Key words: Attention deficit disorder with hiperactivity; Autistic disorders; Child, Exceptional; Child, Gifted; Developmental disabilities. There is a growing interest in the gifted field on the topic of the high ability student who presents with a coexisting psychiatric or medical disorder or special education disability - termed 'the twice exceptional' or '2 e ' student. This article reviews key issues published on the twice exceptional student and discusses two of the more high-prevalent disorders associated with gifted students, specifically Attention Deficit Hyperactivity Disorder ADHD and specific learning disabilities.
The article also discusses suicide and the gifted student. High ability students can have co-existing behavioral, social and emotional difficulties.
The co-existing difficulties can vary in terms of severity of impairment, ranging from quite mild and almost imperceptible to severe and debilitating Pfeiffer, The great majority of information on the twice exceptional student is based on case study and anecdotal clinical reports. There is not even one prospective, epidemiological study that has examined a large community sample of non-referred cohorts of gifted children to explore the etiology, pathogenesis, course, and prevalence for those who are twice exceptional.
We need to be cautious when reading reports based on clinical studies of the twice exceptional. There are real limitations when generalizing from clinical samples; clinical samples are anything but representative of the general population of gifted children and youth in the community at large, a small percentage of whom we expect to have a coexisting psychiatric or medical disability. Gifted children who show up at gifted specialty treatment centers or are referred to wellknown therapists in the gifted field tend to present with more serious or dramatic symptomatology and tend to be more impaired.
Some of the information in this article is based on the author's clinical experience working with gifted students with behavioral disorders, cerebral palsy, Asperger's disorder, orthopedic impairments, specific learning disabilities, cancer, diabetes, and a variety of psychiatric disorders.
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However, the article emphasizes what we know based on material that has appeared in peer-review journals. It is tempting to grandstand, but only very brief personal case material will be included to help illustrate a point. It is unclear exactly when the term twice exceptional was first used or who, in fact, first coined the term. Many contend that James Gallagher first coined the term, and it would be nice to believe that he did, if for no other reason than because he was the author's professor and mentor in graduate school at the University of North Carolina.
However, the earliest reference appeared in a chapter entitled, "Gifted handicapped: A desultory duality", written by Yewchuk and Lupart The term twice exceptional was likely borrowed from a similar concept in medicine, namely "comorbidity". In medicine, comorbidity refers to patients with an index disease e. Comorbidity is a frequently studied diagnostic phenomenon in psychiatry as well as general medicine Angold et al. There are at least three reasons for the interest in comorbidity in medicine: comorbidity is highly prevalent in the population; persons with comorbid medical conditions are associated with less favorable outcomes; and comorbidity can cloud our understanding of the etiology, course, and treatment of each medical disease and psychiatric disorder coexisting in one index patient.
In the author's clinical practice working with gifted children, it is very unusual for the referred child to present as a "pure" case of a gifted child with one very specific and clearly demarcated psychological disorder e. In the great majority of cases, the gifted child presents with an admixture of maladaptive symptoms and at times two or more distinct psychological disorders. Boundary problems are common in childhood mental disorders, just as they are in medicine Pfeiffer, A number of factors can complicate the diagnostic and treatment challenges that psychologists face when assessing or counseling a gifted student who is presenting with one or more co-existing psychiatric or medical disabilities.
What follows is a brief discussion of five such issues:. Medicine has found it helpful to distinguish between the onsets of each disease among comorbid patients. Clinical researchers in the gifted field have not yet begun to examine the times of onset when gifted students present with two or more co-existing disorders, for example the twice exceptional gifted student with ADHD and conduct problems. In medicine, a secondary condition is considered caused by a primary condition.
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For example, renal failure secondary to a myocardial infarction generally results from hypo-perfusion of the kidneys, caused by a calamitous drop in the patient's blood pressure following the heart attack Angold et al. However, very few if any of the common child psychiatric comorbidities have been shown to result from one disorder causing another. However, although ADHD and bipolar disorder show high comorbidity in multiple clinical studies, no one has proposed that one causes the other.
Some, in fact, argue that being gifted serves as a potential advantage, a prophylactic which serves to increase the gifted youngster's resilience and ability to effectively cope with adversity, stress or conflict. There is some logic to this argument in that students of high intellectual ability have, by definition, more advanced cognitive skills and could be expected to better understand the nuances of social and interpersonal situations and possess a greater array of problem-solving strategies.
This intriguing hypothesis has yet to be empirically tested with a representative cohort of gifted youngsters in the community. Some gifted students, however, do struggle with psychological problems and psychiatric disorders that can be distressful, dysfunctional and even dangerous Cross, in press. Not all gifted children easily navigate the often challenging social and emotional waters of childhood and adolescence.
Medicine has documented that the interacting effects of two or more concurrent diseases complicates their management. There is little research, and an urgent need, for testing the impact of treatment guidelines for patients with comorbid diseases. An analogous, although not parallel, case can be made for the twice exceptional student.
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There is no peer-reviewed research that has examined the effectiveness of evidence-based treatment protocols e. Of course, being gifted is not the same as having a medical disease such as angina, hypertension, renal failure, depression, or diabetes. Co-morbidity is the concurrent co-existence of two or more medically diagnosed diseases in the same patient, with the diagnoses of each disease based on clearly established and widely accepted diagnostic criteria Nardi et al.
The concept of complexity is related to but not exactly the same as co-morbidity. Complexity or "case mix complexity" is a term used in medicine to refer to a set of multiple patient attributes that include, in addition to co-morbidity, socioeconomic factors, lifestyle factors, access to healthcare, severity of the illness, prognosis, treatment difficulty, need for intervention, and resource intensity to manage the illness Nardi et al. The more complex the case mix the greater the need for multiple resources, and the less predictable the course and outcome for the treated patient. In addition, the more complex the case mix, the greater the reliance on clinical judgment and a tailored treatment plan, and the more important coordination of services.
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In this sense, case mix complexity perhaps is a more useful concept than co-morbidity when considering the twice exceptional student. In other words, it would be helpful to conceptualize the gifted student with a sub-clinical or even full-blown psychological or psychiatric disorder from a "complex case mix" perspective, rather than from a co-morbidity model, since giftedness is not a disease but rather a relevant characteristic of the individual that can contribute to making the case more challenging to treat.
Most authorities recognize that diagnostic boundaries in medicine are not absolutely precise and that there exists a gray area and degree of overlap among disorders Angold et al. For example, there are shared symptoms in arthritis, hypertension, ischemic heart disease, and stroke Gijsen et al.
The same is true in terms of diagnostic boundary issues clouding precise diagnoses with gifted students presenting with possible co-existing problems. Some experts in the gifted field contend that "misdiagnoses stem primarily from the widespread ignorance among otherwise well-meaning and well-trained professionals about the social and emotional characteristics of gifted children and adults" Webb et al. There is the potential for misdiagnosis if the practitioner incorrectly attributes characteristics of some gifted children as indicative of defining symptoms of one or more underlying disorders.
For example, the high activity level, boredom, resistance to rules and regulations, or intellectual over-excitability of an intellectually gifted youngster might be misinterpreted as defining symptoms of ADHD. Some authorities estimate that as many as half of gifted children with the diagnosis of ADHD are misdiagnosed Webb et al.
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This is probably an overestimate of what is, however, a real problem with some gifted children being misdiagnosed. A recent survey of school psychologists in the USA found that the great majority of practitioners - all members of the National Association of School Psychologists -, were provided very little graduate training on the gifted. One can understand how misdiagnosis is both a serious and not uncommon phenomena in the gifted field.
Misdiagnoses can lead to improper and even dangerous treatments. Following up on the example cited above, the bored, highly excitable and intellectually impetuous gifted student incorrectly diagnosed with ADHD could very likely be improperly prescribed psycho-stimulant medication.
In addition to misdiagnoses, there is the risk of a missed diagnosis. What this means is that the student's intellectual gift or special talent can serve to mask from the teacher or parents the presence of an actual disability. And equally probable, the adverse impact of a disability can mask or disguise the student's gift or special talent. In both instances, the student is not identified as twice exceptional when they are.
In the first instance, the student is recognized as gifted but not diagnosed as also having a co-existing disability because their advanced intellectual or academic abilities camouflage recognition of the disability. And in the second instance, the student is not identified as gifted because their disability serves to overshadow their intellectual or academic gifts. In both instances, the student is denied much-needed special services or programs because their twice exceptional status goes unrecognized.
A final possibility exists. It is conceivable that in some instances, a high ability student with a disability could go unidentified as both gifted and disabled. One could overlook both the giftedness and the disability if components of each conceal or mask one another with neither readily noticeable.
The National Education Association published a white paper on the twice-exceptional student. The white paper states, ' The white paper notes that the twice exceptional "are among the most frequently under-identified population in our schools.
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Twice-exceptional students present a unique identification and service delivery dilemma for educators" National Education Association, , p. There are likely a considerable number of high ability students with disabilities who have been missed and not identified in the schools.
The article now discusses ADHD and specific learning disabilities and the gifted.