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Interview with Marianne Kuzujanakis on Misdiagnosis

Gifted and Twice-Exceptional

The following Q&A on misdiagnosis was written by Marianne Kuzujanakis, MD, MPH, a pediatrician with a masters degree in public health from Harvard School of Public Health. She is a director of SENG (Supporting Emotional Needs of the Gifted) and a co-founder of the SENG Misdiagnosis Initiative, as well as a homeschool educator.

What is meant by misdiagnosis?

Misdiagnosis is a mismatch between the child’s actual learning and health needs and the perception of those needs by others (teachers, medical professionals, other adults). Sometimes this mismatch results in either a health disorder or learning need being overlooked. At other times this mismatch results in a labeled mental health or learning disorder being erroneously placed upon a child. Specifically for the gifted child, this often means being misunderstood and not supported for one’s actual needs – including giftedness.

Why are gifted children at risk for misdiagnosis?

When the developmental trajectory of gifted children is atypical (asynchrony) and/or gifted children experience heightened sensitivities (Dabrowski’s overexcitabilities), these issues can lead to the manifestation of behaviors that may resemble such diagnosable conditions like ADHD, autism, and OCD. Simultaneously, gifted children may sometimes be able to draw upon the strength of their innate giftedness for a period of time – even years – to overcompensate for actual weaknesses and mask actual diagnosable conditions.

A gifted child’s asynchrony is sometimes only first noted as obvious in a classroom situation when the child’s emotional maturity is starkly contrasted with those of his/her age peers. The gifted child’s overexcitabilities may likewise be obvious only when comparisons again are made with classroom age peers. Prior to school, parents may naturally compensate for any issues by supporting and encouraging interactions with older peers and/or interest peers where the inappropriate behaviors often are minimized or absent. Parents too may experience similar overexcitabilities, and their sense of what is perceived as typical of their children’s age peers may be unrealistic.

Another obstacle for gifted children is the relatively common though inaccurate societal belief that if one is gifted, one cannot simultaneously have learning or behavioral weaknesses. High cognitive abilities do not protect gifted children from also having learning disabilities and/or behavioral disorders. This situation is called 2e (twice exceptional), and we say that the child has a dual diagnosis. Recognizing that gifted children can have dual diagnoses places the emphasis on schools and society to support gifted children’s strengths as well as weaknesses.

Even without a diagnosed learning or behavioral disorder, gifted children with asynchrony and/or overexcitabilities still need the support of both their strengths and weaknesses. School districts assess the need for an IEP (Individualized Education Plan) or 504 Plan that offers government-subsidized services based upon several criteria including medical diagnoses and school performance. A gifted child with a mental or learning disability who under-performs relative to his/her giftedness may still have passing school grades and may not be perceived as a candidate for an IEP or 504 Plan. Sometimes the parent may feel caught in a bind wondering how they can support their gifted child’s weaknesses. The temptation for some parents is to obtain a medical diagnosis in order to obtain services, even though a medical diagnosis may not always qualify for services. If in seeking a medical diagnosis, the parent does receive an evaluation by an appropriately trained professional, the child may be more likely to obtain proper services if a weakness is found. Yet if an incorrect diagnosis is made or a real diagnosis overlooked by a professional, the child may still be inappropriately supported.

Finally, even in the most gifted children, their giftedness is not always even across all disciplines. Some may have talent in only a few subjects. Schools, parents, and society do not typically recognize this variability in performance, and such gifted children may be overlooked as gifted and as a result misdiagnosed and unsupported. The gifted children with strong visual/spatial strengths are at highest risk of misdiagnosis, since their learning strengths are not recognized as such with most classroom settings.

What are the types of misdiagnosis in the gifted student population?

The combination of a gifted child in a school setting can pose a variety of challenges that can lead the child to exhibit inappropriate behaviors that can be misinterpreted. Gender, age, and personality all may play roles in the expression of these behaviors as well as in how these behaviors are interpreted by others. The most commonly seen types of misdiagnosis in gifted students include the over-diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorder, Bipolar disorders, Obsessive Compulsive Disorder (OCD), and Oppositional Defiant Disorder (ODD). Missed diagnosis (under-diagnosis) in gifted children may occur for these same conditions when giftedness over-compensates for the weakness. The presentations of each of these five conditions may appear similar to symptoms seen in asynchrony, overexcitabilities, and as normal traits of giftedness.

For example, giftedness can exhibit high energy and impulsiveness in some settings, but high energy and impulsiveness are also seen in ADHD. Giftedness may express itself at times through deeply focused and sometimes unusual interests, all with perfectionistic detail. Autism can do likewise, as can OCD. Gifted children may question authority and be strong-willed, and this strong will may come across as oppositional, such as in ODD. Difficulties with social interactions can occur in conditions like autism, but also in gifted children who feel isolated from peers with whom he/she can relate. A large percentage of gifted children are introverted, and their shyness can also be interpreted as a social weakness instead of a normal personality trait.

An evaluation, preferentially by someone trained and experienced in both giftedness and dual diagnosis, is crucial to distinguish giftedness from learning and behavioral conditions requiring treatment. The range of testing is wide and usually falls into categories of intelligence, achievement, and the more comprehensive neuropsychological testing that can better evaluate parameters like executive functioning. A trained specialist will be able to pick up subtle findings indicating a masked disorder or a missed diagnosis of giftedness. These same specialists may also offer individual or family counseling, educational planning, and any necessary referrals for treatment if a dual diagnosis is found.

What are the signs educators need to look for regarding misdiagnosis?

If educators see an unevenness in a student’s academic abilities, there is always a possibly that there is an overlooked weakness that needs identification. Other clues may point to misdiagnosis as well. For example, is the student repeatedly unhappy in school? Does the student seem to have a poor self-opinion? Is he/she a harsh critic of making mistakes to the point where the student avoids challenges or doesn’t accept even the slightest constructive criticism? Does the student over-react and become easily frustrated? Is it typical to hear of the student “not working at potential”?

It is beneficial if teachers regularly communicate on shared students. A student who begins the school year eager to learn, but shortly thereafter seems to shut down his/her enthusiasm may possibly be a gifted student who for a myriad of reasons may be underachieving and hiding his/her giftedness. One such reason may simply be to “fit in” with the other classmates, when the student cannot either find intellectual age peers, or feels ostracized by classmates due to his/her intellectual strengths. In another scenario, this same student may instead be struggling with overwhelming sensory issues and/or attention issues in the classroom that prevent concentration. Perhaps an educator may recall a student who always failed to complete homework, yet was the first one in class to know the answers in in-class discussions. That student may be bored with the homework assignments especially if the student has already mastered the material, or that student may instead have a reading or writing disability.

There are as many examples as there are students. If a teacher is quick to note that a student seems smart but is perceived as lazy, dominating, troublesome, or isolated from peers, perhaps a more thorough examination of that student’s life is in order.

What should educators do if they suspect a student has been misdiagnosed?

If a misdiagnosis is suspected, one of the first things an educator should do is speak with the parents about what the student is like at home. What are the student’s self-chosen interests and abilities? Can these abilities translate into school-directed strengths? What are the student’s perceived fears about school, noted learning weaknesses and worries as communicated to the parents? How much time does the parent report that the student takes in completing homework? Periodic checks about home environment, changes, and stressors may help better understand a student’s progress. Everything in a student’s environment may be a clue in assessing a student’s academic abilities and social/emotional health. Perhaps the father recently lost his job, and the family is financially struggling. Perhaps a grandparent recently passed away. Perhaps an educator is concerned that a student is not reading as expected, yet the parent tells the educator that the student is reading far ahead of grade or only reads books where there is no risk of a character suffering or dying.

Educators must work in equal partnership with parents to bring together the best opportunities for student success by identifying and supporting both strengths and weaknesses. Addressing whether the student’s educational placement is appropriate and sufficiently challenging is an often overlooked and necessary first step. Educators may also wish to meet regularly with the school psychologist to discuss students who are puzzling to understand. School psychologists, in turn, may wish to keep copies of books handy like the recent Handbook for Counselors Serving Students with Gifts & Talents (Drs. Tracy L. Cross & Jennifer R. Cross, Editors), as well as Serving the Gifted: Evidence-Based Clinical and Psychoeducational Practice (by Dr. Steven I. Pfeiffer) and Misdiagnosis and Dual Diagnoses in Gifted Children & Adults (by Drs. James T. Webb, Edward R. Amend, Nadia E. Webb, Jean Goerss, Paul Beljan, F. Richard Olenchek).

Teachers and school psychologists may both wish to periodically participate in yearly gifted conferences, statewide and national, where expert sessions are presented on the myriad of complex variables surrounding giftedness. Online gifted-related seminars are also available from organizations like SENG and NAGC to assist when it is not possible to travel.

It is critical that proper gifted student support involve a thorough education of teachers and psychologists and medical professionals in the triad of giftedness, misdiagnosis, and dual diagnosis.

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