Wednesday, January 14, 2009

Twice Exceptional and AD/HD

By Marlo Payne Thurman, M.S.

2e Newsletter asked Marlo Payne Rice to comment on hyperactivity and other behavior issues that can be part of the “twice-exceptional package.” Marlo prefaced her comments by saying, “My model is derived from my own ideas and is not yet supported in the literature. I’m not sure I'll ever think about this in the same way that others do because I have such a unique experience with this population. I guess that makes me a bit of ‘the odd man out.’ Having worked with over 2,500 2e families, however, I’m not often too far off base.”

I believe that AD/HD is horribly over diagnosed in the twice-exceptional population. When you have a 2e child who is cognitively gifted but can't take in enough information due to auditory, visual, or sensory processing issues, that child will manifest with the symptoms of AD/HD. Therefore, a basic understanding of energy and arousal is critical to any discussion on the behavioral aspects of AD/HD.

Let’s start with arousal. What if you, as an adult, were placed in the 7th grade for a year. To stay cognitively alert and focused, you’d need more information than the 7th-grade classroom normally provides. In a few days you’d probably start to fidget. You would soon begin to think about other things and over time, staying in your seat would be unbearable.

For twice exceptional children with input problems, school life is like the adult in the 7th grade. 2E children simply can't take in enough information to stay alert and aroused. This results in restlessness and boredom. For this reason, behavior problems are common in twice-exceptional children. Improperly identified, these children fall into existing mental health diagnosis, even though the label may not be accurate. This notion may seem simple but a further understanding of energy is necessary to complete the model.

Each of us has a specific allotment of energy in our physical, emotional and cognitive capacities. Being gifted usually means having a larger “slice” of cognitive energy. If we use the analogy of a pie, we can say that the pie is divided into four sections, with the three areas of energy and a backup or reserve as the fourth slice. Twice-exceptional children, although given a large slice of cognitive energy, use up their allotment and often dip into their reserves to compensate. Tapping into the reserve further complicates the energy-arousal dilemma.

Typical gifted children have as much cognitive energy as they need to perform to their own levels of expectation. However, for gifted children with attention or learning difficulties, the large cognitive allotment gives them the reasoning skills to expect more of themselves and the ability to perform at the gifted level over time. But because they use more energy in compensating, they fall short in day-to-day consistency and performance.

It would be easy if, once their cognitive energy is used up, these children stopped being gifted. However, the internal expectations and emotions of gifted children do not change simply because they cannot continue to push through their learning disabilities. In fact, 2e children learn very early that they can borrow energy from their reserves to continue on.

This seems like a good solution. However, reserves are “funded” on the basis of adrenalin. Children who go past their allotment of cognitive energy force themselves into a state of hyper-vigilance or over-arousal, which then allows them to continue on despite fatigue. This certainly complicates the AD/HD picture. The adrenalin energy, unlike cognitive energy, comes with increased heart rate, pupil dilation, altered blood flow, heightened skin response, and so forth. It unnecessarily prepares a child for fight or flight. Because we are programmed to react to adrenalin by running away or defending ourselves in battle, when the catalyst (a big bear) presents, the adrenalin surges through our body and out in the form of a reaction.

However, for the 2e child, the big bear never shows up. We are now dealing with a child who has no original cognitive energy but a large slice of emotional energy. Furthermore, this child may not have depleted his/her physical energy and is agitated, angry and in a state of sensory reactivity because the adrenalin released in the child’s body can’t be dispelled easily. Plus, the child is still bored from the original arousal problem! Unless the child can explode, implode, or trick his/her body out of the adrenalin state, the adrenalin will keep the child in a constant state of unrest. This impacts eating, sleeping, and wakeful resting. As a result, the child will need to dip into energy reserves sooner the following day.

When the pattern goes on for days, weeks, months or even years, the child adapts by raging, internalizing, and/or acting out in small bursts. Over time, we simply see an overly sensitive, often sensory-reactive, bored child who cannot seem to control behavior or organize thoughts (AD/HD), inwardly, the child may also be anxious and/or depressed.

Recognizing this pattern is the first step in dealing with the problem. As a seasoned behavior management specialist, I can confirm that no level system, punishment or positive reinforcement system in the world will change the 2e behavior until the child can be successful within their cognitive limits and comfortably settled into their bodies. A child who is at constant battle with a pending “big bear” and not enough information to be turned on, cannot be expected to ignore their physiology and simply calm down. Without specific attention to the adrenalin-driven body of the 2e child we cannot implement change in the mind. Without appropriate accommodations and support for deficits in input, we cannot calm the body.

I certainly recognize true attention deficits in all children. However, I also believe that there are a lot of false positives in the twice-exceptional population. Accurate diagnosis is problematic. In many cases the stimulants even work. However, the additional compensatory energy allowed through medication does not solve the original input problem and often, only exacerbates the arousal-energy mismatch. The answer to this complex system of variables lies in accommodations and therapies for input, appropriate cognitive stimulation (from the classroom), modifications for output, and sensory awareness training. Until we include all of these issues into a comprehensive model, we will not get AD/HD identification and treatment right for our 2e kids.

The Continuums of Autism: Cognition, Sensory Processing and Arousal

Does intelligence play a significant role in the manifestation of autism spectrum disorders?

The following paper will discuss my impressions about cognition, sensory processing and arousal in the symptomology of autism.

By Marlo Payne Thurman

Like all children, those with autism have unique sensory needs, cognitive skills, and individual strengths and weaknesses for learning. However it is common, because autism itself is so difficult to understand, for us to label all autistic children as the same in an attempt to create a clean service model. Autism is messy. In thinking that all autistic children are alike we fail to recognize the sensory and cognitive continuums of the autistic individual and in turn we render ourselves unable to provide appropriate arousal states for new learning. Furthermore, by lacking good information about learning styles and different modalities for learning, we limit the ultimate potential for our autistic children by expecting them to succeed in our traditional language driven model of education.

For new learning to occur, each of us must have the right amount of information coming in. Not too much, not too little, calm yet still alert. When things are coming at us too quickly, we feel anxious and over stimulated. This causes us to shut down, tune out or avoid by filtering everything away. Not enough information results in feelings of boredom, restlessness and irritability. In turn, we fidget, seek novel stimulation, self stimulate or daydream. For the autistic individual, the ability to find the perfect state is difficult because so much energy is consumed through the simple tasks of seeing, hearing, touching, tasting, feeling pressure and motion and regulating body systems. When we recognize that autism is an extreme state of sensory integration and modulation difficulty, it is not hard to understand why social interaction, attention and learning become problematic. Simply put, these children are not “in” their bodies.

Further complicating the picture is the role that is played by the adrenalin response process. We each have a biological system that prepares us to fight or flee in a dangerous situation. This body reaction gives us energy to keep going, even if we are exhausted. Breath, blood flow, pupil response, respiration, skin sensitivity etc. all react when we are over our limit. Yet for the autistic individual the over-the-limit state becomes the norm as they attempt to fit into our sensory rich, language based, socially intensive world. For many autistics, the adrenalin state that is usually reserved for crisis becomes a habitual pattern of anxiety, withdrawal, feelings of fear and panic and, if forced to keep going, behavioral reactivity. In order to effectively deal with adrenalin issues for our autistic children, we must understand arousal, identify the individual sensory issues of each autistic child, (because each is very different), and provide sensory accommodation and modulation training to help them feel safe. To do this we often must rely on their behaviors to tell or show us what we can do to bring them to a calm/alert state. All too often, we focus on eliminating or substituting these “needful” behaviors, and as such, we miss the best clues we have in working with the over aroused autistic individual. Once these children are in safely in their bodies then they can find the calm and alert state that is necessary for us to begin addressing their cognition and learning.

Historically, autism has been associated with mental retardation. Up until the late 80’s, published college textbooks taught that 75% of all autistic individuals had inferior mental capacities. Yet as early as the 1950’s, and at the same time Dr. Leo Kanner was laying the foundation for the autistic diagnosis, Dr. Hans Asperger argued that a normal continuum of intelligence was present in the autistic population. Kanner, the “father” of autism, ultimately won the popular vote and thereafter we defined intelligence in autism as a characteristic set of specialized “splinter skills.” For many years, all autistics were thought to be of somewhat inferior intelligence. It has only been in the past two decades that we have finally begun to identify those individuals with high functioning autism or Asperger’s as normally intelligent. Even today however, I find it impossible for educated professionals to recognize giftedness in autism once the autism label has been assigned. I still hear the argument that the child may have average intelligence but those characteristics that we would usually associate with giftedness in other populations are, for autistics, splinter skills. We have a long way to go in our understanding of the continuums of intelligence and this in turn will ultimately define our delivery of appropriately challenging services and programs for autistic individuals. For now, as a professional specializing in gifted and learning disabled individuals, I am constantly faced with highly intelligent and even gifted autistic children who because of language, social delays or behavior are served in self-contained learning labs alongside those individuals with severe mental retardation.

Furthermore, and in addition to our lack of understanding about cognition, we also fail to recognize the autistic as different minded. Eureka, a term coined from the non-linear, deeply abstract thoughts of a physicist in his bath, best characterizes the thinking of the autistic individual. Yet because we define education as a verbally acquired, linear, sequential system of thought that is demonstrated through speaking and writing, little room for strength-based learning is given to our autistic individuals. It is about time we recognize that our existing systems of education do not work for our autistic children, or for many other visually minded children. So, faced with the obstacle of teaching the abstract, visual and kinesthetic child in our language based school system, much emphasis is given to emotional, social and behavioral modification and little actual learning is obtained. Yet, it is my experience that in the higher cognitive ends of the autistic population, if appropriately placed in settings that do provide adequate cognitive challenge and good multi-sensory learning, these children find success as adults in our world of technology. Today, individuals no longer need to remember oral facts. Intelligent, “eureka” thinking supported with secretaries and advanced organizers allow these individuals to revolutionize our world. Why then can we not rethink education for some of our most alternative minded children and teach the autistic population within their innate areas of strength? We assume that the goal is to “fix” the autistic child, making them more like their peers when it is my opinion that we should help them find ways to achieve their potentials, find their unique strengths and ultimately have a place in our society where they, like all children can contribute and feel success.

In conclusion, I believe that once we can identify and modify our schools, support programs and our community at large, on the basis of the sensory needs, arousal issues, cognitive continuums and learning styles, we will then be able to tap the invaluable resource of our different minded, “eureka” thinkers. While autism may be on the extremes of the continuum, if we pay attention, we find that each of us, at times, has a little taste of the autistic world. Every once in a while, we ourselves fall into the adrenalin state, or we find ourselves cognitively under or over challenged, some days we can’t find our words, or the thought of facing yet another social event might feel too exhausting. Perhaps when we experience these bits of autism, it is then that we can begin to see autism as a continuum. Autism isn’t really so difficult to understand. But, it is time for us to acknowledge intelligence in autism and create a better system of education. We must teach our autistic children how to find their own calm/alert learning state, and, at long last, perhaps we ourselves need to locate that arousal balance point in which we have enough information to stay excited and engaged, but not so much that we lose those defining moments of peace and self-reflection.

Twice Exceptional Continuums

Are mental health disorders in gifted childen secondary to sensory processing issues?

Below is a paper written to address the subject of sensory arousal and the mental health continuums

Marlo Payne Thurman (Formerly Marlo Rice)

Children of high intelligence take in more information than their peers of average cognitive ability. However, because the sensory skills of filtering, regulation and modulation mature with age, innately asynchronous sensory development in the gifted and twice-exceptional populations places our most intelligent youth at risk for academic, social and emotional problems. When compounded by learning disabilities, most twice-exceptional children simply cannot access enough cognitive energy to compensate and function successfully in their day-to-day lives. This, in turn, leads to cognitive and emotional fatigue, heightened physiological arousal and ultimately mental health symptoms.

This paper will discuss the unique relationship between intelligence and sensory regulation and illustrate the impact of modulation abilities on learning, social and emotional function and the mental health diagnoses commonly seen in our gifted and twice-exceptional populations.

Back in the late 80’s, when I began my work with gifted children, the field of education had not yet adopted the term “twice-exceptional.” Characteristics associated with high intelligence were barely discussed in courses and not a single text book covered giftedness. That a child could be both gifted and learning disabled was something we did not consider. I think that we placed the notion of twice-exceptionality somewhere on a back shelf with those uncommon disorders like Wilson’s Syndrome. Little did I know then, that the next 20 years of my life would be dedicated to understanding gifted, asynchronous, children.

I began my career as a skills trainer in a reputable autism training program. In the autism world, we also had no use for a discussion about advanced cognition. The term Asperger's Syndrome was beginning to make its way back into the developmental disabilities literature (originally coined in the 40’s) and high functioning autism was explained with these two words, “splinter skills.” In fact, I was unaware of any identified, gifted-autistic individuals. While we had all heard about some autistic individual who could memorize phone books, solve puzzles in record time or mimic the sound of every brand of sprinkler ever invented, we had been trained to dismiss the innate intellectual potentials underlying these skills with the term “idiot savant.”

Other fields assumed that children with above average intelligence were somehow elite, or lucky, or even just over-achieving, but all-in-all, above average intelligence was something we need not, as young educational professionals, concern ourselves with.

Then I met “Joey” and I could not accept the traditional explanation I was given about his “splinter skills.” Joey was profoundly gifted. He entered our program at the age of four with no functional language, yet when we observed him he seemed to be able to “read” books that were above the 8thgrade level. Joey could sign only ten words and he used gestures, points and grunts to communicate his needs. While words had little meaning and he could not write the letters of his own name, numbers meant everything and he wrote them down in what seemed to us, eternal, random sequences. One day, when the class was calm, we started quizzing him about facts he seemed to know. In a yes or no question format and over the next two hours, Joey proved what we all had suspected; he had knowledge for facts in science, math, literature and social studies that could be measured beyond the 12th grade level. Joey also kept track of everyone he knew by memorizing their license plate number. When he finally began to speak eight months later, he knew us by our numbers rather than our names. And Joey “knew” hundreds of people.

Joey also had what I now know to be severe sensory processing issues. He was painfully sensitive to sound, struggled with the lights, could not stand to be touched and ate only white foods. Even with one-on-one supervision, Joey had a magical way of disappearing. On more than one occasion we found him wedged into some insanely small space that we could not imagine a child fitting into. Once Joey managed to lock himself into a nearly full toy chest during clean up time and we looked for him for hours, with police support, while he slept comfortably nearby.

Looking back on those years, we certainly lacked a good understanding of giftedness. High cognitive potentials, particularly in the fields of severe mental health and developmental disability were also not properly understood. But in my opinion, what we lacked more than anything was a basic understanding of how individuals process sensory information based on their innate cognitive potential. Even today, we are only beginning to understand the sensory issues and their impact on social and emotional functioning and behavior.

And, as we move through the continuums of cognition, we suspect that the more highly gifted an individual is, the more sensory information they must process. We also know that asynchronous development is common in gifted and twice-exceptional populations. While we can speculate as to which came first, high intelligence, uneven development or sensory processing difficulties, we can certainly agree upon the relationship.Yet we are only beginning to realize how this impacts our gifted and 2E children.

Furthermore, it seems that processing sensory information takes considerable energy, energy that is not always available to gifted individuals with disability. It is my premise that when an individual lacks the necessary amount of energy to simultaneously compensate for skill deficits and filter extraneous sensory information, that a system of emergency reserve energy is employed through the accessing of the flight or fight mechanisms. When this happens, despite the positive effect on continued cognitive processing, the result is often exacerbation of symptoms and/or demonstration of behavior for a mental health disorder or a developmental disability. To understand this logic, we must begin with a discussion about learning.

For each of us, new learning occurs best when we have the right amount of information coming in, not too much, not too little. If new concepts or experiences come at us too quickly, we feel anxious and over stimulated. This causes us to shut down, tune out or avoid, and we feel rigid, irritable and fatigued. If we lack information the result is feelings of boredom, restlessness and annoyance. This, in turn, drives us to fidget, seek novel stimulation or daydream.

We regulate our internal arousal levels by engaging in our world or withdrawing from it. We can respond physically, emotionally or cognitively. When we block certain stimuli out, we can appear detached or hyper-focused. For example, our children often tune everything else out but he screen and sound when watching television. Physical withdrawal takes us out of the setting or causes us to create a large physical space between ourselves and the overwhelming stimulus.

In school, we are taught to remain in the classroom and stay on task. We have created a standardized curriculum that sets conceptual content, cognitive pacing standards and developmental expectations regarding productivity. Unlike the real world where individuals are rewarded for offering up their best abilities, despite age or school training, typical schools, expect all children to learn and perform within a norm. As such, the typical child has arousal levels that are minimally maintained to keep them calm and alert in a school classroom and learn just enough to stay on task. However, children who engage or perform at a different level, either above or below the average are subject to issues with arousal because the presentation of material is not well matched to their own innate levels of input and output.

For the “vanilla” gifted child (a gifted child without areas of delay or asynchrony) who is under-challenged, we see a lack of stimulation, boredom and inattention. It’s hard to attend when the material being covered is well below one’s ability. When I talk to individuals who don’t understand that gifted, inattentive children are often bored, I like to suggest that the adults who struggle with this concept spend a few weeks as students, in a 4th or 5th grade classroom. It wouldn’t take very long for any normal adult to look pretty fidgety, restless and inattentive once the novelty of being in the 5th grade again wore off, and in fact, as the weeks progressed, I would expect to see irritability, attention problems and possibly even aggression as our attempts modify the fidgety or daydreaming behavior of the adult in the 5th grade increased. When we are bored, we do what we need to do to stay awake, alert and engaged. Our minds require that. And when our attempts at engagement are met with disapproval or failure, the outcome is likely a negative one.

Twice-exceptional children have an even more complicated dilemma because not only are they bored and under stimulated conceptually, but given their intelligence, they are also over aroused and anxious when faced with tasks of production that should be easy. Much like pushing ideas through a funnel, most 2E kids struggle with the organization and demonstration of their thoughts. While an original idea may have started out as a master’s thesis on the species of turtles, by the time the child struggles to organize their complex ideas and get those thoughts onto paper, what comes out may sound like “I have a little turtle that lives in a box in my room.” To fully understand the frustration and difficulty of the 2E situation though, we must first talk about energy.

About ten years ago, I sustained a mild traumatic brain injury. After the accident I was still as “smart” as I had always been but I couldn’t do things with the consistency and efficiency with which I had done them before. I could, however, do pretty much everything as long as I found a way to stay rested. A light came on for me for both my situation and that of the twice-exceptional clients with whom I was working, when one day my own cognitive therapist explained to me the role of energy in cognitive processing.

She told me that as humans we consume energy to perform cognitive tasks, to engage in physical activity and to experience social interactions and emotions. And, while these tasks are certainly not mutually exclusive, we do have a finite allotment of energy for each. Simply put, an individual can be cognitively, physically or emotionally too tired to perform a certain task although they can still successfully engage in other tasks. As an example, our children often tell us they are too tired from school to complete their math homework but we observe them to be miraculously rested when it comes time to engage in the physical activities of running around outside or playing with friends. Given the rules of energy, my therapist explained that our children are not really conning us. They are accurately reporting on the energy state that is depleted and those states that still have fuel. This made perfect sense.

According to the rules or energy, we cannot borrow from one energy state to fuel another state. Each energy state, once consumed, can be replenished only by sleep, food and time. Every day we get a fresh allotment of energy in each area or state, and when we feel best, we find that we have consumed energy in cognitive tasks, social and emotional situations and physical activities. Every individual has a differing amount of energy in each state, but when consumed, the response is the same for all. Finally, the energy rules dictate that to sleep well, all 3 of the energy states should be equally depleted. So, while we can certainly fall asleep without adequate cognitive processing, meaningful social time or physical activity in our lives, according to our understanding about energy, we only feel rested, refreshed and happy when these three states are in balance. For twice-exceptional individuals, who consume tremendous amounts of cognitive energy in compensation for their disabilities, finding a balance to feel both calm and alert while maintaining an even flow of energy consumption is challenging. However, a final variable enters in that makes things even more difficult.

As biological survivors, in addition to our energy allotments in the areas of cognition, physical activity and social/emotional processing, we are also given a reserve energy source that, fueled through the adrenal system, is best described in lay terms as the body’s fight or flight defense mechanism. In other words, when we are cognitively, physically or emotionally tired, we can press on if necessary, continuing to perform tasks in a depleted area, by dipping into our adrenaline fueled reserves. This practice, however, is costly and in my own case, explained why, despite my best attempts at compensation for my head trauma, my consistent, day-to-day functioning failed. I simply could not continue on using only these emergency reserve energies.

Cognitive energy levels are not equal for all individuals. In fact, each individual has a specific allotment of energy in each of the energy states. Gifted athletes can press on physically because they have more stamina, just as cognitively gifted individuals can perform complex thinking tasks for longer. Gifted people have a larger than average “slice” of cognitive energy. But, gifted individuals expend more cognitive energy because they use more to sort out their greater than average thought processes and filter their larger than normal amounts of sensory input from the outside world. Bright individuals think more thoughts and take in more information. So, for the typical gifted child, their high amount of cognitive energy allows them to keep going long after their peers have lost interest. They not only think more thoughts and take in more information but they are able to sustain appropriately challenging cognitive tasks for longer periods of time. We have known for a very long time that gifted individuals sleep less.

But, for the asynchronous, twice-exceptional learner who must consume larger amounts of cognitive energy in compensation of their learning disabilities, a shortage in cognitive energy results. And, while it would be nice if their giftedness simply diminished with their fatigue, what we find is that the deep abstract reasoning portions of the mind still crave input, long after the more peripheral aspects of sequencing, organizing, multi-tasking and demonstrating knowledge through written output are depleted. The child is both bored and over-aroused.

Now that we understand learning, withdrawal and avoidance and the energy states necessary for consistent performance, we can add yet another important layer to our concept, the sensory system. One of the biggest consumers of our cognitive energy is the taking in, processing, filtering and storing of input from the outside world through our senses. We are taught in school about the five senses: seeing, hearing, touching, tasting and smelling. But we also process information about motion, pressure, temperature and the inner states of our body’s responses to breathing, digestion, circulation etc..

At birth, assuming we have an adequate caretaker, we are carefully swaddled, fed when we are hungry and protected from bright lights, loud noises and uncomfortable temperature variations. For most of us, this results in a calm-alert body system that can, over time, successfully take in, filter and process increasing amounts of new sensory information.

However, gifted children remain out-of-sync in their sensory processing because their high cognitive potentials allow them to take in larger than normal amounts of sensory information, and their sensory “filters,” maturing at even an advanced rate, take a while to catch up. But, despite the immaturity of the gifted child’s filtering mechanisms relative to their sensory input, larger than average amounts of cognitive energy work to their advantage. Gifted children have more cognitive energy, so, they can accurately filter, even though they have more information to filter. Extra cognitive energy gives them what they need to eventually process, filter and store their heightened amounts of information, unless that energy is needed elsewhere.

For the 2E child, an entirely different phenomenon seems to occur. In my observation, twice-exceptional children develop, from a very young age, an innate ability to tap into their energy reserves as a means of staying alert and focused. Given the energy demand required for filtering their also heightened amounts of sensory information and the equally large amount of energy required for compensation of their asynchronous skills, 2E children come up short in the cognitive energy department. However, it has been my experience that these children quickly learn about the emergency reserves, which generally allocated for short-term use, can be accessed on a day-to-day basis. However, because the reserve system is fueled through what we can best describe in lay terms as an adrenal or “fight or flight” response, the borrowed energy does not give the user the same outcome as would be obtained through the use of original cognitive energy. “Adrenal” energy as we will call it (despite the over simplification of the term), has a severe impact on the overall body system.

To understand the adrenal response better, let me guide you through a common scenario in which your own system likely dipped into reserve energy. Imagine yourself in your home, alone, at night. Overly tired, you struggle to fall asleep, only to be startled awake by some foreign sound. Your mind automatically prepares your body for a reaction. Nothing more happens but think how you now notice the faucet dripping, the neighbor’s dog whining, the prickly sensation of your skin or uncomfortable position of your blanket and pillow. Your startled awakening has heightened you to a state of discomfort and over-arousal. Now, as you again try to fall asleep, you find that your thoughts are racing. In fact things that seemed not very important yesterday now require your immediate attention. The kids’ college fund, your aunt Gertie’s forgotten birthday, the transmission service on your car, all become problems that feel as if a solution this instant is imperative. As your mind searches for those solutions, even more “important” problems surface so that even though you are extremely tired and have a long and important day ahead of you, you can’t sleep. If you have ever wrestled with this process, you know that you have several options, short of taking a sleeping pill: You can continue to chase your illogical thoughts although in doing so you find that you can’t seem to make organizational, prioritization sense of anything. You can get up and be “productive,” actually taking on a few of the important projects you're worried about while the burst of cognitive energy lasts. You can find some distraction, like watching television or reading a book until the arousal state passes and you are able to fall back to sleep. But in any case, when you awaken the next morning, you might find that you have a bit of a sick feeling, (almost like a little hangover for those of you who have had the pleasure of drinking too much). In this example, your own adrenal response and over-use of energy reserves has created for you a pretty hectic next day at work, but if all goes well, you rest the following night and the adrenal state has passed.

Now imagine being a 2E child who must continue to dip into his cognitive reserves each and every day to allow him the necessary energy for functioning. This method of “getting by” is, in my opinion, at the very heart of the mental health issues and exacerbated behavioral and social emotional symptoms often seen in our gifted and learning disabled population.

Let’s return for a moment to the basic tenants thus far:

1. All individuals need the right amount of new information coming in to feel calm and alert.

2. Too much information creates feelings of anxiety and results in avoidance.

3. Too little information causes us to feel bored. We react to boredom by seeking more stimulation.

4. Twice-exceptional individuals feel both bored and over-stimulated.

5. Cognitive energy is greater in the gifted, but it gets used up to filter additional sensory information and sustain more thoughts.

6. Sensory processing is learned by time spent in the body and therefore cannot be inherently “gifted.”

7. Twice-exceptional individuals must dip into their energy reserves to compensate for the cognitive energy shortage created when their sensory filtering, gifted thought processing and learning disability compensation consumes too much energy.

8. Reserve energy is fueled through the complex bio-physical responses usually saved for short-term emergencies.

9. The use of reserve energy on a regular basis causes a number of complex problems that manifest in physical, mental, socio-emotional and behavioral dysfunction.

10. Heightened sensory responses create heightened arousal levels which in turn alters sensory sensitivity. This becomes a chicken or egg phenomenon in twice-exceptional individuals.

It is not at all surprising then, that in my experience with over 5,000 twice exceptional children, most have sensory arousal issues. This is not the same as sensory integration dysfunction, although 2E kids can have that too. Let me explain. Sensory integration disorders are usually thought of as inaccurate registration of sensory information. Sensory modulation disorder however, is best described as the inability to filter and process only what is important.

Sensory modulation cannot therefore be adequately explained without first understanding the continuums of arousal and the “adrenal” response.

To explain, let’s take another imaginary journey. Assume that while hiking with friends in the mountains you have became separated from your group and somehow have managed to get lost. You see a slight trail, but with the sun rapidly descending you are hesitant to take it, not knowing for sure which direction it will lead. Sitting down for a moment to gather your thoughts, adjust your pack and make a plan, you notice the faint yet distinct cry of a mountain lion in the distance. Immediately your fight or flight response kicks in. You have renewed physical energy for your hike, your pack feels lighter, and for a moment it even seems as though your thoughts are clearer. However, now assume that you don’t find your way out of the forest. Your mountain lion seems to be getting much closer with every step, and as the sun goes down you are on edge to the point that the snap of every twig and branch along the way startles you. Your breathing, heart rate, skin response, body temperature, blood flow, vision and hearing have become heightened. You pick up a stick to defend yourself if necessary and hike on. Now assume that a friendly but unannounced fellow hiker crosses your path. Depending on your state of arousal, you might actually hit the person accidentally with the stick even though your odds of encountering a person on the trail are far more likely than the that of crossing a mountain lion. Carry this further. What if you never encountered any one at all and your mountain lion never came again but you were too afraid of the possibility of being eaten to sleep? After several days, your heightened arousal may cause you to actually lose track of time, be unable to read simple directional cues like sunrise and sunset or even stop feeling hunger or pain. Countless instances are told where seasoned hikers with fairly minor injuries die just making stupid mistakes.

As sensory arousal increases, sensory sensitivity is heightened and adrenal responses kick in. But there seems to be some critical point at which logical thought decreases. Furthermore, if the physical aspects of the adrenal response are not dispelled through a fight or flight outlet, as would be the case in our story of the mountain lion who never makes an actual appearance, then our kinetic or stored fight or flight reaction seeks another outlet. We need something to do with all that adrenal energy, especially once our reasoning skills have reached a cognitive processing wall. Our bodies have prepared us to run or fight, so short of outthinking the lion,the waiting is the hardest part. It actually feels good when we get to finally fight the mountain lion. Without the mountain lion to fight as a release of this pent up energy, we might get angry and take our frustrations out on a tree or an unsuspecting traveler instead.

With 2E children, aggressive behavioral outbursts, or dark, internalizing behaviors such as head banging, cutting etc. allow unused physical energy to flow. But, the adrenalin state that arises in filling the energy shortage and then the subsequent need for a release of the physical part of the adrenal state, over time, can become habituated. More specifically, because a child’s body is readily prepared to fight a mountain lion, a demanding mother, a peer, or anger turned inward can become the source for dispelling the unused physical portion of the energy acquired from the adrenal response state.

Very often when a child has what we would describe as a “melt down” we are actually dealing with a situation in which there is no cognitive reasoning energy intact. The child is unreasonable, illogical and can’t seem to see even an obvious solution to the problem. Even more, the child tells us that everyone hates them, they will never have friends and nothing will ever change. No logic will help them see that things will feel differently tomorrow. But the child still has plenty of emotional and physical energy to spend and since we are unlikely to employ reason, we find ourselves dealing with what seems to us as a rather ridiculous emotional drama or physical outburst.

More often than not, the explosive or shut-down child has also been in a heightened adrenal state for several days prior, although we may have missed the clues. Moms sometimes tell me that they can see rages coming on in their children because they look “glassy eyed.” Interestingly at the heightened arousal state pupil dilation changes. So what we describe as the look of “deer in the headlights,” is actually a pretty accurate description of the child’s pupils not properly reacting to the surrounding light source. Sugar or simple carbohydrate cravings, sensory sensitivity, inability to sleep, emotional lability and even high, shallow breathing patterns are all indicators of the adrenal response.

We know that individuals who struggle with sensory modulation issues can’t seem to find and maintain appropriate levels of arousal for their day-to-day tasks. As semi-functional adults, these people have learned to work in short burst or push themselves up against time deadlines to create the necessary levels of arousal for task completion. This impacts their productivity in work, their enjoyment of play and their social discourse abilities, but they get by.

Twice-exceptional children with arousal problems have not yet found ways to cope and inflexible school system sometimes eliminate strategies that could work. These kids often report feeling as if they are constantly falling apart. One young man told me “There are either ping pong balls in my head that make me crazy, or there is white noise, like on the old TV screens that make me too sleepy to think.” When children struggle with arousal their academic skills falter, their friendships dissolve and their self-esteem plummets. For the gifted/learning disabled individual, modulation is an inherent problem given the asynchrony between their cognitive demand for new stimulation and their cognitive drain of energy due to sensory filtering and compensation. But add in the adrenal response and we have a recipe for disaster.

More specifically: Take a highly intelligent child who is bored and under-challenged but unable to find success consistently in even fairly simple tasks due to fatigue, energy shortages and sensory sensitivity. Next ,blend in social problems with feelings of failure and criticism from parents and teachers. Then create an imbalance in the child’s bio-physical adrenal states and turn up the heat around academic performance. Stir constantly over the next several months of a school year. Once fully cooked you will surely see the child explode or implode depending on personality.

Once the arousal state is activated, the sensory sensitivities increase and the need for additional cognitive energy to filter the newly heightened state of sensory processing goes up. This further shortens the cognitive fuel available for other situations and rapidly, with a little sleep deprivation, becomes a chicken or egg situation. Often when we look back we are not quite sure what happened when everything goes wrong. But it is important that we don’t forget where it all started.

In the mental health world however, we are forced, for lack of a better system, to rely mostly on the clinical histories and behavioral observations that the patient presents with. For the majority of our diagnoses, we must rely on professionals who despite clear expertise in other areas, have very little experience with gifted children. Most psychiatrists and psychologists have little if any training in sensory processing. With the complexity of our twice-exceptional children, the task of accurate diagnosis is challenging if not impossible, even for the skilled practitioner.

What then is a mental health disorder for a twice-exceptional child? Do mental health disorders look the same or different for the gifted and twice-exceptional populations? Are twice- exceptional children more susceptible to mental health disorders or are they just more likely to draw a false diagnosis? Children who are bored and seek more information appear to be off task. They fidget, look restless, become impulsive and can’t complete tasks. Are these not the very same characteristics for which we diagnose AD/HD? Clearly some sort of imbalance is created in the 2E child’s over-use of reserve energy. When a child is depressed, couldn't that possibly be the body’s way of saying stop using your adrenal reserves? Over-arousal equates with anxiety. Is anxiety in the twice-exceptional population the same as it is for other populations? Over arousal causes avoidance, rigidity, conformity and adherence to predictable routines (I can think of several diagnoses that fit this bill), but wouldn’t that be the logical course for anyone living in a fight or flight world? And mood disorders, don’t they seem to be at least in some part, the vacillation between states of over and under-arousal? Even in the obvious case of autism, aren’t the extreme states of inaccurate and heightened sensory processing difficulty at the core of the diagnosis? And… don’t social skills get impacted when we can’t register the world around us accurately?

I am confused and I hope you are too. I certainly don’t claim to be a diagnostic expert and I admire those professionals who must look at all of this and give a name and a prescription to a twice-exceptional child. But I am not certain that we are working with the best tools. Isn’t there a better way to balance this all out? It is time to be asking these questions, especially for our most truly twice-exceptional and divergent minded children.

Traditionally defined, twice-exceptionality is reserved for those individuals with gifted IQ scores that are combined with a specific identifiable learning disabilities. However, it is my experience that an uncomfortably large percentage of our most highly gifted, twice-exceptional individuals go through life without identification. Even when referred for assessment some of my most intelligent, creative and talented clients did not test with high IQ scores. I have seen files where poorly trained clinicians have reported score scatter ranging from the 99th percentile to the 5th percentile as “average ability.” Then, with our new “No Child Left Behind” Special Education Act, average academic achievement scores and classroom performance with C’s in all classes have left our most ignored 2E kids without any services at all. Yet, these very same children might spend five hours per night on homework, have high absenteeism due to physical illness and are being referred for depression, aggression or particularly in our girls, cutting behavior. Or worse yet, these kids simply give up and drop out of school entirely. By the time the psychiatrists get involved, the children are in actuality nowhere near their starting point and the truth about whether they do or do not have mental health disorders may never be found. Just as concerning is the high number of twice-exceptional, behaviorally disordered or mental health challenged individuals who never even receive a cognitive assessment because they simply appear lazy or unmotivated. These kids get angry and act out. In short, it is my opinion that our greatest loss to society are those most creative and intelligently different-minded children who, for whatever reason, cannot reach anyone’s standard of potential because they are trapped behind an unrecognized challenge that prevents them from being seen with any cognitive potential at all.

So, left with more questions than answers, I can only say that I know that behavioral interventions alone don’t get us where we need to be because they don’t address the heart of the problem. Psychiatric referrals and medications are also not the only answer because in my opinion, the mental health conditions in many of our 2E kids are not innate, but secondary to their imbalances in energy, sensory processing and cognition. Our traditional education programs fail these children because 2E kids are not challenged in their cognitive strengths or supported in their processing weaknesses. Special Education services frequently overlook these kids and when our 2E children are served, it is often under an emotional or behavioral disability label.

Just as we lacked certain areas of knowledge in the 80’s, we are just coming into our knowledge about twice-exceptional individuals. What is needed now is more research on the actual incidence of twice-exceptionality. My colleagues and I agree that gifted children with learning disabilities occur in much more than 5 or 7 % of the gifted population as we had been led to believe. In fact, twice-exceptionality may be closer to the norm rather than the exception in gifted populations. More information is also needed on what is normal for a gifted or twice-exceptional child. We cannot continue to compare these children to typical IQ peers. We also need to understand sensory arousal better and realize that some aspect of gifted, twice-exceptionality places these kids at risk for modulation disorders and mental health symptoms. Finally, we need more appropriate programs to educate these children, programs that employ good services for special needs, behavioral issues, sensory processing difficulties and social issues, while at the same time still teaching to the strengths. Finally, as professionals and parents, we really need to better address the energy issues that shut our 2E kids down. No matter what else we do, it is my premise that without attending to cognitive continuums and their relationship to energy arousal and sensory processing, we will be right back where we started.

Now, 20 years after I began my work with twice-exceptional children, I feel as if I am once again ready to start over. Having owned and operated the Brideun School for Exceptional Children and with the the unique opportunity of working with thousands of the most gifted and twice-exceptional children in the country, I now feel ready to start again, by asking the hard questions and continuing to experience 2E from the inside out.

In order to effectively deal with adrenalin issues for our twice-exceptional children, we must understand arousal, identify the individual sensory issues of each child, (because each is very different), and provide sensory accommodation and modulation training to help them feel safe. To do this we often must rely on a child’s behaviors to tell or show us what we can do to bring them to a calm/alert state. All too often, we focus on eliminating or substituting “needful” behaviors, and as such, we miss the best clues we have in working with the over aroused individual.

Once children are safely in their bodies, then they can find the calm and alert state that is necessary for us to begin addressing their cognition and learning. When that occurs, we must be prepared to face hard facts about the inefficacy of our existing models of education. Our 2E children will never be adequately served in regular schools, existing gifted programs or traditional special education models. We must create educational systems that attend to the complexity of the twice-exceptional learner. We must also begin to deal with the physiological issues in our 2E kids that stem from long-term adrenal use. Our 2E kids are physically sick. I have started referring many of my clients to AMA approved biomedical doctors and the high numbers of “odd” test results reported back to me are astounding. While none of this is, of yet conclusive, I am constantly hearing feedback about adrenal taxation or exhaustion. Finally, we must advocate for more research, better methods of identification and better training for our educators and our medical professionals. Once exhausted and depleted, our 2E kids look mentally ill. But, if we simply go down that path, in my opinion, we are treating only the symptoms and as such, prolong identification and treatment of the root issues we continue to face in meeting the needs of our twice-exceptional populations. It is time that we start down a path where cognition above the norm and cognitive asynchrony are considered meaningful in diagnostics, education, mental health and medicine.