one setting, must persist for = at=20 least 6 months, and must affect the individual "to a degree that is = maladaptive=20 and inconsistent with developmental level".

Under optimal circumstances, a team, including a qualified clinician, = such as=20 a pediatrician, family physician, psychiatrist, neurologist, or = psychologist=20 should make the diagnosis of ADHD because only these types of = specialists can=20 assess the physical and psychological problems that mimic ADHD. = Information=20 about these conditions is rarely available to school personnel, no = matter how=20 observant, experienced, or well trained.

For the majority of children with ADHD, symptoms become clear-cut = when their=20 behavior can be observed regularly and compared to other children over a = sustained period. The classroom teacher, therefore, is typically the = best person=20 to make such comparisons, especially when systematic behavioral = checklists or=20 rating scales are employed. When the child in question is gifted, an = individual=20 who specializes in giftedness should also be included in the process to = provide=20 information about the child=92s behavior in comparison to other children = of=20 similar abilities (Silverman, 1998).

ADHD or gifted: Either or both?

In recent years, several authors have expressed concern that = giftedness is=20 often misconstrued as ADHD and that the diagnosis of ADHD among the = gifted=20 population has run amok. We acknowledge for the purposes of this = discussion that=20 there are cases of mistaken diagnosis, although as of this writing, we = have=20 found no empirical data in the medical, educational, or psychological = literature=20 to substantiate the extent of this concern.

The lack of scientific data heightens our dismay over the wave of = skepticism=20 that appears to prevail about the existence of ADHD in gifted children.=20 Specifically, we are concerned that the question "ADHD or gifted?" = dismisses the=20 possibility that the two conditions may coexist. Prudent attempts to = avoid=20 over-diagnosis must be balanced against a child's need for evaluation = and=20 treatment in the context of inevitable uncertainty when medical = diagnoses are=20 invoked.

In this context, Silverman notes that some professionals erroneously = assume=20 that a child who demonstrates sustained attention, such as a gifted = child=20 engaged in a high-interest activity, cannot have ADHD. It is = understandable that=20 an observer might discount the possibility of ADHD because from all = appearances=20 the child is so absorbed in a task that other stimuli fade into = oblivion. While=20 this state of rapt attention is often described as "flow"), it can also = be=20 ascribed to "hyperfocus," which is a similar condition that individuals = with=20 ADHD frequently experience.

Activities that is continuously reinforcing and "automatic,=94 such = as video or=20 computer games or reading for pleasure, do not distinguish children who = have=20 ADHD from children who do not have ADHD, whereas effortful tasks do. By = virtue=20 of their giftedness, the range of tasks that are perceived as = =93effortless" is=20 broader for gifted children, which is why their ADHD may be less = apparent than=20 in children who struggle more obviously and to lesser effect.

Recent work suggests that the gifted child with ADHD is particularly=20 predisposed to exhibit this state of =93flow" or "hyperfocus." While = this can be a=20 positive aspect of task commitment and a sign of motivation, it becomes = a=20 problem when the child is asked to shift from one task to another. = Therefore,=20 while cognitively this state can have positive aspects, behaviorally it = can also=20 cause problems. Furthermore, ADHD is not characterized by an inability = to=20 sustain attention, but rather by the inability to appropriately regulate = the=20 application of attention to tasks that are not intrinsically rewarding = and/or=20 that require effort. Such tasks are, sadly, characteristic of much of = the work=20 that is typically required in school, even in programs for gifted = students.

While a misdiagnosis of ADHD is undesirable, diagnostic errors of = omission=20 are just as serious and may be even more prevalent among gifted = students. This=20 difficulty occurs when a student=92s over-reliance on strengths = inadvertently=20 obscures the disability. While emphasizing strengths may highlight a = student's=20 gifts and talents, it does not eliminate the reality of the condition = and can,=20 in fact, lead to a worse predicament in which the student distrusts his = or her=20 abilities because of the struggle to maintain them. On the other hand, = if a=20 student is allowed to acknowledge and experience the disability, he or = she may=20 learn appropriate compensatory or coping skills.

We believe that acknowledging that a child can be both gifted and = have ADHD=20 and that exploring the ways in which these conditions might interact in = each=20 child is a more productive way of looking at the problem than agonizing = about a=20 false dichotomy.

Given the realities of the co-existence of giftedness and ADHD, the = question=20 should not be "ADHD or gifted?" but rather =93how impaired is this = student by=20 his/her ADHD?" Some children are able to compensate in most situations = for their=20 ADHD (and neither they nor their parents or teachers may be aware of = it); others=20 are seriously handicapped. The single most relevant element that must be = considered in evaluating ADHD is the degree of impairment a child = experiences as=20 a result of the behaviors.

A child whose behavior causes him/her to be impaired academically, = socially,=20 or in the development of a sense of self, should be examined from a=20 clinical/medical perspective to exclude potentially treatable = conditions, even=20 if the behavior may be similar to the traits typically ascribed to = creativity or=20 giftedness or to "overexcitabilities". However, this does not mean that = every=20 child who is impaired needs medication. As many authors have noted, = non-medical=20 interventions can be used within the school and home and should be tried = before=20 more intrusive interventions are employed.

The 1999 reauthorization of the Individuals with Disabilities = Education Act=20 explicitly recognized, for the first time, ADHD (and ADD) as disorders = that=20 should be classified as Other Health Impaired, when they adversely = affect a=20 child's educational performance. The reader is referred to http://www.ldonline.org/=94http:// for further = detailed=20 information and relevant hyperlinks.

ADHD and giftedness: Where do we go from here?

Clearly, there is need for additional empirical research on = giftedness and=20 attention deficit disorders. Questions such as incidence of DSM-IV = subtypes of=20 ADHD among the gifted population must be investigated before other types = of=20 research can proceed. If such research were to show that current DSM-IV = criteria=20 identify significantly different proportions of gifted students compared = to the=20 general population (over or under diagnosis),subsequent studies would be = able to=20 explore the sources and characteristics of the discrepancies. The = availability=20 of data would in turn facilitate and encourage the development of = strategies for=20 appropriate identification and curriculum. Contact the NRC/GT website if you know of = identical=20 twins (ages 5-16), one of whom presents characteristics of ADHD or = ADD.ADHD is=20 not a defect that must be "cured." In fact, our experience of many = gifted=20 children with ADHD resonates with our colleagues' perceptions that the = condition=20 can not only inhibit, but enhance the realization of gifts and = talents.

Educators of gifted students with ADHD face a formidable task in that = they=20 must provide opportunities for students to apply their strengths while=20 ameliorating their deficits. Although the same might be said of any = sound=20 educational program, this is more daunting for gifted students with ADHD = because=20 of the striking disparities these conditions can create. Only through = consistent=20 attention, immeasurable creativity, and enduring patience by educators, = parents,=20 and students, coupled with substantive research, can these challenges be = adequately addressed.

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Felice Kaufmann Independent Consultant Bethesda, MD. = M. Layne=20 Kalbfleisch University of Virginia Charlottesville, VA. F. Xavier = Castellanos=20 National Institute of Mental Health Washington, DC