The gifted child with attention deficit disorder: An identification and intervention challenge. Wg: Leroux, Janice A., Levitt-Perlman, Marla, Roeper Review, 02783193, 20000401, Tom 22, Wydanie 3
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THE GIFTED CHILD WITH ATTENTION DEFICIT DISORDER: AN IDENTIFICATION AND INTERVENTION CHALLENGE
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Studies of children with attention deficit hyperactivity disorder (ADHD) often emphasize the problems, diagnosis and treatment, but rarely consider the characteristics which are remarkably similar to those of creativity. This study reviews the literature on ADHD traits, their similarity to gifted and creative behaviors, and the implications for educational interventions. A case study of a boy identified with ADHD provides the focus for our discussions. The conclusions point to the need for more varied instructional interventions, emotional and social support, and collaboration between educators and parents.
Jason is an energetic third grader who is bright, funny, creative, and talented. Jason crawled at four months, spoke at ten months, and read at four years. Academically, he has always been at least two years ahead of his peers, yet emotionally, he seems very immature. Jason's teachers have not recognized the possibility that he may be gifted. The child that they see on a daily basis does not present himself as particularly gifted or talented. He is defiant, angry, restless, impulsive, aggressive, and often rude. Jason, at age eight, is a gifted child with attention deficit hyperactivity disorder.
Attention deficit hyperactivity disorder (ADHD) is a neurobiological condition which exhibits developmentally inappropriate levels of inattention, and/or hyperactivity, and/or impulsivity (American Psychiatric Association, 1994). The characteristics of these symptoms, and the intensity of them, present themselves in individualized random patterns which manifest uniquely in each child. Academic performance and social/emotional functioning are affected to varying degrees (Zentall, 1993). The multi-modal approach to treatment of ADHD usually involves behavioral and educational intervention, counseling and often medication (C.H.A.D.D., 1993). The diagnosis of ADHD does not include any intellectual boundaries (Garber, Garber, & Freedman Spizman, 1990), and the characteristics of it are remarkably similar to those of creativity (Cramond, 1994). It is therefore reasonable to assume that there exist ADHD children who also have high ability levels, gifts, and talents. Within the pages of current literature, these children rarely appear. It is time to recognize the gifted/ADHD child for study.
Literature reviewed showed a heavy concentration on the deficits, negative behaviors, and educational implications of ADHD, yet high ability levels, leaderships skills, creativity, artistic and musical talents in these children were not addressed. In addition, it is important to note that these children are not necessarily learning disabled (LD). While there is a likeliness of LD and other disorders (oppositional, conduct, depression) in ADHD children, they often do not meet the criteria required to be classified as learning disabled, though learning may certainly be impaired by inattention, impulsivity, and hyperactivity (Parker, 1992).
In discussing the coexistence of giftedness and ADHD, there are many issues to address. First, the traits and characteristics of each must be reviewed. How these traits may appear in combination is the next consideration. Next, it is imperative to determine whether or not current diagnostic procedures provide ample opportunity for correct identification. Finally, implications for identification, education, social/emotional support, parental roles, and future research are explored.
To begin examining the characteristics of the gifted child with ADHD, it is necessary to note the many similarities in characteristics associated with both giftedness and ADHD, and how easily misdiagnosis can occur.
Hyperactivity
It is commonly stated that hyperactivity occurs in both gifted and ADHD children (Clark, 1992; Barkley, 1990). A definition of the term is essential. Hyperactivity in the gifted child is known as high energy levels which are focused, directed, and intense (Clark, 1992). In the ADHD child, hyperactivity is known as a whirlwind of constant motion, diffuse and random energy, which can manifest differently as the child matures, from running and touching to squirming restlessness. Often excessive loudness, noises, and continuous talking are additional traits of hyperactivity in the ADHD child (Parker, 1992). It is curious to look at how hyperactivity is evident in the gifted/ADHD child:
When Jason is stimulated by a subject, he can focus endless amounts of energy toward it; however, he has trouble focusing on his homework. He has shown the signs of hyperactivity associated with ADHD all of his life. He was a kicking squirming infant, a five month old baby who would crawl laps up and down a hallway as though he were in training for a marathon, and a tireless toddler. Reaching school age, Jason had difficulty making friends as his disruptive behavior was too much to tolerate. At home, excessive noise levels, dented walls, sibling conflict, and difficulty settling down to sleep, are the results of hyperactivity. Like the gifted child, Jason can productively focus his energy on activities that stimulate him; however, he also displays the unfocused, disruptive, hyperactivity associated with ADHD.
Challenge of Authority
Another trait common to children who are gifted and those with ADHD is their facility at challenging authority. In the gifted child, this is considered the result of heightened intellectual perception, the unwillingness to accept the judgment of others unquestioningly (Vail, 1987). In the ADHD child, the challenge of authority is often the result of oppositional behaviors and impulsivity. In the gifted/ADHD child, enhanced complex thinking is often ignored because of the negative way in which it is expressed. The child's challenge is more hostile and aggressive in manner (Mendaglio, 1995). The gifted ADHD child's valuable contributions can easily go unnoticed. Jason resists taking direction .from his parents and teachers, creating constant power struggles. He has his own agenda and resents deviating from it. Instead of verbalizing his needs, Jason becomes persistent, angry and rude. It is the way he communicates, not what he communicates, that attracts the attention of authority figures.
Disruptive Behavior
Both gifted children and ADHD children can be the cause of disruption in the school setting. In the gifted child, disruptive behavior is related to boredom in response to unchallenging activities, curriculum, and learning style (Webb & Latimer, 1993). Disruptive behavior in the ADHD child is the result of any or all of the ADHD core symptoms: inattention, impulsivity, and hyperactivity (Parker, 1992). The ADHD child may become distracted by outside stimuli or by his/her own thoughts. A weakness in organizational skills can make staying on task difficult. A rigid environment due to classroom organization may also induce a disruptive reaction. In the gifted/ADHD child the frustrations of impulsivity, inattention, and hyperactivity, combined with under stimulation can lead to oppositional behaviors:
Always feeling frustrated by the tasks which he perceives as dull, and restrictive within the classroom, Jason not only becomes disruptive, he becomes oppositional. He simply refuses to do tasks which bore or frustrate him. He disrupts those who are attempting the task by vocalizing his dissatisfaction, and creates a power struggle with his teacher.
Social/Emotional Development
It is in the areas of social and emotional development that much of the similarity between gifted children and those with ADHD is evident (Mendaglio, 1995). Gifted children have an unequal balance between advanced intellectual ability and/or creative talent, and an emotional level which has not advanced to the same degree (Silverman, 1992). Due to their heightened perceptions of self, the gifted child is vulnerable to the self knowledge of being different, and may experience stress from self evaluation and critical thinking (Altman, 1983). Difficulties also occur when gifted children have a cognitive understanding of knowledge that they are not emotionally equipped to deal with (Silverman, 1992). Uneven intellectual and motor development can also cause distress, resulting in frustration and emotional outbursts (Webb, 1994). Social isolation may be experienced and in turn, lower self-concept.
The ADHD child suffers from social and emotional difficulties as well. This child is often immature and has difficulty picking up social cues (Garber et al., 1990). Impulsive actions and words, and aggressive disruptive behavior cause dislike by peers. This rejection can cause sadness or anger leading to a cycle of inappropriate behaviors and further peer rejection (Parker, 1992). These problematic social interactions then result in lowered self-esteem.
The ADHD child who is not hyperactive tends to be more withdrawn and anxious, which can also lead to social isolation (Barkley, 1990). The child is constantly criticized as he/she struggles to stay on task, follow directions, and control impulsive behaviors. With lowered self-concept, explosive tempers, mood swings, or withdrawal may occur and coexisting oppositional disorder, depression, or anxiety may develop (Wender, 1987).
Mendaglio (1995) suggests that the combined social and emotional factors resulting from the coexistence of giftedness and ADHD, produce a heightened sense of alienation, sensitivity, and overreaction in the gifted/ADHD child. The social isolation experienced by the gifted in addition to the peer rejection of the ADHD child, can cause a disturbing sense of alienation, affecting attitude toward school, achievement, and self esteem. The sensitivity of the gifted child joined with the emotional overreaction, frustration, and irritable moods associated with ADHD can cause manipulative and egocentric reactions (Mendaglio, 1995). Without acquiring the skills for emotional development, these difficulties can become life long concerns (Goleman, 1995).
Jason has difficulty accepting "no" for an answer. He attempts to manipulate situations, with persistent negotiations, explosive outbursts, threats, or physical aggression. When he loses control, Jason shows little regard for the feelings of others. He will not take responsibility for his words and actions. After Jason has calmed down, there comes a realization of what he has said or done. It is at this point that his emotional safety is threatened, as he feels embarrassed and saddened by the behaviors he could not control.
While counseling is often suggested for the gifted child and the ADHD child with social/emotional difficulties (Clark, 1992; Fontanelle, 1992), it is imperative that the gifted/ADHD child receive adequate emotional support and training.
The difficulty differentiating between characteristics of giftedness and those of ADHD, and recognizing when they coexist, can easily lead to inaccurate identification. The following are examples of cases where gifted/ADHD children might be misdiagnosed:
Amy is a six year old, first grader, Her parents report that she has endless amounts of energy and she requires very little sleep. In school, Amy tends to daydream. She often loses her place and begins to talk to her friends becoming disruptive. Amy does not complete tasks and she makes many careless mistakes. Her teacher has noticed her advanced reading level and wonders whether or not Amy is a gifted underachiever. The characteristics of inattention and impulsivity have been interpreted as a lack of interest and willful choice to avoid tasks.
Jason is disruptive, displaying traits of hyperactivity and impulsivity. He has always been considered a behavioral problem by his teachers, whose primary goal is to control the behavior. Jason's high level of ability is a secondary issue, often going unnoticed by his teachers due, in part, to a lack of opportunity for creative expression and divergent thinking. Enrichment has never been considered relevant. School administrators have been in agreement with the teachers, believing that all Jason needs is some really effective discipline.
Similar to gifted/LD students whose disability may mask the gifts (Baum, 1990), in many cases gifts may mask the ADHD, and the ADHD may mask the gifts. The lack of research available on gifted/ADHD children may indicate the possibility that many of these children are not being correctly identified. Multiple diagnostic measures which would reveal gifts, attentional problems, learning disabilities, and emotional problems, are necessary (Webb & Latimer, 1993). As is the case with many gifted children whose gifts and talents in various areas are not identified by standard IQ or achievement tests (Gardner & Walters, 1993), the current diagnostic measures are less than perfect for many ADHD children.
There is no assessment protocol for comprehensively assessing ADHD (McKinney, Montague & Hocutt, 1993). The most widely accepted definition and assessment tool is the Diagnostic and Statistical Manual of Mental Disorders (DSM)(American Psychiatric Association, 1994), which lists behavioral characteristics which must be displayed for diagnosis to be made. Research has shown that ADHD can co-occur with LD, oppositional disorder, conduct disorder, depression or anxiety. McKinney et al.(1993) suggest that identification should reveal the presence of these problems to accurately assess educational needs, and to separate those who require special education intervention and those for whom general education would be suitable.
Identifying those who are gifted and ADHD is a perplexing task, given the tools in current use. Results from the WISC III-R for instance, may not be accurate in many children with ADHD whose lack of attention to the tasks may affect scores. Their high levels of creativity may go undetected. The WISC III-R Freedom From Distractibility Factor is not always considered a reliable indicator of ADHD (Anastapolous, Spisto, & Maher, 1994). When school boards require identification before beginning enrichment programs, gifted/ADHD students fall through the assessment cracks:
Though Jason displayed many of the characteristics of ADHD, his kindergarten teacher told his concerned parents that it was not possible because Jason was too smart. As he continued through grades 1 and 2, teachers focused on behavioral problems rather than his advanced academic achievement. In fact, on his grade 1 report card, his teacher failed to mention that he was reading at grade 4 level. They never suggested testing for ADHD because they could see that he was able to focus when he so chose. Now, grade 3, Jason has lost interest in school due to the frustration of unchallenging activities and peer rejection. His self-esteem is low and he is performing at grade level, though group achievement tests have placed him significantly above average. Now Jason's teachers see no reason to consider giftedness or ADHD; they just look at him as a difficult child with an attitude problem.
Gifted children with ADHD may be at risk as they sustain a deeply misguided interpretation of their own skills, talents, capabilities, and self worth. High ability children with low self concepts place self imposed limits of what they can achieve (Delisle & Berger, 1990). How can we break this cycle? These children require a wide range of opportunities for success. Standard achievement tests, teacher reports, peer and parent nomination, and intelligence tests commonly used to identify gifted students, do not cover all the many possible facets of giftedness, nor do they allow for the characteristics of ADHD which may cause imperfect results. Unless diagnostic measures which can give every child the opportunity for correct assessment are used, gifted/ADHD children will not have the occasion to be understood or challenged, nor will they have the chance to reach beyond mediocrity.
The acknowledgement of skills and talents within individuals must be expanded to include and acknowledge the strengths of the gifted/ADHD child. Maker, Neilson, and Rodgers (1994) suggest combining Gardner's theory of multiple intelligences and a matrix of problem types, to design ways to identify and serve the diversity and skills in students. Their findings conclude that students identified using this method made equal or greater gains in enrichment programs as those identified by traditional methods.
This prospect takes on greater importance for the gifted/ADHD child whose gifts often go unnoticed. Vaidya (1994) suggests that identification of the gifted include portfolio assessment in addition to IQ, achievement, and creativity testing. The opportunity for teachers to gain insight into thought processes and divergent thinking could be of great benefit to the gifted/ADHD child.
It is clear that research is essential to determine what type of diagnostic process would best serve the gifted/ADHD child. Only with a wider range of holistic measures can the gifts shine through the learning gaps which may exist. Assessing where these gifts lie is of utmost importance.
Reflecting upon the serious challenges gifted/ADHD children must face and the deficiencies in current diagnostic processes lies the question of how we can best intervene to ensure that their learning potential is fulfilled. It is at this point that the focus of the issue must be redirected from the difficulties to the learner.
Olenchak (1995) reported that a highly structured individualized school wide enrichment program (based on Renzulli's model) was found to have a positive impact on the attitudes, self-concepts, and creative productivity of gifted/LD students. While the positive effects of focusing on strengths within this program could have merit with all students, it would be especially beneficial for gifted/ADHD students, giving them the opportunity to focus their energy on challenging and meaningful tasks. It is the development of abilities and talents, in conjunction with the remediation of weakness, that induces successful treatment. Rather than employing methods which highlight deficits, such as those commonly used in the treatment of ADHD (Fiore, Becker, & Nero, 1993), Armstrong (1996) suggests developing individualized educational plans which reflect the strengths of the children and assist them in achieving success. Armstrong's idea of internal empowerment as a motivating factor could well apply to gifted/ADHD children.
Pirie (1995) pays special attention to the process of learning. By teaching English through kinesthetics, he uses the area in which students are skilled to approach another subject. A musical child, for example, might react more positively to the prospect of writing a song about the environment than to the idea of writing an essay on the topic. Methods that support learning in ways that present gifted/ADHD children as equal to their peers, with validated strengths, would be both motivating and uplifting to their self-esteem.
A comparison of the interventions suggested in the literature reviewed for both the gifted child and the child with ADHD, is noteworthy in attempting to analyze the needs of the gifted/ADHD child. The number of similarities in recommended strategies between the two groups is remarkable. Incorporating the recommendations for each group, it is possible to propose strategies for the treatment of gifted/ADHD children (see Table 1.)
In parenting and teaching the gifted/ADHD child, strategies to deal effectively with both the characteristics of ADHD and giftedness must be employed. Many researchers suggest that behavior management techniques are useful to parents of children with ADHD and parents of gifted children (Fontanelle, 1992; Garber et al., 1990; Alvino & Eds., 1985; Phelan, 1985; Perino & Perino, 1981). In the case of ADHD children, it is crucial that they learn anger and stress control techniques. Many of the techniques suggested specifically for one group or the other may not invoke the expected reaction in the gifted/ADHD child. Alexander-Roberts (1994) offers the idea of giving the ADHD minor choices when enforcing a nonnegotiable rule. For example one might ask "Would you like to do your homework at the kitchen table or at your desk?". While the ADHD child might be satisfied with the power of choice, a gifted/ADHD child who is defiant might react by answering "Neither, I am not doing homework!", and by refusing the task no matter the consequence. It is important to deal with the situation without continuing a power struggle. Reminding the child of the positive consequences of getting the work done can be helpful, for example, "if you get your work done now, we will have time to go get your skates sharpened". The child must have some motivation for completing the task. There are times when extrinsic motivation can be beneficial.
The significance of effective parental training was reported by Anastapolous, Guevremont, Sheldon, & DuPaul, (1995). Children whose parents underwent training in understanding ADHD, and in management strategies, showed better long-term outcomes that were successful for both.
Parents of the gifted/ADHD must fully understand the implications of the coexistence of the conditions, employ successful management strategies, and then learn to advocate for their children. It is also imperative to encourage the creativity of these children, for in many of them, this is where strengths lie (Colangelo & Davis, 1991). The gifted child, the verbally hyperactive child, and the impulsive child, constantly question. Parents and teachers must remember that curiosity is an indicator of creativity, and it must be encouraged (Torrance & Goff, 1990). Strategies should be offered for acquiring knowledge and expressing what has been learned in keeping with learning styles. Good communication between home and school is essential as well (Meckstroth, 1991).
The asyncronous development of the gifted child (Silverman, 1992) compounded with the social/emotional difficulties of the ADHD child implies serious concerns for the gifted/ADHD child. It is imperative that emotional skills are taught to assist the child in dealing with frustration, anger, stress, self concept and depression, for it is this ability which will either facilitate or interfere with all other abilities (Goleman, 1995).
Jason's parents began teaching him to recognize his feelings by offering him a jellybean reward for each time he recognized his anger toward his younger brother but did not take action. They then used those opportunities to discuss how Jason might solve his problem. This slowly transferred to the school playground, where his aggression has been noticeably reduced. While Jason's first impulse is to react physically, awareness of his anger is leading to increased self control.
Careful consideration of the individual pattern of characteristics in the gifted/ADHD child, the intensity of behaviors, particular strengths and weaknesses, and social and emotional needs, can lead to an effective course of treatment. It is, therefore, crucial to design, assess, and designate accurate measures for the identification of gifted/ADHD children. It is their individual gifts which will help them overcome the difficulties of ADHD. Their strengths must be recognized and celebrated, and their weaknesses must be identified and remediated.
It is evident that there is a void in research with respect to gifted/ADHD. Further study is essential to determine characteristics and traits; design and evaluate diagnostic measures; to appreciate the implications for teaching and learning; to identify successful teaching strategies, behavioral management strategies, and emotional support strategies; and to predict long term outcomes.
Without this research gifted/ADHD children will remain frustrated, angry, and stressed, unsuccessful in school and in social interactions. Deeper knowledge is required to provide these children with the tools they require to be well adjusted, valuable, and valued members of society.
Gifted/ADHD children must be motivated by opportunities to pursue areas of interest, by pride in their accomplishments and progress, and by success that is viewed as attainable. If every gifted/ADHD child would have a flexible environment in which to thrive, have social and emotional needs met, and strengths used to construct knowledge in a stimulating, respected way, perhaps instead of focusing on deficits, they would be known to have selective attentional gifts.
Manuscript submitted December, 1997.
Revision accepted March, 1998.
Table 1. Behavioral, curriculum, and instructional strategies for the gifted, ADHD, and gifted/ADHD child
Legend for Chart:
A - GIFTED
B - ADHD
C - GIFTED/ADHD
A
B
C
non authoritarian rules and regulations
clearly defined rules, non authoritarian
non authoritarian clearly defined rules
defined limits and consequences
defined limits and consequences
defined limits and consequences
positive guidance
continuous positive reinforcement
continuous positive reinforcement and guidance
coping techniques
coping techniques, self monitoring
coping techniques, self monitoring
modeling
modeling
modeling
--
behavioral contracting
behavioral contracting
build self esteem
build self esteem
build self esteem
social skills training, counseling
social skills training, counseling
social skills training, counseling
provide flexible environment
provide flexible environment
provide flexible environment
stimulate and challenge
stimulate/high interest activities
stimulate, challenge, high interest activities
enrichment
remediation
nurture strengths, remediate weakness, promote creativity
set attainable goals
set attainable goals
set attainable goals
compact
short term objectives
compact strength areas, short term goals
differentiate
hands on projects, audiovisuals, computer
differentiate with focus on strengths, hands on/technology
when required
accommodate learning style
accommodate learning style
accommodate learning style
independent study
self paced study
independent/self paced study
flexible evaluation
modify test delivery
flexible evaluation/portfolio
--
reduce distraction
reduce distraction
mentorships
peer mentors
mentorships
help accepting limitations
help accepting limitations
help accepting limitations
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By Janice A. Leroux and Marla Levitt-Perlman
Janice A. Leroux is a professor of Educational Studies and Marla Levitt-Perlman is a graduate student at the Faculty of Education, University of Ottawa, Ontario, Canada.