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Citation Information : Apex. VOLUME 15 , ISSUE 1 , ISSN (Online) 2324-1284, DOI: 10.21307/apex-2009-005, July 2009 © 2018.
License : (CC-BY-NC-ND-4.0)
Published Online: 06-July-2018
The misdiagnosis issue, of the gifted as having ADHD, has been described as an overseas concern (i.e., predominantly American). However, in New Zealand psychologists and paediatricians, perhaps without knowledge of the gifted, utilise the same diagnosis process outlined within the
This article provides a brief overview of the recent literature on the gifted with ADHD. The gifted/ADHD literature appeared to begin around the late 1980s as the oldest publication this literature review found was Deirdre Lovecky’s (1989) Huh…?Attentional Problems in Gifted Children. Lovecky’s (1989) article suggested that the gifted/ADHD literature has developed for nearly twenty years yet there does not appear to be a significant amount of literature on the gifted with ADHD. This scarcity of literature could be because there is considerable debate surrounding the gifted/ADHD topic in relation to misdiagnosis. There are two key conflicting perspectives. The first was:
1. Some children are both gifted with ADHD (e.g., Baum & Olenchak, 2002; Flint, 2001; Kaufmann et al., 2000; Leroux & Levitt-Perlman, 2000; Lovecky, 2004; Mika, 2006; Turk & Campbell, 2002). Silverman (1993; 2003) indicated there may even be under-identification. Furthermore, writers (e.g., Kaufmann, et al., 2000; Mika, 2006) argued there was no evidence to support the claim that gifted children were misdiagnosed with ADHD and maintained that further exploration of the gifted with ADHD should occur based on the assumption that the combination is real “…as we have found no empirical data in the medical, educational or psychological literature to substantiate the extent of this [misdiagnosis of giftedness as ADHD] concern” (p. xiii, emphasis in the original).
In contrast, the second perspective was that:
The New Zealand Ministry of Education (2000) suggested that the misdiagnosis of giftedness as ADHD was an overseas concern. It is true that much of the recent literature is from American publications (e.g., Leroux & Levitt Perlman, 2000; Lovecky, 2004; Zentall, Moon, Hall & Grskovic, 2001).1 This includes that from writers who believe that both giftedness and ADHD can co-exist and from others who argue giftedness is often misdiagnosed as ADHD. However, the purpose of this article is to make New Zealand educators aware that misdiagnosed gifted children could be in their classrooms. This is because it is this writers’ perspective that giftedness and ADHD do not co-exist but that the similarities lead to misdiagnosis of giftedness as ADHD. This article underlines the identification issues relating to both giftedness and ADHD so educators are aware of these so they can either correctly identify, or question, a misdiagnosis and thus provide appropriate educational provision for gifted children.
Because there is limited literature on the gifted with ADHD other literature will be reviewed. This literature included that on the Gifted with Learning Disabilities (GLD)2, ADHD and giftedness (these terms are defined in the section the follows the introduction). Then identification issues that could lead to misdiagnosis are addressed. These identification issues included: the similarity between the characteristics of the gifted, the creatively gifted and those with ADHD and how Intelligent Quotient (IQ) tests, although no longer commonly used in New Zealand schools, could identify gifted children who exhibit negative behaviours. Other identification issues included inappropriate learning environments, teachers who lack knowledge of the gifted, the gifted who like to move and the gifted who are not easy to teach.
Davis and Rimm (2004) described how the Gifted with Learning Disabilities (GLD) have amazing gifts but also have weaknesses associated with their disabilities. Winebrenner (2003) suggested an alternative term for the GLD was twice exceptional. However, there is debate surrounding who the twice exceptional are. Some stated that it was all people who have both gifts and disabilities (e.g., Bourne, 2004; Bruzzano-Ricci, 2003; King, 2005; Reis & Ruban, 2004; Silverman, 1998; Sturgess, 2004). In contrast, other writers indicated the twice exceptional were only those who were gifted and had social, emotional disturbances or behavioural disabilities (e.g., Emotional Behavioural Disorder, EBD, or ADHD) (Benge & Montgomery, 1996; Kaufmann, Kalbfleisch & Castellanos, 2000; Morrison & Omdal, 2000). Although the gifted with ADHD could be considered GLD the GLD or twice exceptional literature may not be generalisable to the gifted with ADHD because it is questionable how appropriate the general GLD and twice exceptional literature is for those with specific disabilities (e.g., the gifted with ADHD). However, as previously mentioned due to the scarcity of research on the gifted with ADHD, GLD literature is utilised throughout this article.
The New Zealand guidelines for the assessment and treatment of Attention-Deficit/Hyperactivity Disorder (Ministry of Health, 2001) suggested the DSM-IV-TR (American Psychiatric Association, 2000, cited in MOH, 2001)3 criteria for ADHD must be met in order for a diagnosis of ADHD to occur. Part of the requirement for the Diagnostic and statistical manual of mental disorders-text revision (APA, 2000) to diagnose a subcategory (either inattention or hyperactivity/impulsivity) is that six out of nine criteria need to be met. Two examples of inattentive criteria included:
“Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities” (p. 92).
“Often forgetful in daily activities” (p. 92).
Two examples of hyperactive/impulsive criteria included:
“Often fidgets with hands or feet or squirms in seat” (p. 92).
“Often has difficulty playing or engaging in leisure activities quietly” (p. 92).4
In order to be diagnosed as having ADHD other criteria has to be met. These included:
That the characteristics were present before the age of seven.
Impairment from the symptoms was present in two or more settings (e.g., home and school).
“There must be clear evidence of clinically significant impairment in their academic, social or occupational functioning” (p. 93).
“These symptoms do not occur exclusively during the course of Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder)” (p. 93).5
There are distinct differences between the predominant inattentive and hyperactive/impulsive subtypes (as suggested by previously mentioned differing characteristics). However, a significant amount of literature appeared to use the terms ADHD and ADD (often related to those who are predominantly inattentive) loosely and did not define subtypes of ADHD. This is significant as it can confuse the reader about which literature relates to the subtype of ADHD they are investigating. Writing that occurred in or before 1994 could be excused for using the term ADD when referring to children who exhibit what are now recognised as ADHD tendencies as it was only in 1994 that further research led the DSM-IV (APA, 1994) to distinguish between the predominant subtypes of ADHD, inattention and hyperactive/impulsive. Regardless of this apparent lack of clarity between the terms ADD and ADHD, many writers6 and researchers7 appeared to agree with DSM-IV-TR (APA, 2000) definition8 and have referred to the three main characteristics of ADHD being:
Or a combination of these characteristics9
Like the characteristics associated with ADHD the New Zealand definition of the gifted and talented is also quite general. The Ministry of Education (2000) document stated “gifted and talented learners are those with exceptional abilities relative to most other people. These individuals have certain learning characteristics that give them the potential to achieve outstanding performance” (MOE, 2002, p. 2). However, identifying the learning characteristics of the gifted is not straight forward as there are many differing beliefs about what characteristics the gifted exhibit. These differing beliefs occur for many reasons including that the gifted are individuals with differing characteristics.
Although there are differing views relating to the definition of giftedness there is not the scope within this article to critically review these. Therefore, this article has used McAlpine and Reid’s (1996) Teacher observation scales for children with special abilities as it is a representation of gifted characteristics developed through New Zealand research. McAlpine and Reid (1996) researched the literature, for commonly mentioned gifted characteristics, gained agreement on these characteristics from New Zealand authorities on gifted children and assessed whether these gifted characteristics could be observed in the New Zealand classrooms. The Ministry of Education (2000) has a full list of the characteristics McAlpine and Reid (1996) identified, they included:
Displays logical and analytical thinking
Is quick to see patterns and relationships
Masters information quickly
Strives for accurate and valid solutions to problems
Easily grasps underlying principles
Likes intellectual challenge
Jumps stages in learning
Seeks to redefine problems, pose ideas, and formulate hypotheses
Finds as well as solves problems
Reasons things out for her- or himself
Formulates and supports ideas with evidence
Can recall a wide range of knowledge
Independently seeks to discover the why and how of things
Produces original ideas
Displays intellectual playfulness, imagination, and fantasy
Creates original texts or invents things
Has a keen sense of humour and sees humour in the unusual
Generates unusual insights
Enjoys speculation and thinking about the future
Demonstrates awareness of aesthetic qualities
Is not afraid to be different
Generates a large number of ideas
Is prepared to experiment with novel ideas and risk being wrong
Seeks unusual rather than conventional relationships
Takes the initiative in social situations
Is popular with peers
Communicates well with others
Actively seeks leadership in social situations
Shows ability to inspire a group to meet goals
Persuades a group to adopt ideas or methods
Is adaptable and flexible in new situations
Actively seeks leadership in sporting activities
Is socially mature
Is willing to take responsibility
Synthesises ideas from group members to formulate a plan of action
Is sceptical of authoritarian pronouncements
Questions arbitrary decisions
Pushes teachers and adults for explanations
Displays a precocious interest in ‘adult’ problems
Is reluctant to practice skills already mastered
Is easily bored with routine tasks
Expresses ideas, preferences, and opinions forthrightly
Relates well to older children and adults, and often prefers their company
Asks searching questions
It was important to outline gifted characteristics as a significant issue in the recent gifted/ADHD literature is misdiagnosis due to the similar characteristics associated with both giftedness and ADHD. Some of these characteristics will be outlined in the following table.
Accurate identification of gifted children is important because the consequences of misdiagnosing (i.e., identifying a gifted child as having ADHD) could mean the child will not meet their academic potential. Gifted children may not meet their academic potential because as Guenther (1995) indicated once a child is negatively labelled it is unlikely the child will be seen as gifted. This claim was also supported by GLD literature10 that referred to how negatively labelled children do not get their names put forward for programs due to educators focusing on their negative behaviour (Davis & Rimm, 1993; Reis & McCoach, 2002; Reis, Neu & McGuire, 1997).
The following section will address some of the reasons why misdiagnosis of gifted children as having ADHD could occur, the main issues included: the similarity between gifted, creative and ADHD characteristics; the negative view of Intelligent Quotient tests; the learning environment; teachers’ lack of knowledge, the gifted who like to move and the gifted who are not easy to teach.
The Diagnostic and statistical manual of mental disorders (commonly referred to as the DSM-IV-TR, APA, 2000) diagnostic criteria suggested those with ADHD (predominantly hyperactive/impulsive) could exhibit characteristics such as difficulty remaining in their seat when expected (APA, 2000). Characteristics like these seemed to lead writers to suggest there were similarities between the characteristics of the gifted and those with ADHD (e.g., Brown, 2006; Bruzzano-Ricci, 2003; Turk & Campbell, 2002;11 Webb, Amend, Webb, Goerss, Beljan, & Olenchak, 2005).
The creatively gifted also share characteristics with those who have ADHD (as addressed in the table below) although there are three differing views evident in the literature on the creatively gifted and ADHD. The differing views were:
Those with ADHD can naturally have creative ability as creativity could be the ‘other-side’ of ADHD (Flint, 2001; Lovecky, 1994; McCluskey & McCluskey, 2003; Montgomery, 2003; Shaw & Brown, 1991; Zentall et al., 2001).
Because the issue surrounding whether children with ADHD are creative seems unresolved the following table will address ADHD and creative characteristics and their similarities to ADHD characteristics. Within the literature there were tables which compared the similarities between gifted and ADHD characteristics (e.g., Brown, 2006; Bruzzano-Ricci, 2003; Webb et al., 2005). Some of the similarities between the gifted and those with ADHD included that they often do not seem to listen when spoken to, are easily distracted by erroneous stimulation and have difficulty organising tasks and activities (Webb et al., 2005). It is possible because the characteristics of the gifted and those with ADHD are so similar they could lead to masking of a child’s giftedness (Leroux & Levitt-Perlman, 2000; Neihart, 2003).
No tables were found that compared gifted characteristics, creatively gifted characteristics and ADHD characteristics. In the following table I have done this as I outlined some of the characteristics of inattention, hyperactivity and impulsivity. These characteristics are presented here as they are written in the Diagnostic and statistical manual of mental disorders: DSM-IV Text Revision (APA, 2000). I have then linked these ADHD characteristics to some gifted and creatively gifted characteristics.
There are many issues associated with the use of IQ tests including cultural bias or scatter.14 Also, in New Zealand IQ tests are not commonly used in schools and the Ministry of Education (2000) recommends identifying gifted children by utilising a multi-modal method of identification (e.g., peer nomination, assessment of portfolios). Gifted children would also benefit if a teacher would develop a challenging learning environment that allowed their abilities to surface (MOE, 2000).
However, a participant in Gates (2005) study required an IQ test in order to be recognised as gifted. This is because he presented negative behaviour in the classroom which as previously suggested can mean children are not identified as gifted as inappropriate behaviour is not usually associated with giftedness. This suggested that the IQ test itself is perhaps not as important as an educator overlooking negative behaviour in order to recognise the child’s abilities.
Literature maintained inappropriate learning environments could lead bored gifted children to exhibit behaviour associated with ADHD.15 Thus bored gifted children could be misdiagnosed with ADHD. Maxwell suggested this misdiagnosis could be catastrophic due to inappropriate medication and ADHD educational strategies16 being applied to gifted children thus, emphasising the importance of appropriate identification (1989, cited in Cramond, 1994, p. 205). The DSM-IV-TR also indicated the environment could be a possible cause of inattention (APA, 2000). “Inattention in the classroom may also occur when children with high intelligence are placed in academically unstimulating environments” (APA, 2000, p. 91).17
Doug (Turk & Campbell, 2002) referred to how he was often bored at school. He often distracted other children because he was easily distracted, or rather than distracting others he would day-dream. However, Doug stated “I found it ironic that teachers reprimand daydreamers, which forces a student who was content distracting himself or herself to begin distracting others” (Turk & Campbell, 2002, p. 50). Doug’s daydreaming seemed to link to Webb’s (1993) suggestion that bored gifted children may daydream and not pay attention (see table). It is possible that Doug’s teacher, who prevented him from daydreaming, may have lacked knowledge of those who are gifted. In contrast, another teacher (Mr Turk) used the Socratic Method “…so as long as I could perform on cue with some kind of coherence, I was allowed to let my mind wander” (Turk & Campbell, 2002, p. 52).
If gifted children do become bored they could be seen as underachieving, lazy and perhaps eventually be labelled as having ADHD (Flint, 2001). This implied a gifted child could stop trying to learn if they are not stimulated. If they stop completing work it is also unlikely they will be recognised as gifted (Hartnett et al., 2004; Lovecky, 2004; Webb, 2000). As previously suggested an appropriate learning environment could assist gifted children’s abilities to surface.
Not recognising giftedness implies some teachers’ lack knowledge on the gifted could lead them to misdiagnose gifted children as having ADHD. As Doug (Turk & Campbell, 2002) stated “I recall as I moved through the grades, things either got better or worse entirely because of a particular teacher” (p. 50). Many GLD writers18 referred to teachers’ lack of knowledge of giftedness being problematic due to the difficulty that can be involved in identification of the two exceptionalities (e.g., gift and the disability) (e.g., Baum & Olenchak, 2002; Higgins & Nielsen, 2005; Reis et al., 1997; Sturgess, 2004).
Rather than purely a teacher issue, lack of knowledge by other professionals may contribute to identification issues. For example, Brown (2006) and Webb and Latimer (1997) suggested that it is the people who diagnose and treat ADHD (e.g., paediatricians and psychologists) that could be causing the issues as most do not appear to have knowledge on the gifted.
Many writers have also referred to how there are similarities between Dabrowski’s overexcitabilities19 and ADHD particularly in relation to psychomotor overexcitability (Baum & Olenchak, 2002; Bruzzano-Ricci, 2003; Flint, 2001; Hartnett, et al., 2004; Lind, 2000; MOE, 2000). Flint (2001) argued, while gifted children with psychomotor overexcitability love moving, those with ADHD can not stop. Nevertheless, White (2004) suggested there was not clear research to support the link between ADHD and psychomotor overexcitability.
However, Tucker and Hafenstein’s (1997) description of a gifted girl, Katrina, clearly showed the similarity between psychomotor overexcitability and the movement described in the DSM-IV-TR (APA, 2000). The ADHD hyperactivity criteria included, often on the go and often run around and leave their seat when they are expected to stay seated (APA, 2000). Tucker and Hafenstein’s (1997) stated:
Next, she went back to the table to paint. For another few minutes, then she changed tables to draw. She would choose one marker from the marker box, run over to the table to draw with it, and then run back to the marker box to put it away and get another marker. (p. 72)
McCluskey and McCluskey (2003) indicated their daughter shared similar characteristics to Katrina as she too wanted or needed to move. McCluskey and McCluskey’s (2003) daughter (who was diagnosed with ADHD and they believed also had gifted tendencies) had a teacher who allowed her to move and dance her understanding of biology.
One flexible high school biology teacher allowed her to take some of her tests orally-to talk, act out, move and dance-and it helped (you haven’t seen any thing until you’ve seen the Photosynthesis Shuffle and The Dance of the Reproductive System!). (p. 38). Both gifted children who have psychomotor overexcitability and those with ADHD may benefit from being able to move when learning.
A child wanting to move when learning does not seem highly unreasonable. However, allowing movement could conflict with some teachers established classroom practices (e.g., when learning on the mat most teachers expect children to sit still). What these teachers may benefit from acknowledging is that some gifted children do not ‘fit’ within the ‘normal’ classroom expectations as gifted children may be difficult to live with or teach (e.g., Chorlton, 1997; MOE, 2000; Webb, 2000). Gowan (cited in Turk & Campbell, 2002) referred to how it is often the able child that is the ‘biggest nuisance.’ However, as Hunter (2006) suggested, it seems it is often only those gifted who exhibit positive characteristics (e.g., co-operation) that are valued (e.g., that are recognised for gifted programmes).
Baum and Olenchak (2002)20 suggested that medication is often used to prevent inappropriate ADHD behaviours in schools (inappropriate behaviour was not defined). This medication could also make children exhibit compliant behaviour in the classroom but it could also prevent bright children from producing creative work (Baum & Olenchak, 2002).
Because there are numerous difficulties relating to the identification of gifted children and those with ADHD it is imperative that teachers become educated about these children. Teachers could learn about the gifted through professional development. Alternatively both teachers and those who diagnose ADHD (e.g., paediatricians) could read about the gifted (e.g., about the characteristics that are not as positive as it is these characteristics which seem to overlap with ADHD).
Gaining further understanding, about the similarities of the gifted and those with ADHD, through research is imperative as teachers could benefit from reading the findings. Without this knowledge it is highly probable that it will be these children’s learning difficulties that are recognised rather than their gifts. It is important that their gifts are recognised otherwise they could be the misbehaving children in the classroom who never meet their true potential.
Teachers should become more knowledgeable about those who are gifted and those who have ADHD. This could occur through participation in pre-service gifted tertiary programmes or through professional development within a school. Alternatively knowledge could be gained by talking to others for example the GATE co-ordinator within a school. However, other professionals (e.g., paediatricians) who diagnose ADHD should also acquire information about the gifted to try and prevent misdiagnosis.
Empirical research should be conducted in New Zealand to find evidence of misdiagnosis of gifted children as having ADHD. This research should also further investigate the reasons, suggested in the literature, why misdiagnosis could be occurring (e.g., due to reasons such as the similarity between the characteristics of the gifted, the creatively gifted and those with ADHD). Once this has occurred parent/teacher resources that outline the misdiagnosis issues could be developed so that appropriate identification and educational provision provided.
Even though I do not believe giftedness and ADHD co-exist, it was necessary to utilise this literature as it provided insight into the gifted/ADHD issue.
A requirement for diagnosing the combined ADHD sub-type is if both inattentive and hyperactive criteria (such as that previously mentioned) are met.
If these criteria are not met (e.g., the behaviour onset occurred after the age of seven) a person can be diagnosed as Attention-Deficit/Hyperactivity Disorder Not Otherwise Specified (see APA, 2000 for further details).
However, some writers are now investigating whether these are the primary characteristics of ADHD (e.g., Adler, Barkley, Wilens, Ginsberg, 2006; Barkley, 1997; Douglas, 2005). Barkley (2003) has argued that the primary characteristics of ADHD are actually ‘poor inhibition and deficient executive functioning (self regulation)’. Barkley (1997) indicated executive function difficulties could relate to social and emotional problems (e.g., difficulty interacting in a group).
As previously mentioned Davis and Rimm (2004) described how those who were GLD had amazing gifts and weaknesses that were associated with their disabilities.
It should be noted that in future reference to Turk and Campbell (2002) I have referred to Doug (Turk & Campbell, 2002) this is because although not explicitly stated it seems Doug Campbell, the young man who is gifted with ADHD, is a co-author and Mr Turk, the other author was one of Doug’s teachers. In addition I have referred to Doug’s statements as being made by Doug because some statements relate to his references to experience of which Turk, for the most part, had no part.
The letters beside the ADHD characteristics relate to either inattention (1a-1i), hyperactivity (2a-2f) or impulsivity (2g-2i).
Characteristics a teacher may see in a classroom that could relate to all three (ADHD, giftedness and the creatively gifted).
When IQ results appear average as students can do exceptionally well in some of the subtests and poorly in other subtests with results from the subtests then added and averaged.
An example of an inappropriate ADHD educational strategy that could be applied to a gifted child would be to give them tasks in small parts with the aim being to keep them focused. However, as Webb (1993) suggested gifted children do not complete tasks they view as purposeless. It could be argued that if a gifted child does not have the whole task they could view the small tasks as purposeless.
This was also referred to by Lovecky (2004).
Writers on the Gifted with Learning Disabilities which as previously suggested the ADHD could be a small sub-group within.
Dabrowski (1972, cited in White, 2004) suggested that most people that reach high potential (which could be considered giftedness) possess some overexcitabilities. The overexcitabilities included psychomotor, sensual, intellectual, imaginational, and emotional (Dabrowski, 1972).