Imagine a nine-year-old who builds a working catapult out of building bricks on Saturday, then leaves her math worksheet half finished on Monday. Her teacher suspects ADHD. Her father wonders about autism, since she can talk about siege engines for hours. Her mother thinks she is simply bored. Any of them could be partly right. She may be twice-exceptional (2e): a child with high ability and one or more disabilities. A good 2e assessment doesn’t stop at the first label that fits. It looks for what explains the whole pattern.
The story comes before the score
No single test can diagnose ADHD, and sleep problems, anxiety, depression and some learning disabilities can all produce similar symptoms. That’s why the American Academy of Pediatrics asks clinicians to gather information from parents and teachers, look for problems in more than one setting, and rule out other causes before diagnosing. For our nine-year-old, the key question is where the struggles show up. Unfinished work only in a math class that moves too slowly for her tells one story. Trouble that follows her home and into her friendships tells another.
Autism calls for a look back in time, too. Under the diagnostic criteria, signs of autism are present in early childhood, even if they don’t become obvious until social demands grow or a child learns strategies that cover them up. So a good evaluator asks what she was like when she was little, not only how she copes today.
Each explanation gets a fair test
More than one explanation can be true at once. ADHD often comes with other conditions, so pediatric guidelines call for screening for anxiety, depression, learning and language disorders, and autism. That unfinished worksheet might mean the material is far below her level. It might also point to ADHD, worry about timed tasks, a reading difficulty, or several of these together.
A high IQ doesn’t rule out ADHD, either. A Massachusetts General Hospital study compared children with IQs of 120 or higher, with and without ADHD, and found that ADHD is a valid diagnosis in high-IQ kids. So a good evaluation guards against two opposite mistakes: calling a mismatch between a child’s ability and her classroom ADHD, and brushing off real ADHD as boredom.
One number flattens the skyline
Describing a gifted child by one IQ score is like describing a city skyline by its average building height. The average is true, but it hides the towers and the low blocks. That’s one reason federal special education rules require school evaluations to look at specific areas of need, not just produce a single score. Neuropsychological testing can help map a child’s learning strengths and weaknesses in detail, though the pediatric guideline notes it hasn’t been shown to make ADHD diagnoses more accurate in most cases.
Strengths and difficulties can also hide each other, which researchers call masking. It’s a known problem, but a 2026 review of 2e identification research found that while 60% of studies discussed masking, only 7% described how their methods accounted for it. It’s worth asking any evaluator how they will look for it.
School evaluations ask a different question
A clinical evaluation asks whether a child meets the criteria for a diagnosis. A school evaluation asks whether she has a disability that creates a need for special education. Federal special education law (the Individuals with Disabilities Education Act, or IDEA) doesn’t mention twice-exceptional students by name, but the U.S. Department of Education has confirmed that it protects children with high ability who have disabilities and need special education.
A few rights are worth knowing. Schools must identify and evaluate children they suspect have a disability, even if those children are advancing from grade to grade. Parents are part of the group that decides eligibility. If a family gets a private evaluation, the school must consider it as long as it meets district criteria, and a family that disagrees with the school’s evaluation can request an independent one at public expense. Keep in mind that, as the AAP cautions, eligibility decisions can vary a lot between districts, and school teams may reach different conclusions than outside clinicians. For more on advocating for your child at school, see Part 4 of the Davidson Institute’s “Working With Your Gifted Child’s School” series.
A good evaluation ends in a plan and a conversation
A strong report describes strengths and needs side by side. The National Association for Gifted Children recommends “strength-based, talent-focused, and inclusive identification and intervention strategies” for twice-exceptional youth. For our nine-year-old, that could mean an advanced engineering project along with help planning multistep tasks. A good report is also clear about its limits, and the American Psychological Association’s ethics code asks psychologists to make sure results are explained to the family.
Before you book an evaluation, ask:
- Will you gather information from home and school?
- Which other explanations will you check?
- Will the report cover advanced learning needs and support needs?
- Will we meet to go through the results?
Even a careful evaluation is a snapshot, and some signs of autism only surface as demands grow. Ask the evaluator what would be a reason to take a second look.
About the Author
Philip Lindersten is a psychology master’s candidate at Karolinska Institutet in Sweden and a co-author of research in JAMA Network Open. He is operations lead at Rikta Psykiatri, a Swedish clinic for ADHD and autism. This article draws on U.S. guidance and research.
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