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.