Amend Beljan 2009

Introduction
Of course, having a gifted intellect does not

mean the child carries a psychiatric

diagnosis, nor does it mean that one is
exempt from such diagnoses. However, lack
of understanding of the common behaviors

and typical expressions

of giftedness creates
situations like the one described above.

The
traits and characteristics are misunderstood
and, thus, mislabeled or misdiagnosed.

It is
the authors' belief-based on almost three
decades of collective experience as licensed
psychologists working with gifted children,

parents, and school

programs-that this type

of misdiagnosis of gifted children is a
prevalent phenomenon.

How prevalent is this problem? We
simply do not have the research data to say
with certainty, but professionals in the field
of gifted education concur that it happens

with regularity (Webb et al, 2005). The

severity of this problem is paramount

because, in present day American public

schools, any diagnosis often results in
medicating a child. When a child is misdiag­
nosed, he or she will not only receive inap­

propriate treatment, which may include

medication,

but he or she will also be
deprived of the appropriate interventions

that could be provided

if the diagnosis were
accurate. There is no doubt that medication

has its place in the management of
behavioral and psychological disorders, and
it has helped many children manage difficul­
ties previously beyond their control.

However, when medication is incorrectly

used to suppress the misunderstood
behaviors of gifted children, the practice
inappropriate.

When a child is excited about
a topic or answers and interrupts to make his

point, does

he have Attention­
Deficit/Hyperactivity Disorder (ADHD)?
Although it is possible, unless giftedness is

factored into the situation, it

is likely that the

132, Gifted Education International
behavior will be misunderstood and quickly
labeled ADHD.

It appears clear to the
authors that there is such great misunder­
standing and scarcity of knowledge about
the typical behaviors of gifted children that

their behaviors (traits) are being seen
pathological at ever increasing rates.

The Origins of Misdiagnosis

One might wonder how it is possible for
competent medical and psychological pro­

fessionals to misinterpret the typical

behaviors of the gifted child
as pathological.

The simple answer has to do with a
nationwide lack of training about giftedness

and its implications. There are very

few

psychology graduate programs that even
mention giftedness in courses on intellectual

assessment, let alone provide specific
coursework or clinical experience.

We know

of no medical programs that provide

physicians-in-training with even basic

information about how giftedness can
impact development, and neither author has
met a pediatrician, family practitioner, or
psychiatrist who received even a lecture

about gifted intelligence during their
medical training. Discussions with teachers

also reveal that most were not offered
coursework related to gifted intelligence and

best educational practices for gifted
individuals during their college education.

Some coursework in gifted and talented
offered to teachers who are working on an

advanced degree in education, and even

then the educator will need to work

to find a

program with a specific

focus on gifted intel­
ligence. This lack of training and knowledge
in and of itself too often predisposes gifted
children to being severely misunderstood

and subsequently misdiagnosed with

psychiatric disorders that include

ADHD,

Bipolar Disorder, Obsessive-Compulsive
Disorder and other anxiety disorders, and Asperger's Syndrome or other pervasive
developmental disorders.
Twelve-year-old Ronald was a model student.

He was conscientious and diligent. He
followed instructions, assisted teachers, and

completed quality work. Teachers simply
loved having Ronald in class and wished for

20 more just like him. At home, Ronald

respected his father and behaved in his

presence. With his mother, however, he
argued and refused to do as she instructed.
He routinely failed to complete chores, picked
on his siblings, and stayed up past bedtime.

Eleven-year-old Ralph showed a similar
pattern, but in reverse. He was exemplary at
home and in most classes. With one teacher,
however, he clashed. He failed to complete

work, opted not to turn in completed
assignments, and was routinely sent to the
office for disrespecting this teacher. Which
has Oppositional Defiant Disorder? Or, are
they gifted children whose behavior can be

explained, though not excused, by their
giftedness? Both of these children are indeed
gifted, and neither has Oppositional Defiant
Disorder. Neither shows the pervasive diffi­
culties necessary to make a formal diagnosis,

and both are more likely to respond to
therapeutic or educational interventions that
address the giftedness as part of the issue.
Certainly, these children have maladaptive
behaviors that need to be modified, but doing
so without an inappropriate pathological
label increases the chances of a positive
outcome.

Other Reasons for Misdiagnosis
While it is clear to us that misdiagnosis
begins with lack of knowledge and training
about giftedness and its implications, there
are many other facets that play a role.
highlight some of these here. The 'stigma' of giftedness. Ask anyone
he or she is gifted, and watch the response. It
is very uncomfortable to acknowledge one's
gifts and talents in public, unless they occur
in a socially acceptable domain, like sports

or the arts. Acknowledging academic
strengths or intellectual accomplishments is

seen
as arrogant or conceited in our society,
yet we continually laud the accomplish­

ments
of gifted athletes and actors.

For gifted youngsters, there is stigma
associated with talents, particularly when
adults engage in thinking that mandates that
no child should be treated differently than
another. 'Every child should be treated

equally,' they

think. But, they forget that
treating every child fairly does not mean
treating every child exactly the same, as all
have different strengths, characteristics,

and
abilities. This occurs in home and profes­
sional settings alike. Some parents do not
accept that 'being gifted' means anything,
and the child is expected to do well despite

the
fact that his needs are not being met.

Some teachers fail to understand the

educational implications of giftedness,

and
mental health professionals do not recognize

the impact

on development due to the lack of
training noted above. Teachers and profes­

sionals often think or

say, 'If he is so smart,
he can solve his problems.'

The views of these important people
ultimately reach the child and affect his view
of himself. When gifted children are met
with lack of acceptance or are stigmatized
the response, they are more likely to deny
their own giftedness-refusing to accept a
vital part of themselves.

Failing to consider giftedness. Denying
giftedness due to stigma can result in this

failure, but,

on other occasions, intellectual
ability is simply ignored. More than one
parent has heard 'Let's take giftedness

out of
Volume 25 No 2, 2009, 133 the equation,' from a well-meaning psychol­
ogist.

You cannot buy pants without
knowing the child's height any more than
you can deny the role that giftedness plays in
one's difficulties. Though intellectual ability

or giftedness is

not always the cause or even
a major contributing factor to a problem, it

influences much of

what a person does. Not
taking a child's IQ into consideration when
attempting to determine whether or not that
child has a psychiatric diagnosis removes a

critical element of

that child. Too often,

medical

and allied health professionals,
including pediatric neuropsychologists, state

that high intellect

has nothing to do with
how a child behaves. However, those same
professionals recognize that the idiosyncrat­
ic behavior of a mentally retarded child is

often related to that child's

IQ. The DSM-IV

also reflects this distinction, as most
diagnoses have a mental retardation exclu­
sionary criterion that states the behaviors in
question are not a result of limited intellectu­
al ability. Intellectual ability-gifted, average

or below average--must be considered in

diagnostic decisions

and treatment planning
for maximum positive effect.
Failing to account for twice-exceptionality.
Chase was a profoundly gifted child with
ADHD. Educationally, he was well placed in
an advanced curriculum with older students.

His disorganization, however, was more
pronounced when the expectations were higher
than those typically expected for a child his
age. In an age-level class, he would have been
able to handle the curricular and organization­
al expectations easily. Once his curriculum
was advanced to meet educational needs, his
problems were exposed and additional modifi­
cations were needed to address his twice­
exceptionality. Without training, educators
and mental health professionals might have

concluded that Chase was misplaced and
eliminated the proper curriculum instead of
accommodating for the weak areas.

134, Gifted Education International

There is no doubt that some gifted

children can and

do have a learning issue or a

psychiatric illness, though there is no
conclusive evidence that these problems are

more common among the gifted than any
other group. Gifted children and adolescents
with psychiatric problems or learning disabil­
ities are labeled twice-or multi-exceptional.
When both giftedness and limiting conditions
are present, intervention must address both
areas to yield the most positive results. Some
improvement may be seen by intervening in

one area,

but optimal functioning is unlikely
unless both areas are targeted.
In late-elementary school, Ethan was experi­
encing a period of depression related to his
school situation -he was frustrated due to an

inappropriate curriculum. He was also
demonstrating attention difficulties.
Initially, school officials thought a child could
not be gifted and also have an attention
disorder-'It must be one or the other,' they
thought. Once identified as gifted, he was

served with appropriate educational

strategies and some improvement in mood

was noted, though attention problems
persisted. After evaluation by a professional
trained to work with gifted students, Ethan's
attention difficulties were identified and

appropriate treatment with stimulant
medication was provided in addition to on­
going curriculum modifications.

Ethan progressed well through school,
and was about to graduate from high school
when the family contacted the psychologist
again. Ethan's half-brother Mark, a seven­
year-old finishing second grade, was experi­
encing difficulties managing his emotions in
school. School officials expressed concerns

about possibilities such

as ADHD and Bipolar
Disorder. Previous consultation with school

officials

and mental health professionals
failed to take into account Mark's giftedness
and its role, focusing solely on the difficulties. Mark, like his half-brother, is a twice­

exceptional youngster,

and improvement

would only be seen by addressing both
areas-giftedness and impairment. Mark's

diagnosis of Intermittent Explosive

Disorder-an impulse control disorder

resulting

in aggressive, emotional

meltdowns-indicated that the school's
suspicions were incorrect. The frequency, per­
vasiveness, and severity of behavior were not

present

to diagnose either ADHD or Bipolar
Disorder. Had the parents simply consulted a

local professional, it

is likely that Mark would

quickly have been placed on a powerful
medication, which may have produced some

positive results,

but would not have
addressed the root of his difficulties.

With a focus on misdiagnosis, we can
sometimes forget that difficulties also arise
when giftedness is assumed to be the only
factor affecting the problem and the difficul­
ties or weaknesses are not addressed to the

extent needed. That is, the focus on
giftedness obscures the twice-exceptional
issues.
Eleven-year-old James was referred by his

parents due to concerns about possible
depression. He was highly intelligent, yet
struggling in school. He was liked by all of
his teachers except the one who taught the
gifted pullout-she did not appreciate his
questions about her way of teaching.
Evaluation revealed a moderate depressive

episode. With modifications to his
curriculum along with supportive therapy
and targeted cognitive-behavioral interven­
tions, James' mood improved. Addressing the
gifted piece did create positive changes.
When the school year ended, eliminating a
major stressor, the family took a collective
sigh of relief Unfortunately, James'

compromised coping skills had not been
strengthened enough to handle additional
stressors. When his father was diagnosed
with a treatable cancer, a friend unexpectedly
moved away, and his sibling had an accident,
James experienced a more significant episode
of depression. The stressors overwhelmed him

and the focus on giftedness as the
predominant factor had not allowed proper
intervention to address the depression to the
extent needed.
Using medication as a diagnostic tool. Just
because someone responds to a medication
does not necessarily mean that a diagnosis is
accurate. Stimulants, ranging from caffeine

to amphetamine, as well as stimulant
medications such as Ritalin and Adderall,
can increase focus and attention, and many
people respond positively to small amounts.
As a result, some stimulant medications may

be prescribed as performance enhancers

rather than to address concerns
(Ruff, 2005).
Anecdotal evidence shows that many people

visit one of the

myriad neighborhood

Starbucks each day, sometimes multiple

times,

for their 'pick-me-up dose.' Thus, a

self-confirming bias can occur

when
psychiatric medication is used to reach a
diagnostic conclusion.

You will not hear a

physician

say, 'I am not sure if your arm is

broken, but let's

put a cast on anyway. If it is

better in 6 weeks when

we take it off, we'll
know it was indeed broken.' A patient would

most certainly be skeptical

upon hearing
that.

Unfortunately, when it comes to

psychiatric medication

in general, and

stimulants in particular, parents do

sometimes hear an equally concerning
comment, 'Take this stimulant, and if it

works, we will
know he has ADHD.'
Consider this example:
A gifted child displays affective dysregulation

in response to agitating situations or
frustration with repetitive learning. The child
is taken to a psychiatrist because a teacher or
other parents suggest significant issues. The
Volume 25 No 2, 2009, 135 psychiatrist makes a preliminary diagnosis of
Bipolar Disorder and prescribes Depakote or
Tegretol, medications originally used as anti­
seizure medications, which have side effects
including cognitive slowing, fatigue, and

listlessness. The medications do indeed
flatten the expression of emotions and even
some of the affective asynchrony of the gifted
child. When the parent attends a follow-up
visit with the psychiatrist and reports that
the child's behavior has improved and the
affective outbursts have decreased, the psy­
chiatrist is now convinced of the diagnosis.

Prescribing medication as a diagnostic

tool lacks specificity and creates the
possibility of a false positive response
because changes in behavior may have more
to do with side effects than accuracy in

diagnosis. Medications

are indeed effective
for many, but it is important to address the
root cause of the behaviors-which can only

be determined through comprehensive
assessment-so that medication can be used
most appropriately.

Insurance influences. The impact of
changing mental health insurance practices
on the process of diagnosis and treatment
cannot be overlooked.

As anyone who has
dealt directly with managed care plans can

say, the time allowed

for the diagnostic
process is limited as a cost-saving measure.
That is, when a mental health professional
would like to administer testing that may

determine whether

or not a child has a
particular disorder, the insurance company

may limit the professional to only one
covered hour for a diagnostic interview, or

perhaps one covered hour
for further testing.
Having limited time means that the profes­

sional cannot perform a comprehensive
evaluation of the child and his difficulties, let
alone measure his intellect. Completing an
accurate and robust assessment of intellect
alone usually requires at least two hours, and

136, Gifted Education International

much more time is usually needed to

evaluate disorders like

ADHD or Bipolar

Disorder. However, insurance companies
with an eye toward cost containment suggest
that a checklist can be sent home with a
parent in lieu of full and comprehensive
evaluation by a trained clinician. Checklists,
while cost effective, provide a limited view of
a child and his behavior, sometimes from a
skewed perspective. For instance, the teacher

of an energetic gifted child may

think that
child has ADHD. The teacher easily can read

between the lines of the checklist

to endorse
the items that will facilitate that diagnosis.
The goal may be for the child to receive a pre­
scription for Ritalin to improve classroom
behavior. While checklists provide a single

point of data, or perhaps two

pomts, they
lack the specificity and ability to contextual­

ize the behavior, which

is very important in
differential diagnosis of complex disorders in
children. Cost containment policies of the
insurance company can inadvertently lead
misdiagnosis of a gifted child.

Citing the school's responsibility,

insurance companies often compound the
problem by declining testing directed at
measuring a child's intellect. Unfortunately,
with limited or non-existent funding for
gifted services, schools lack the proper
resources to individually test gifted children,
while most of the available resources are

directed at special needs children with

limited cognitive functioning or severe
learning disabilities. Additionally, many

parents do not have the wherewithal to
navigate the procedures of the public school

system, and they simply cannot afford
testing by a private psychologist. Most at
risk within this scenario are families of low
socioeconomic status and children for whom

English

is a second language. As a result,
appropriate testing gets omitted from the
evaluation, increasing the risk of misdiagno­
sis and improper treatment. Lack of Diagnostic Thoroughness. The
medical and psychological professions have
numerous diagnostic tools at their disposal.
Too often, limited assessment is used when
determining whether or not a gifted child
actually suffers from a psychiatric illness.

There are

many reasons thorough

evaluations are

not conducted, such as

insurance mandates or the philosophical
approach of the professional. Physicians
simply do not have the time to engage in
thorough evaluation of mental health and
behavioral issues, since their focus is on the
primary medical care of their patients.
course, if the physician or mental health pro­

fessional does

not know to look for

giftedness

as a possible explanation, he will
see no reason to factor it into the diagnostic

process, resulting

in truncation of the
assessment phase.

These abbreviated processes may result
in reaching diagnostic conclusions after a
brief interview with the child, by only inter­
viewing the parents, or through use of a few
simple behavior checklists.

Too often, the

failure

to use available tools affects the
process of determining the origin of a child's
difficult behaviors. Physicians do not rule
out heart disease based on a checklist or an
interview with the patient's mother; they use
proper tools. Most patients simply would
not allow a physician to take such shortcuts

even

if the insurance company did not
approve the appropriate test. Unfortunately,
parents too often forego a formal evaluation
for their child's problem behavior because
insurance companies limit a psychologist's
ability to use all of the tests necessary to
make an accurate diagnosis. The following
fictional vignette illustrates the difficulty
with making hasty conclusions without fully
evaluating the patient or situation.
A cardiologist enters the examination room
where his patient is waiting. The profusely
sweating patient informs the cardiologist that
his left arm aches, he is short of breath, his
ankles are slightly swollen, and he has chest
pain characterized by a burning sensation.

The physician acts on the symptoms and

immediately goes into cardiac arrest
treatment mode. The symptom presentation
seems clear and he does not listen to the
patient's heart or even ask questions to rule

out the symptoms as being related to
anything other than heart failure. Therefore,
he fails to find out that the patient ran fifteen
miles to the office, did thirty left arm push­
ups while waiting in the examination room,
and then rapidly consumed a hoagie. Relying
solely on the observable symptoms, and not
asking the key questions or using available
diagnostic tools to rule out that the patient is
having a heart attack, the medical interven­
tion may inadvertently harm an otherwise
healthy patient. The physician renders a false
positive diagnosis. The incorrect diagnosis
then causes a misapplication of otherwise
appropriate interventions as the physician

treats the patient's symptoms without
considering their origin. The possibility for a

catastrophic outcome is exponentially
increased.

While it is quite unlikely that such a

scenario would occur in real life, the
physician's misdiagnosis is clear when all of

the data are taken into account and the
proper frame of reference is used. Similarly,
the misdiagnosis of gifted children results

from the teacher's, the school's, the
physician's, or the psychologist's frame of
reference when all data are not considered.

Certain diagnoses may be considered

at the

exclusion of others, depending

on belief

systems

and training. False positive

diagnoses for learning or emotional

problems are rendered

when outcome
behaviors are the sole basis for the diagnostic
conclusions, as opposed to determining the

cultural, situational,

or brain-based
Volume 25 No 2, 2009, 137 antecedents. Inaccurate diagnosis can lead

compulsory-and perhaps even
harmful-intervention, similar to historical
accounts of trephining a hole in the head of a
patient with a seizure disorder in an attempt
to release 'demons.'

Poor diagnostic thinking. Another con­
tributing factor in misdiagnosis of gifted
children is poor diagnostic thinking, which
can be on offshoot of a lack of thoroughness.
The old saying, 'One swallow does not make

a summer,' means that one should not

generalize fact from a single

incident-to
reach broad conclusions from minimal data
is poor diagnostic thinking. Consider the
following example:

An overzealous postdoctoral student in
clinical psychology was evaluating a young
child. Previously that day, the child had been
given a travel size bottle of Purell hand
sanitizer. Being a young child with an active
fantasy life, he began pretending that germs
were everywhere and that everyone must use
the Purell. When the evaluation was over for
the day, and without scoring any test data,
the postdoctoral student went to the waiting
area and proudly proclaimed to the child's
mother that based on the observed behavior
the child had Obsessive-Compulsive Disorder
(OCD). When the child returned the next day
to complete the evaluation, he was out of

Purell and was observed licking the
assessment table, indicating that the child
was not compulsive about germs and that the
Purell had simply been a novel toy for a day.

This example highlights the important
responsibility medical and psychological
diagnosticians assume on a daily basis.
People are complex beings, and generating
diagnoses based on a single point of data
irresponsible. Identifying OCD, as in the

example above, or labeling a child with
Asperger's syndrome because the child is

138, Gifted Education International

overly-interested in something like
Pokemon, is simply thoughtless, inappropri­

ate, and unethical. There is more

to a child
than one behavior or one focused interest. A

child must be viewed within the context
how they were raised, their family, their

school behavior

and performance, their
social behavior, their neuropsychological

functioning,

and their intellect. Although

this process takes more time and

is more
expensive initially, the odds of rendering a
false positive diagnosis are significantly
reduced, which likely saves money over the
long-term.
School influences.
Eight-year-old Samuel was reading at eighth­

grade level when he was referred for
evaluation. He was described by teachers as

frequently off-task and prone to
daydreaming, though most adults who knew
him outside of school described him as mature
and interesting. The lack of challenge for
Samuel in school was creating a child who
appeared to have attention problems. With
idle time in class, Samuel acted his age and
often left the teachers puzzled as to how

someone could be so 'mature' in some
situations and so 'immature' in others. An
under-challenged eight-year-old's behavior is
not often the most adaptive behavior in the
classroom and can be quite annoying.
Samuel's behaviors caused teachers to suspect
ADHD.

Can a chronically under-stimulated
eight-year-old realistically be expected to sit
at his desk with his hands folded in his lap?
A bored child will act his age, regardless
his intellect. Imagine an adult being placed
back into the second grade and being taught
multiplication or another skill she mastered
years ago. She would most certainly stare
out the window, fidget, or doodle. In our

experience,

it is often the situation that elicits
the inappropriate behavior and not the will


Amend Beljan 2009

PDF file: Amend_Beljan_2009.pdf