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Diagnostic and Therapeutic issues to consider when working with gifted and talented persons: The least you NEED to know

I would like to invite other mental health professionals and consumers to add, subtract, or expound upon anything I write here in the comment section.

For psychiatrists, psychologists, therapists, and other mental health professionals it is vitally important that you learn about how giftedness and exceptional talent can impact diagnosis and treatment. There are countless numbers of child and adult consumers of mental health care who every day who are misdiagnosed and receive improper treatment because the education of mental health professionals (at every level) fails to include important information about the differences in development, neurological and psychological functioning, and experience that are “normal” and appropriate for gifted and talented people but can be pathological for the “general population.”

It is important for all of us to recognize the characteristics and signs of people who are gifted/talented because many in this population do not identify themselves as such, have never been identified, and may not be particularly willing to accept a label or diagnosis as being a part of this group. However, no matter how it is defined, if they experience the collection of traits that combine to produce the qualitatively different experience of life that is common to this population it is important that they be identified and that diagnosis and treatment be modified to reflect their differences in order to respect their unique needs and experiences as a vulnerable population.

If you haven’t yet worked with clients from this population I can pretty nearly assure you that you will at some point encounter at least one of them in your work as a mental health professional. While this population accounts for less than 5% of the general population they likely make up a much larger portion of mental health consumers because many normal and normative characteristics they experience are pathologized and potentially detrimental to their ability to cope with the issues of life.

Gifted Individuals: Identification and special considerations
Individuals may come to you identified as gifted but more often they will be brought in for mental health services without being identified. These people may be obviously “bright” in many cases, though not all, and may be difficult cases to figure out or treat. Gifted people are often asynchronous (especially as children). This means that their development is uneven and there may be dramatic lags between different areas of development; their mental,intellectual, and moral age can be profoundly advanced while their physical, emotional, social, and/or self-regulation development is normal or even far below what would normally be expected for a person of their age. The amount and distribution of asynchrony is variable, though it is thought to increase according to degree of giftedness, and it is believed to be a universal experience for (at least) gifted children to one degree or another. Asynchrony can increase a child’s vulnerability to unrealistic expectations and abuse from adults who may expect emotional and social development to match intellectual development. Asynchrony also increases the child’s vulnerability to pathological perfectionism, low self-esteem, unrealistic expectations of self, adjustment problems in school and social situations, fear of failure, underachievement etc…  All of this can and often does lead to issues that are helpful for adults who come to therapy to explore, process, and heal.

If a child with asynchrony issues is brought for mental health care they are vulnerable to misdiagnosis of many types including diagnosis with Oppositional Defiant Disorder, Attachment disorders, developmental disorders, Autism Spectrum disorders, socialization related disorders, and many others. Clinicians must be careful to remember that this uneven, even profoundly so, developmental trajectory is very normal and normative in this population and that diagnosis & treatment of this asynchrony as pathological will negatively impact the person’s developmental and psychological outcome– it is important to be very conservative when working to distinguish the normal effects of asynchrony from possible mental illness that could also be present. Educating parents (and adult clients with this experience) about the normal asynchrony of gifted children is helpful and will assist in reducing pressures to misdiagnose or pathologize the child’s normal developmental progress.

Gifted people will usually experience extra-intense energy, sensitivity, and awareness (called overexcitabilities… OEs) in 5 areas:

  1. Psychomotor OEs refer to extra physical energy, need for movement, problems getting to sleep due to inability to quiet mind, increased use of gestures, decreased need for sleep, and trouble sitting still. People with psychomotor OEs are at increased risk of being misdiagnosed with ADHD and Bipolar disorders.
  2. Sensate OEs refer to heightened awareness and sensitivity to sensual (of the senses) stimuli. These people may display extra-intense discomfort to physical stimulus such as tags on clothing, bright lights, loud noises, crowds, strong smells, busy environments etc… They may also display acute awareness and sensitivity to their senses; enhanced distinctions between textures & physical sensations, reduced pain tolerance, enhanced ability to distinguish between colors & shapes, sensitive palates and “pickiness” about the taste and texture of foods, exceptional hearing and/or development of other senses, intense emotional reactions to sensate experiences, and sophisticated or precocious development or ability to understand and appreciate aesthetic, musical, tactile, spatial, humor, or emotional input. People with Sensate OEs are vulnerable to misdiagnosis with sensory integration disorder, mood disorders, anxiety disorders, adjustment disorders, and obsessive compulsive disorder. It is a normal developmental experience for these children to take longer to learn how to self-regulate in over-stimulating environments and their guage of over-stimulating can be very different from what would normally be expected. Sensate OEs can also increase the person’s’s vulnerability to problems with parents and peers as their sensitivities can hamper their ability to function in various contexts. Mental health professionals can be very helpful in assisting with development of self-regulation skills, positive coping tools, and normalization. Mindfulness practice and cognitive behavioral techniques may be especially useful.
  3. Imaginational OEs refer to gifted people with heightened or exceptionally developed imaginational experiences. These people may have very complex and detailed fantasy lives/worlds, imaginary friend(s), believe in magical creatures and phenomena, take longer to let go of fictional characters like Santa, the tooth fairy etc.. and may be especially drawn to books, games, and movies that appeal to their sensitive and sophisticated imaginative faculties. These persons are vulnerable to social adjustment and acceptance issues because they may be viewed as strange or different due to imaginational OEs. They are vulnerable to misdiagnosis of disorders that include psychotic or delusional features. Parents and other adults may be concerned with the longevity and complexity of imaginational development in children with this OE but it is normal for heightened imaginational development/expression to last into adulthood in this population.
  4. Intellectual OEs refer to the qualities that most people think of when they think about gifted people. This is the exceptional curiosity, love of learning, speed of processing, comprehension, information retention, associative thinking, divergent thinking, intuitive knowing, and sometimes incredible intellectual complexity that can be found in even very young gifted children. Intellectual OEs can cause gifted people to suffer from social isolation, bullying, and alienation because their mental age may be far older than that of their peers and peers may not understand the language they use, the games they want to play, or their thoughts or ideas. Intellectual OEs can also contribute to the development of “existential depression” in children as young as 6 (possibly even younger in extreme cases) as their intellectual abilities allow them to comprehend situations and events that they are not yet emotionally capable of managing– concepts like death, meaninglessness, freedom, evil, and their own powerlessness to effect change that they see as necessary can cause them to become very despondent and even suicidal. Children with intellectual OEs can be very argumentative and require explanation at ages when this is normally not thought to be possible. Their intellectual independence and precociousness can lead to misdiagnosis with Oppositional Defiant Disorders or other dx related to intractability.
  5. Emotional OEs refer to an unusually sensitive and intense awareness and experience of emotions. Emotional OEs cause gifted people to feel emotions very intensely, often very dramatically, and they are prone to becoming emotionally overwhelmed by events that might seem somewhat insignificant to most people. They often experience a very broad range of emotions and may make distinctions between emotions that seem unusual or difficult to understand. They can be exceptionally emotionally intuitive and may feel others’ pain as much as or more than their own. They may become inconsolable if witness to cruelty, injustice, or maltreatment of people or animals and they may be quite traumatised by emotional experiences that most people would not see as “legitimate trauma.” Emotional OEs can cause social isolation and bullying because these people may not be able to control emotional outbursts and reactions. They are vulnerable to misdiagnosis with mood disorders, anxiety disorders, and other emotionally related disorders. Mental health professionals can help these people by providing tools for emotional regulation, normalization and validation of their emotional experiences; the use of mindfulness and cognitive behavioral techniques may be especially useful.

Gifted people can present with “symptoms” of many kinds that result from their idiosyncratic combination of OEs and asynchrony. It can be exceptionally difficult to differentiate between normative traits and those that might indicate the development of mental illness. In most cases it will be prudent to hold off on diagnosis or seek consultation with a mental health professional who is experienced in working with gifted populations if the situation is unclear. In all cases involving gifted individuals it will be useful to provide psychoeducation about what is “normal” for gifted people, how they differ from other populations, and information about tools and methods that may help them as they adjust to the changes they will encounter in their unique developmental trajectory– this information is vital to adults as well as children and their parents.

Parents may require individual counseling sessions as they process information about their child’s giftedness– it can trigger unresolved issues, traumas, negative attitudes, and feelings of loss or grief related to their own childhood, giftedness, or the hopes/expectations they previously held about the child. As giftedness has been shown to be at least partially hereditary, there is a good chance that one or both parents and also any siblings will also be gifted.

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