Disorder Versus Disability:
The Challenge of ADHD in
the Context of a High IQ
Kevin M. Antshel, Ph.D., Kaitlin Hendricks, Stephen V. Faraone, Ph.D,
and Michael Gordon, Ph.D.
Most research on ADHD has focused
on individuals with average intel-
ligence. Considerably less is known
about ADHD in populations at either
end of the IQ spectrum. Indeed, wheth-
er ADHD should even be considered in
individuals with low IQ has generated
much debate (Antshel et al., 2006) and
research (Fee, Matson & Benavidez,
1994; Pearson & Aman, 1994; Pearson
et al., 2000). Similar questions have
been raised about how ADHD might
be manifested differently in high IQ
populations. For example, some have
expressed concerns that individuals
with superior intellectual abilities are
vulnerable to being overdiagnosed as
having ADHD (Baum, Olenchak, &
Owens, 1998; Gallagher & Harradine,
1997; Hartnett, Nelson, & Rinn, 2004;
Leroux & Levitt-Perlman, 2000; Mika,
2006; Webb & Latimer, 1993). In this ar-
ticle, we review current debates and at-
tendant (albeit scant) research related to
ADHD diagnosis and high IQ.
Much of the controversy regarding
the interplay between superior cog-
nitive ability and ADHD focuses on
the potential for bright children to be
misdiagnosed with having the disor-
der. Many who warn about the over-
diagnosis of ADHD in children with a
high IQ cite Dabrowski’s (1966) theory
of positive disintegration. Dabrowski’s
theory asserts that children with a high
IQ have “overexcitabilities” in five
general areas: psychomotor, sensual,
intellectual, imagination, and emotion-
al. Psychomotor “overexcitabilities”
may be rapid speech, excessive move-
ment, fidgeting, or impulsive actions.
Hartnett, Nelson, and Rinn (2004) ar-
gue that these behaviors, which may
be common in children with a high IQ,
4 • The ADHD Report
are misinterpreted by teachers or care-
givers as hyperactivity.
Similarly, Webb and Latimer (1993)
assert that inattention or inability to stay
on task in children with a high IQ may
be the result of boredom rather than
an underlying impairment. They claim
that off-task behavior in these children
may be the result of their attempts at
self-amusement due to poorly matched
curriculum or boredom associated with
waiting for their classmates to catch up.
The majority of critics against the valid-
ity of ADHD in the high IQ population
argue that large symptom overlap leads
to misinterpretation about the cause of
the behavior by health care profession-
als, teachers, and parents. These critics
argue that on the surface, the behavior
of individuals with a high IQ may look
very much like ADHD and may lead to
a misdiagnosis.
Hartnett, Nelson, and Rinn (2004) ex-
amined the possibility of misdiagnosis
of ADHD in high IQ individuals. Spe-
cifically, they investigated suggestion
effects in the diagnosis of ADHD versus
high IQ in children. Participants were 44
graduate students enrolled in a school-
counseling program. Participants were
randomly assigned to one of two condi-
tions. Two case vignettes were used in
this study, form A and form B. Both case
vignettes had identical descriptions of a
7-year-old boy. The passages were con-
structed based on previous research ex-
amining the similarity between ADHD
symptoms and high IQ (Webb & Latim-
er, 1993). Both forms required the par-
ticipants to read the description and
identify the cause of the child’s behav-
ior. However, the vignettes differed in
the amount of diagnostic suggestion be-
ing made. For example, form A asked,
“If this child were referred to you by
his teacher for evaluation, what do you
think the underlying explanation for his
behavior would be?” Form B asked, “If
this child were referred to you by his
teacher for evaluation, do you think the
cause of his behavior could be attrib-
uted to Attention Deficit/Hyperactivity
Disorder (ADHD) or due to his being
gifted and talented (G/T)?”
Results indicated that participants
given form B were significantly more
likely to diagnose giftedness, other, or
both giftedness and ADHD than partic-
ipants given form A. Forty-six percent
of participants given form B diagnosed
the child with giftedness (14%) or both
(32%). None of the participants given
form A suggested giftedness or both as
a diagnosis. The researchers concluded
that there is a possibility that counselor
training programs do not clearly de-
lineate the differences between ADHD
and high IQ. The authors suggested
that without the suggestion of gifted-
ness, participants were unaware of the
similarities in behavior between ADHD
and giftedness.
Baum, Olechak, and Owen (1998)
more specifically addressed the mis-
diagnosis and over-identification of
ADHD in children with a high IQ. They
first asserted that there has been an in-
crease in the number of children with
high IQs diagnosed with ADHD, and
they outlined several alternative expla-
nations as to why those children may
struggle with inattention and hyperac-
tivity in a traditional education setting.
The authors opined that children with
a high IQ possess “psychomotor over-
excitabilities” (Piechowski, 1986) that
may be the result of either boredom or
simply excitement about new ideas. Ac-
© 2011 The Guilford Press
cording to the authors, these “psycho-
motor overexcitabilities” are the result
of an overly restrictive classroom setting
that is stifling to the high IQ child’s cu-
riosity. A second possible explanation is
that children with a high IQ found their
classes too boring and routine. Research
has demonstrated that many high IQ
students are being taught below their
instructional level and that much of the
curriculum is redundant (Gallagher,
1990; Stanley, 1978). This may lead chil-
dren with a high IQ to act out due to
boredom or sensation seeking.
Gardener’s theory of multiple in-
telligences is also cited as an explana-
tion for inattention and hyperactive
behavior in children with a high IQ
(Baum, Olenchak, & Owen, 1998). Gar-
dener’s theory states that intelligence
is grouped into eight domains: verbal,
logical-mathematical, spatial, kinesthet-
ic, musical, naturalistic, interpersonal,
and intrapersonal. Many high IQ stu-
dents are often low achieving and inat-
tentive in school. The authors attribute
this low achievement and inattention
to a discrepancy between the students’
strengths and the intelligences being
assessed in school. For example, the in-
telligences being assessed in school are
primarily verbal and logical-mathemat-
ical, whereas the students’ strengths
may lie in the spatial and kinesthetic
domains. This mismatch causes the
child to be inattentive and unsuccessful
in a classroom setting. However, when
engaged in tasks in an area of strength,
these children may perform exception-
ally with virtually no behavior prob-
lems or inattention. Additionally, the
adults’ inability to deal with precocious
children may be a possible explanation
for ADHD-like behaviors in those with
a high IQ. The authors argue that adults
may be overwhelmed or intimidated
by an extremely intelligent child and
will therefore not be able to control that
child’s behavior.
Overall, skeptics of the validity of an
ADHD diagnosis in the high IQ popu-
lation focus on the potential symptom
overlap between high IQ and ADHD
(Baum et al., 1998; Gallagher & Harra-
dine, 1997; Leroux & Levitt-Perlman,
© 2011 The Guilford Press
2000; Webb & Latimer, 1993). They also
provide some evidence of suggestion
bias in clinicians who may be working
with these children (Hartnett, Nelson,
& Rinn, 2004).
Mika (2006) addressed the issue of
misdiagnosis of ADHD in children
with a high IQ by directly responding
to the article by Hartnett and colleagues
(2004). Mika argued that the Hartnett
study on suggestion bias was interpret-
ed incorrectly. Mika asserts that the case
vignette provided no evidence of high
IQ; however, after being given the op-
tion of giftedness as a cause, significant-
ly more counseling students selected it
as a possible diagnosis. Mika also con-
tends that the case vignette described
many behaviors that would support
ADHD as a possibility, such as hyperac-
tivity, poor impulse control, inattentive-
ness, careless, and noncompliance.
Mika (2006) also directly addresses
Dabrowski’s notion of “overexcitabili-
ties” and that the idea of overexcit-
abilities has been misinterpreted. Mika
argued that severe psychomotor over-
excitability and hyperactivity associat-
ed with ADHD are descriptively identi-
cal; there is no clear distinction between
these two behaviors. Additionally, as a
single indicator, intense psychomotor
overexcitability has never been an indi-
cation of high IQ. Mika contended that
Dabrowski implies that psychomotor
overexcitability must occur in conjunc-
tion with other excitabilties (e.g., imagi-
nation) in order to contribute to positive
personality development.
Despite these theoretical consider-
ations, no solid empirical evidence has
been present to support any of these
contentions. The only data showing
that ADHD is not overdiagnosed are
inferential. It comes from the notion
that, were ADHD commonly over-
diagnosed in individuals with high IQ,
studies would find higher IQs in the
ADHD population compared with the
non-ADHD population. In fact, the op-
posite is true. A meta-analysis compar-
ing 1,021 ADHD adults with 928 non-
ADHD adults found lower IQs among
those with ADHD (Bridgett & Walker,
2006). A pediatric meta-analysis simi-
larly suggests that children with ADHD
have an IQ about 9 points lower than
typically developing peers (Frazier, De-
maree, & Youngstrom, 2004). Likewise,
while there is an association (r = −0.3)
between ADHD symptoms and IQ in
the general population (Goodman, Si-
monoff, & Stevenson, 1995; Rapport,
Scanlan, & Denney, 1999), this relation-
ship is modest at best. Thus, not all (or
even a majority of) individuals with a
high IQ will demonstrate ADHD symp-
toms.
From our perspective, much of the
debate about high IQ and ADHD has
unfolded because it has focused on
the potential symptom overlap, not on
whether those symptoms cause impair-
ment. As we and others have demon-
strated (Gordon et al., 2006), having the
symptoms of this disorder is not tanta-
mount to having impairment because
of those symptoms. Therefore, the IQ
factor is irrelevant unless it can be dem-
onstrated that having a high IQ some-
how impacts the onset or staging of the
functional impairment required by the
diagnosis. Put another way, if a bright
child with ADHD symptoms is 1) more
impaired than other bright children and
2) as impaired as children with typi-
cal IQs, controversies about ADHD in
highly intelligent individuals become
largely moot.
To supplant conjecture and opin-
ion with data, the first author and col-
leagues have addressed these questions
with a series of studies (Antshel et al.,
2007, 2008, 2009, 2010). For example, in
one project, (Antshel et al., 2007), we
examined the validity of an ADHD di-
agnosis in the pediatric high IQ popu-
lation. We hypothesized that 1) high
IQ children with ADHD would have
greater levels of functional impair-
ment compared with high IQ controls;
2) high IQ children with ADHD would
have similar impairments with aver-
age IQ children with ADHD; 3) high IQ
children with ADHD would have more
first degree relatives with ADHD than
high IQ children without ADHD; and,
4) the rate of first-degree relatives with
ADHD would be comparable between
high IQ children with ADHD and chil-
The ADHD Report • 5
dren with average IQ and ADHD. Data
from the Massachusetts General Hospi-
tal (MGH) Longitudinal Family Stud-
ies of ADHD was used in this study. In
addition, controls were selected from
pediatric practices in the greater Bos-
ton area. High IQ was defined as an IQ
greater than 120.
Participants included 92 children
with high IQ who did not meet the cri-
teria for ADHD and 49 children with
high IQ who met the criteria for ADHD.
Participants were given the Block De-
sign and Vocabulary subtests from the
Wechsler Intelligence Scale for Children
– Revised (WISC–R) or the Wechsler
Intelligence Scale for Children – Third
Edition (WISC–III) to estimate cognitive
ability. They were also given the Wide
Range Achievement Test – Revised
edition (WRAT–R) to assess academic
achievement and the Social Adjustment
Inventory for Children and Adolescents
(SAICA) to assess global functioning.
Parents completed the Child Behavior
Checklist (CBCL) as a parent report
measure of psychopathology.
We examined group differences in
academic achievement and global
functioning. Results revealed support
for all four hypotheses. Compared to
controls, high IQ children with ADHD
exhibited significantly more functional
impairments in social, academic, and
behavioral domains. High IQ children
with ADHD were also more likely to
repeat grades and require academic
support than controls. Also, relative
to high IQ controls, children with a
high IQ with ADHD had much higher
rates of mood, anxiety, and disruptive
behavior disorders. Additionally, chil-
dren with a high IQ with ADHD had
significantly more first-degree relatives
with ADHD (22.9% versus 5.6% for con-
trols). The rate of first-degree relatives
with ADHD was similar in both groups
(high IQ, average IQ) of children with
ADHD. We interpreted these data as
providing some support for the valid-
ity of ADHD in the high IQ population.
The clear evidence of impairment in the
ADHD-high IQ cohort, when compared
with controls, and the familiality of the
ADHD, we believed, were the strongest
6 • The ADHD Report
arguments supporting the validity of
ADHD in high IQ children.
In subsequent studies on this topic,
we demonstrated the temporal stabil-
ity of ADHD and associated functional
impairments in the high IQ population;
seventy-eight percent of children in the
high IQ ADHD group maintained their
ADHD diagnosis after 4½ years (Antshel
et al., 2008). Using data from the MGH
family study of ADHD, we showed that
adults with ADHD and a high IQ share
a similar profile of functional impair-
ments in diverse domains such as fam-
ily, occupational, and social domains. In
addition, adults with ADHD and a high
IQ had more comorbid mood and anxi-
ety disorders than their high IQ control
counterparts. Higher levels of familial
ADHD were also found in the first-
degree relatives of high-IQ adults with
ADHD (28%) relative to high IQ con-
trols (5%) (Antshel et al., 2009). Adults
with ADHD and a high IQ performed
less well on multiple tests of executive
functioning relative to high IQ control
participants. Nonetheless, mean perfor-
mance of high IQ adults with ADHD
was average on executive functioning
measures (Antshel et al., 2010).
Taken as a whole, these findings sug-
gest that high IQ is not a relevant diag-
nostic consideration. Superior cognitive
ability seems not to protect a highly im-
pulsive individual from the full range
of impairments that commonly flow
from being highly impulsive. It there-
fore appears that being smart may not
meaningfully forestall or overcome the
symptoms of clinically significant im-
pairment in impulse control and atten-
tion. High IQ children and adults with
a diagnosis of ADHD display more
functional and academic impairments,
higher rates of comorbid psychiatric
disorders, and higher rates of familial
ADHD than high IQ controls (Antshel
et al., 2007, 2008, 2009, 2010). Further-
more, worries that bright children can
easily be overdiagnosed as ADHD are
unfounded as long as the clinical focus
is on impairment and not simply the ex-
tent to which an individual presents as
energetic and active.
Clinical Implications
These findings have an array of impli-
cations for diagnosis and, by extension,
the granting of legal accommodations
based on the diagnosis of ADHD. As
for clinical diagnosis, we cannot find a
justification for considering a high IQ
as especially germane. Bright individu-
als can be just as impaired by ADHD
symptoms as those with average IQs. Of
course, it is also possible that a highly
intelligent individual can be energetic
and excitable without necessarily quali-
fying as having ADHD. The correlation
between having the symptoms and be-
ing impaired by them, whether in high
IQ populations or normal ones, is sim-
ply too modest to be of import.
As for testing accommodations, the
IQ/ADHD link, or lack therefore, has
direct implications. To qualify for aca-
demic accommodations such as extend-
ed time on tests, a high school, college
,or graduate student must document
a disabling condition. In the United
States, the Americans with Disabilities
Act of 1990 (ADA), including changes
made by the ADA Amendments Act of
2008 (P.L. 110-325), includes ADHD as
a disabling condition. Thus, extended
time on examinations like the SAT rea-
soning test (formerly the Scholastic Ap-
titude Test), the Law School Admission
Test (LSAT) or Medical College Admis-
sion Test may be granted to individuals
with ADHD. Most high schools, testing
agencies, and colleges/universities re-
quire psychological testing to support
the validity of an ADHD diagnosis and
the need for academic accommoda-
tions.
By definition, most individuals en-
tering postsecondary education have
managed at least average academic
functioning (Gordon & Kaiser, 1998). In
other words, it is hard to argue that an
individual is significantly impaired if
he or she has performed well academi-
cally under relatively normal circum-
stances and has no history of receiving
academic accommodations. In the face
of this reality, some try to justify a di-
agnosis and/or accommodations by ar-
guing that students with high IQ, while
not impaired in the absolute sense (that
is, compared to most individuals), are
© 2011 The Guilford Press
impaired relative to their intellectual
potential. As some have argued (Gor-
don, Lewandowski, & Kaiser, 1999)
relativistic diagnoses are hard to justify,
especially given the extent to which IQ
accounts for a relatively small percent
of the variance in predicting outcome.
In fact, socioeconomic status comes in a
close second to IQ in terms of predicting
“potential.” Few would argue that indi-
viduals should be considered disabled
if they performed below what might be
expected from their social class.
Neither the original nor the amended
versions of the Americans with Dis-
abilities Act allow for an individual to
be qualified as disabled if the worst
functioning still falls within a normal
range. The law was designed to reduce
discrimination against individuals who
were substantially impaired in a ma-
jor life activity. While the amendment
to the ADA was designed to make the
definition of disability somewhat more
liberal, it is clear in maintaining the
“average person standard” as the met-
ric for judging impairment. Therefore,
arguing that well-functioning individu-
als should receive accommodations
because they might help them perform
even better might well be viewed as
unconvincing by many testing organi-
zations (Gordon, 2009). While these or-
ganizations are quick to help those with
real abnormalities, they are often slow
to offer advantages to individuals who
are already advantaged.
Another argument put forth by some
advocating for accommodations in high
functioning students is that ADHD
takes on a different, less impairing form
among those who are bright. Our data
do not support this position. We have
demonstrated that bright individuals
with ADHD show the same array of
limitations as those with average IQs.
Again, what might qualify a person
with a high IQ for a diagnosis of ADHD
and for legal accommodations should
have little to do with IQ and much to do
with the extent of impairment relative
to most people.
As a field, we need to better under-
stand the relationship between a psy-
chiatric disorder and a disability. Disor-
der is a medical term, disability a legal
© 2011 The Guilford Press
term. The case of ADHD in the context
of a high IQ appears to be an example
of how it may be possible to have a
disorder that would warrant treatment
by a health professional, yet not have
a legally defined disability. Further ef-
forts, both research and clinical, should
attempt to demarcate the line between
disorder and disability. This type of
clarity may help guide practitioners
who evaluate and treat individuals with
a high IQ and ADHD.
The authors are affiliated with the State
University of New York–Upstate Medical
University, Department of Psychiatry and
Behavioral Sciences in Syracuse. Drs. Ant-
shel and Gordon are also on the Advisory
Board of The ADHD Report. Dr. Antshel
can be reached via email at antshelk@up-
state.edu.
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ity, reaching a peak at about 24 months
of age. The content of these behaviors
is described as closely resembling ob-
sessive compulsive (OC) symptom di-
mensions, including arranging objects,
repeating actions, and concern with
dirt or cleanliness, as well as hoarding
behaviors. While direct evidence link-
ing these behaviors to OCD is lacking,
subclinical obsessions and compulsions
are encountered in children at a rate as
high as 8% (Leckman et al., 2009).
Leckman et al. (2003) selected all
available affected TS pairs and their
parents for whom OC symptom dimen-
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Disorder Versus Disability:
The Challenge of ADHD in the
Context of a High IQ
sions (factor scores) could be generated
from data collected by the Tourette Syn-
drome Association International Con-
sortium for Genetics Affected Sibling
Peer Study. They report that 50% of the
siblings with TS were found to have
comorbid tic-related OCD and greater
than 30% of mothers and 10 % of fathers
also had a diagnosis of OCD. Based on
complex segregation analyses, signifi-
cant evidence for genetic transmission
was obtained for all factors (Leckman et
al., 2009).
Neurosurgical procedures have, ac-
cording to Leckman (2002), reinforced
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