Roeper Review

ISSN: 0278-3193 (Print) 1940-865X (Online) Journal homepage: http://www.tandfonline.com/loi/uror20

Giftedness and ADHD: Identification, Misdiagnosis,

and Dual Diagnosis

Dianna R. Mullet & Anne N. Rinn

To cite this article: Dianna R. Mullet & Anne N. Rinn (2015) Giftedness and ADHD:
Identification, Misdiagnosis, and Dual Diagnosis, Roeper Review, 37:4, 195-207, DOI:
10.1080/02783193.2015.1077910

To link to this article: http://dx.doi.org/10.1080/02783193.2015.1077910

Published online: 21 Oct 2015.

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Download by: [Central Michigan University] Date: 24 October 2015, At: 12:41
 Roeper Review, 37:195–207, 2015
Copyright © The Roeper Institute
ISSN: 0278-3193 print / 1940-865X online
DOI: 10.1080/02783193.2015.1077910

DUAL EXCEPTIONALITY

Giftedness and ADHD: Identification, Misdiagnosis,

and Dual Diagnosis
Dianna R. Mullet and Anne N. Rinn
Downloaded by [Central Michigan University] at 12:41 24 October 2015

Many gifted characteristics overlap the symptoms of attention deficity–hyperactivity disor-

der (ADHD). The potential for the misdiagnosis of giftedness as ADHD exists, but so does
the potential for a dual diagnosis of giftedness and ADHD. A decade after the misdiagnosis of
giftedness as ADHD was first investigated we examine lessons learned regarding misdiagnosis,
dual diagnosis, and the identification of giftedness and ADHD. The current study reviewed
empirical studies of the misdiagnosis, identification, and dual diagnosis of giftedness and
ADHD published in peer-reviewed domestic and international academic journals between
2000 and 2014. We explored the literature for diagnostic trends and challenges, theories
of misdiagnosis, and empirical findings on dual diagnosis. We discuss differences between
misdiagnosis and dual diagnosis and conclude with a description of limitations found within
reviewed studies and suggestions for future research.
Keywords: ADHD, dual diagnosis, giftedness, misdiagnosis, twice-exceptional

In 2004, Hartnett, Nelson, and Rinn published one of the
first empirical studies to illustrate the potential misdiagnosis
of giftedness as attention deficit–hyperactivity disorder
(ADHD). Hartnett et al. (2004) argued that gifted students
may be referred to physicians and psychologists for ADHD-
like behaviors that are also characteristic of giftedness. Such
referrals are frequent, yet a presumed 25–50% of gifted
children diagnosed with ADHD fail to meet the diagnostic
criteria to make a diagnosis of ADHD (Webb et al., 2006).
The Hartnett et al. study coincided with a book on the same
topic, Misdiagnosis and Dual Diagnoses of Gifted Children
and Adults: ADHD, Bipolar, OCD, Asperger’s, Depression,
and Other Disorders (Webb et al., 2005), and was followed
by a special section on misdiagnosis in an issue of the Roeper
Review (Ambrose, 2006).
Further, in 2012, an international nonprofit organization,
Social Emotional Needs of the Gifted, embarked on an
international campaign to alert pediatricians about issues
regarding the misdiagnosis of ADHD among gifted children.
In the decade leading up to 2010, the number of vis-
its to a physician that resulted in an ADHD diagnosis
among all ability levels increased 66% from 6.2 million
to 10.4 million visits (Garfield et al., 2012), leading us
to believe that the potential for misdiagnosis of giftedness
as ADHD still exists, but so does the potential for a dual
diagnosis of giftedness and ADHD. At this point, a decade
after Hartnett et al. (2004) published their initial research,
what have we learned about misdiagnosis, dual diagno-
sis, and the identification of giftedness and ADHD? We
selected empirical studies on the misdiagnosis, identifica-
tion, and dual diagnosis of giftedness and ADHD published
in peer-reviewed domestic and international academic jour-
nals between 2000 and 2014. We explore this literature for
diagnostic trends, challenges, theories of misdiagnosis, and
empirical findings on dual diagnosis. Next we discuss dif-
ferences between misdiagnosis and dual diagnosis. We con-
clude with a description of limitations in current studies and
a summary of recommendations for future research.

TRENDS IN ADHD DIAGNOSES

Accepted 4 April 2015.
Address correspondence to Anne N. Rinn, Department of Educational ADHD is a chronic and pervasive childhood disorder char-
Psychology, University of North Texas, 1155 Union Circle, #311335,
Denton, TX 76203. E-mail: Anne.Rinn@unt.edu
acterized by developmentally inappropriate activity levels,
 196 D. R. MULLET AND A. N. RINN
low tolerance for frustration, impulsivity, poor organization
of behavior, distractibility, and an inability to sustain atten-
tion and concentration (American Psychiatric Association,
2013). There are three types of ADHD: predominately inat-
tentive presentation, predominantly hyperactive–impulsive
presentation, and combined presentation. ADHD is among
the most common childhood disorders and occurs in 2–16%
of the population, depending on the diagnostic criteria
used (Biederman, 2005; Cormier, 2008; Faraone, Sergeant,
Gillberg, & Biederman, 2003).
In May 2013, the American Psychiatric Association
released the fifth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5), the reference used
by mental health professionals to make diagnoses such
as ADHD. The American Psychiatric Association made
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important changes in the DSM-5 from the previous version
(DSM-IV-TR; American Psychiatric Association, 2000) in
the diagnostic criteria for ADHD:
● the age criterion for symptom onset was raised from age
6 to age 12;
● several symptoms must now be evident in multiple set-
tings but are no longer required to cause impairment in
multiple settings;
● descriptions were updated to include examples of adult
ADHD symptoms;
● and persons age 17 or older need five symptoms instead
of the six required for younger children.
Notably absent in the DSM-5 is the mention of giftedness.
The DSM-IV-TR states, “Inattention in the classroom may
also occur when children with high intelligence are placed
in academically understimulating environments” (American
Psychiatric Association, 2000, p. 91). This statement was
omitted from the DSM-5, but it is not clear why the omission
was approved by the American Psychiatric Association.
In examining trends in ADHD diagnoses, there are two
camps of researchers and practitioners. One camp maintains
that the U.S. national rate of ADHD diagnosis in children
exceeds the disorder’s true prevalence (e.g., Frances, 2013;
Stroufe, 2012; Watson, Arcona, Antonuccio, & Healy, 2014).
This stance also is supported by a number of researchers out-
side of the United States (e.g., Bruchmüller & Schneider,
2012; Edwards, 2012). The other camp of researchers and
practitioners, on the other hand, holds that the overdiagnosis
of ADHD is a public and media perception and that insuf-
ficient evidence exists to conclude that ADHD is systemati-
cally overdiagnosed (e.g., Sciutto & Eisenberg, 2007).
MISDIAGNOSIS AND DIFFICULTIES IN
MAKING THE ADHD DIAGNOSIS
The comorbidity, or presence of one or more additional
disorders, of ADHD is common, such that as many as
75% of children with ADHD also meet the criteria for
another psychiatric diagnosis (Barkley, 2006). In chil-
dren, disorders comorbid with ADHD include opposi-
tional defiant disorder, conduct disorder, mood disorders,
anxiety disorders, and learning disabilities, among others
(Biederman, 2005; Milberger, Biederman, Faraone, Murphy,
& Tsuang, 1995; Pliszka, 1998). Several studies reported
similar comorbidity patterns in gifted and nongifted indi-
viduals with ADHD (Antshel et al., 2007, 2008; Cordeiro
et al., 2011; Katusic et al., 2011). What is more, the
misdiagnosis of ADHD as other psychiatric disorders and
issues also occurs. Researchers have explored the possi-
bility of an ADHD misdiagnosis regarding a variety of
disorders and conditions, including obsessive–compulsive
disorder (Abramovitch, Dar, Mittelman, & Schweiger,
2013), bipolar disorder (Chilakamarri, Filkowski, & Ghaemi,
2011), scotopic sensitivity/Meares-Irlen syndrome (Loew &
Watson, 2013), lead poisoning (Turner, Dilks, Mayeaux, &
Marceaux, 2005), vision impairment (Granet, 2014), mania
(Biederman & Jellinek, 1998), and pervasive developmental
disorder (Perry, 1998).
In addition to the many overlapping symptoms between
ADHD and other psychiatric disorders and issues (e.g., dif-
ficulty sustaining attention, noncompliance), other factors
complicate the diagnosis of ADHD. For example, the rela-
tive age of children influences whether they are diagnosed
and treated with ADHD, such that the youngest children in
a classroom are significantly more likely to be diagnosed
with ADHD and prescribed medication than their peers in
the same grade level (Morrow et al., 2012). Younger chil-
dren in any given elementary school grade level may appear
immature compared to their older peers, sometimes prompt-
ing a referral for an ADHD evaluation. Researchers have also
indicated that the sex of the child plays a role in diagnos-
tic decisions, such that boys are more likely to be diagnosed
with ADHD than girls (Bruchmüller, Margraf, & Schneider,
2012). Girls with ADHD tend to exhibit lower levels of
externalizing and disruptive behavior and higher levels of
internalizing symptoms and inattentiveness. These symp-
toms are less likely to be disruptive in a classroom setting
and so are more likely to be overlooked (Gaub & Carlson,
1997; Gershon, 2002). Ethnicity also matters. The diagnos-
tic validity of DSM-IV disorders varies across racial and
ethnic groups (Green et al., 2012). Despite equal likelihood
to display behaviors characteristic of ADHD in the class-
room, pre-kindergarten children who are Black or raised
in non-English-speaking households are much less likely
to be diagnosed with ADHD than otherwise similar White
children (Morgan, Hillemeier, Farkas, & Maczuga, 2014).
Similarly, ethnic minority children in kindergarten through
eighth grade are much less likely to receive an ADHD diag-
nosis than otherwise identical White children (Morgan, Staff,
Hillemeier, Farkas, & Maczuga, 2013): the odds of diag-
nosis for African Americans, Latinos, and other ethnicities
were 69, 50, and 46% lower than for Whites. Differences

were similar for boys and girls across ethnicities. Possible
explanations include language barriers, unfavorable parental
attitudes toward mental health services, or a lack of cul-
tural sensitivity on the part of clinicians. Finally, because
of variations in diagnostic decision making and assessment
instruments, ADHD may be diagnosed more often than it
would be if the DSM criteria were properly utilized and/or
if reliable and valid assessment instruments were utilized
(Posserud et al., 2014). Studies of assessment and diagnos-
tic decision making show that psychologists and physicians
often make a diagnosis of ADHD without a comprehen-
sive assessment (Handler & DuPaul, 2005; Wasserman et al.,
1999). The potential for misdiagnosis, then, is definitely
plausible.
Hartnett et al. (2004) conducted the first empirical
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study to illustrate the potential misdiagnosis of ADHD
and giftedness. Hartnett et al. theorized that a number of
issues common to gifted children would complicate the
ADHD misdiagnosis because of an overlap in symptoms
or behaviors characteristic of giftedness and those charac-
teristic of ADHD, including high activity levels, difficulty
paying attention, and impulsivity. Among the gifted, these
behaviors can be explained by asynchronous development
(Silverman, 1997), boredom in the classroom (Gallagher,
Harradine, & Coleman, 1997; Webb & Latimer, 1993),
or overexcitabilities (Dabrowski, 1964; Mendaglio, 2008),
among other explanations. Hartnett et al. (2004) examined
whether graduate students enrolled in a master’s-level school
counseling program had tendencies to interpret identical
behaviors that were characteristic both of ADHD and of
a gifted child (e.g., daydreaming, impulsivity) in such a
fashion that a focus on pathology (i.e., ADHD) was more
prevalent. The participants in the study each read an identi-
cal vignette describing a hypothetical child with overlapping
characteristics of ADHD and giftedness:
Sam is 7 years old and a second grader. He has been referred
to you for assessment by his teacher. He has a high activ-
ity level and appears more restless than other children his
age. Sam has difficulty restraining his desire to talk in the
classroom and interrupts you frequently. You have repeatedly
tried to change Sam’s behavior, but Sam questions authority
and he has a difficult time accepting rules and regulations.
Sam’s homework is frequently messy because he appears
careless or inattentive to details. Sam has a poor attention
span, especially when he is bored. Sam’s home environment
appears to be normal. (Harnett et al., 2004, p. 75)
Hartnett et al. (2004) found that participants were more
likely to provide a diagnosis of ADHD, even when the
suggestion of giftedness as an alternative diagnosis was pre-
sented. The researchers concluded that graduate students
in this school counseling graduate program may not be
receiving training regarding the similarities and differences
GIFTEDNESS AND ADHD 197
between children who are gifted and those who have ADHD,
which could result in a misdiagnosis.
Rinn and Nelson (2008) replicated the Hartnett et al.
(2004) study using a sample of preservice teachers. Because
teachers are often the first to identify students who may
be eligible for gifted programming, and because physi-
cians often request information from children’s teachers
regarding characteristics of ADHD in the classroom (Tripp,
Schaughency, & Clarke, 2006), Rinn and Nelson (2008) con-
cluded that the ability of preservice teachers to distinguish
between giftedness and ADHD is an important skill to have
prior to becoming an inservice teacher. In their study, Rinn
and Nelson (2008) again found that preservice teachers were
more likely to provide a diagnosis of ADHD, even when
the suggestion of giftedness as an alternative diagnosis was
presented.
Rinn and Reynolds (2012) further explored the relation-
ship between characteristics of giftedness, overexcitabilities,
and ADHD among a sample of 116 gifted adoles-
cents. In examining self-report measures of ADHD and
overexcitabilities among a sample of gifted adolescents
who did not have a diagnosis of ADHD, Rinn and
Reynolds (2012) found significant correlations between the
psychomotor overexcitability scores, the sensual overex-
citability scores, and the imaginational overexcitability
scores and various subscales of the Conners’ ADHD/DSM-
IV Scales–Adolescent (Conners, 2001). The findings illu-
minate a potential relationship between the characteris-
tics of overexcitabilities and the symptoms of ADHD.
The researchers concluded that “the potential exists for
gifted individuals to be incorrectly labeled with a diag-
nosis of ADHD” because of a “lack of awareness of
the characteristics of giftedness, specifically expressions of
overexcitabilities, and a predisposition to view these behav-
iors as indicative of the presence of ADHD” (Rinn &
Reynolds, 2012, p. 44). Goerss, Amend, Webb, Webb, and
Beljan (2006), in their support of the original research of
Hartnett et al. (2004), sum up the misdiagnosis issue well
by saying, “What you do not know, you do not recognize”
(p. 249).
DUAL DIAGNOSIS
Giftedness and ADHD coexist in some children. Until
the most recent decade, individuals diagnosed with both
giftedness and ADHD drew little attention in educational
research and programming. Recent evidence supports the
validity of dual diagnosis. Antshel et al. (2007) noted that
gifted children with ADHD show a pattern of cognitive, psy-
chiatric, and behavioral characteristics consistent with the
diagnosis of ADHD documented in children of average IQ.
Cordeiro et al.’s (2011) findings also validated dual diagno-
sis; 10 of the 15 intellectually gifted children in their clinical
study met DSM-IV criteria for ADHD. Parallel patterns
 198 D. R. MULLET AND A. N. RINN
of cognitive and social impairment, family history, and
comorbidity in gifted children and nongifted children with
ADHD also support the validity of dual diagnosis (Katusic
et al., 2011).
The prevalence of ADHD in gifted populations is also
consistent with ADHD in the general population. Antshel
(2008) suggested that 10% of individuals with ADHD are
also gifted. A similar finding from a study of gifted Korean
children estimated a 9.4% rate of ADHD in the gifted popu-
lation (Chae, Kim, & Noh, 2003). Jarosewich and Stocking
(2002) estimated a 3.1% rate of ADHD in the gifted popula-
tion, but that estimate was based on a sample of gifted stu-
dents enrolled in a summer residential enrichment program
and therefore may lack generality.
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Interactions Between ADHD and Giftedness
Dual diagnosis of ADHD and giftedness can be frustrating
to children who sense their elevated potential yet struggle
to reach it. In dually diagnosed children, the individual’s
strengths and disabilities interact in such a way that one
of the exceptionalities obscures the other. Three scenarios
describe the interaction effect. First, when ADHD masks
giftedness, the child’s behavior and academic performance
may appear average or below average. In this case, the
child may be recognized as having ADHD but not as being
gifted. In the second scenario, giftedness masks ADHD.
In this scenario, the student uses strengths advantageously to
compensate for impairments. These students are often recog-
nized for their gifts but go unrecognized for their disability.
A third scenario occurs when giftedness and ADHD inter-
act reciprocally, essentially hiding one another. When this
happens, the child may appear average both academically
and behaviorally and is unlikely to be recognized for either
exceptionality.
Few studies have addressed the first scenario (ADHD
masks giftedness). Existing studies have reported socioe-
motional and cognitive outcomes but have not directly
addressed the masking effect of ADHD on academic per-
formance. Foley-Nicpon, Rickels, Assouline, and Richards
(2012) noted that dually diagnosed children displayed lower
self-esteem than did their gifted peers without ADHD.
Antshel and colleagues (2008) found that dually diagnosed
children were more likely to present mood, anxiety, and dis-
ruptive behavior disorders than their gifted peers without
ADHD. When ADHD coexists with giftedness, ADHD may
impair executive functions including working memory, pro-
cessing speed, and auditory verbal memory (Brown, Reichel,
& Quinlan, 2011). Executive function impairment may rep-
resent substantial difficulty in achieving a level of academic
achievement consistent with the child’s intellectual ability.
The literature has given more attention to the second
scenario (giftedness obscures ADHD). In this scenario, the
child is at risk of failing to be referred for special education
services. Zentall, Moon, Hall, and Grskovic (2001) noted
that gifted children compensated for ADHD impairments but
only to the point of average performance. Dually diagnosed
children still experienced academic underachievement, diffi-
culty organizing, and difficulty maintaining attention. Zentall
and colleagues (2001) noted, however, that dually diag-
nosed children’s specific talents in academic, creative, and
learning areas could protect long-term outcomes when culti-
vated in talent development programs. Some research sug-
gests that intellectual giftedness protects creativity when
ADHD is present (Fugate, Zentall, & Gentry, 2013; Healey
& Rucklidge, 2006; Zentall et al., 2001). Another study
reported that giftedness insulates children from verbal mem-
ory impairment associated with ADHD (Whitaker, Bell,
Houskamp, & O’Callaghan, 2015).
Notably, we found no research examining bidirectional
interactions between ADHD and giftedness. Closer exam-
ination of these interaction scenarios is a precondition to
designing effective educational policies and services for
dually diagnosed students. Because interactions between
giftedness and ADHD are insufficiently understood, gifted
students with ADHD typically receive treatment and sup-
port for ADHD relatively late in their academic careers
(Brown, 2014). Another problem arises when the child’s
gifted status raises parent and teacher expectations to levels
unreasonable for a dually diagnosed student (Zentall et al.,
2001). Emotions may represent an additional interaction:
students who fail to meet parent and teacher expectations
are likely to experience negative emotions. Brown (2014)
argued that emotion mediates the ability of gifted individu-
als with ADHD to compensate for cognitive weaknesses with
strengths.
Dual Diagnosis Profile
We explored the current empirical literature for patterns
of characteristics that discriminate gifted individuals with
coexisting ADHD from their gifted peers without ADHD.
We identified and summarized cognitive, social, emotional,
functional, family historical, and neurobiological patterns
unique to dual diagnosis.
Cognitive Function
Antshel (2008) summarized previous findings that indi-
cate that by having ADHD, gifted children are less
likely to perform in the gifted range on the Wechsler
Intelligence Scale for Children (Wechsler, 1991). The
Wechsler Full-Scale IQ Test includes processing speed
and working memory measures that may depress scores
in children with ADHD (Raiford, Weiss, Rolfhus, &
Coalson, 2005). As reported by Chae et al. (2003),
gifted children with ADHD scored lower on the Korean
Educational Development Institute–Wechsler Intelligence
Scale for Children (Park, Yoon, Park, Park, & Kwon, 1987)
Coding subtest, a measure of visual–motor speed and fine
 GIFTEDNESS AND ADHD 199

motor coordination. Chae et al.’s (2003) findings suggest that
gifted children with ADHD have difficulty performing psy-
chomotor speed tasks despite their cognitive strengths. Chae
et al. noted that gifted children with and without ADHD per-
formed similarly on measures of working memory, whereas
Antshel et al. (2007) reported that gifted children with
ADHD scored significantly lower than their gifted counter-
parts without ADHD. Both findings may have been affected
by limitations. Because Chae et al. used an IQ of at least
130 as the gifted inclusion criterion, the sample included
highly gifted children (M = 138.4, SD = 7.18). Highly
gifted children are more likely to be misdiagnosed with
ADHD as a result of their elevated intellectual drive, higher
capacity for hyperfocus, and greater susceptibility to bore-
dom (Antshel, 2008). Antshel et al. (2007) used an outcome
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relative to their own cognitive abilities and the rate of impair-
ment in this group was greater than in the general population.
Whitaker et al. (2015) compared strategic verbal memory in
gifted children with ADHD, gifted children without ADHD,
and nongifted children with ADHD and found impairment in
gifted children with ADHD despite their cognitive strengths.
Whitaker et al. noted that when verbal memory tasks were
supported with organizational cues (for example, a clus-
tered as opposed to unclustered list of words), both gifted
and nongifted children with ADHD showed similar gains
in verbal memory performance. However, when the cues
were removed, gifted children generalized the strategy to
new tasks and maintained their performance gains, whereas
nongifted children regressed to initial performance levels.
In effect, giftedness may insulate children from strategic

variable (Block Design score) as a sampling criterion and memory dysfunction associated with ADHD.
consequently increased the risk of failure to detect signifi-
cant group differences. Both findings should be considered Social and Emotional Patterns
preliminary.
Antshel et al. (2008) noted that social problems per-
Executive function can be defined as a set of con-
sisted over time in gifted youths with ADHD. According
trol mechanisms that prioritize, consolidate, and modulate
to Willard-Holt, Weber, Morrison, and Horgan (2013),
other cognitive functions. Examples of executive func-
self-concept problems continue into early adulthood; for
tion skills include planning and organizing, sustaining and
instance, gifted college students declined ADHD accommo-
shifting attention, sustaining effort and alertness, manag-
dations to avoid being singled out. Early recognition and
ing emotions, and using working memory (Brown, Reichel,
treatment of low self-esteem in gifted children with ADHD
& Quinlan, 2009). Executive function impairments have
may avert social problems and improve later academic and
been observed in gifted children with ADHD. For exam-
professional outcomes (Foley-Nicpon, Rickels, Assouline, &
ple, ADHD-related executive function impairments inhibit a
Richards, 2012).
gifted child’s ability to self-manage emotions and behavior.
Zentall et al. (2001) described delayed social and emo-
Executive function impairment increases the risk of long-
tional maturity in gifted boys with ADHD relative to their
term educational and occupational failure (Brown et al.,
own intellectual and imaginational strengths. In a related
2011). Brown et al. (2011) cited evidence suggesting execu-
study, Moon, Zentall, Grskovic, Hall, and Stormont (2001)
tive function and IQ skills are only weakly correlated and
noted that giftedness appeared to intensify rather than buffer
noted that IQ tests inadequately assess executive function
social and emotional problems associated with ADHD;
skills. Brown et al. (2009) asserted that executive func-
gifted boys with ADHD had more emotional difficulties
tions are interdependent; moreover, clinical research sug-
relative to both nongifted peers with ADHD and gifted
gests that environmental and emotional factors moderate the
peers without ADHD. Specifically, dually diagnosed boys
relationship between intelligence and executive functioning
displayed immaturity, irresponsible behavior, and annoy-
in individuals with ADHD. Traditional neuropsychological
ing behavior that contributed to social rejection in their
assessments, however, attempt to isolate the executive func-
gifted classrooms. Similarly, Chae et al. (2003) found that
tions from other neurological functions and from one another
social skills of gifted children with ADHD were poorer
(Brown et al., 2009). In essence, executive function plays an
than those of their gifted counterparts without the diagnosis.
important but limited role in the profile of gifted children
Dually diagnosed students observed by Cordeiro et al. (2011)
with ADHD.
all displayed significant but subclinical levels of social
To demonstrate that gifted children with ADHD suffer
problems.
from executive function impairments, Brown et al. (2011)
Foley-Nicpon et al. (2012) compared self-concept and
compared gifted youths with ADHD against published
self-esteem in gifted children with and without ADHD
norms on eight standard measures of executive function:
and found gifted children with ADHD had substantially
working memory, processing speed, verbal auditory memory,
lower self-esteem, self-concept, and overall happiness than
activation, focus, effort, emotion, and memory utilization.
those without ADHD. Gifted children with and with-
Sixty-two percent of gifted children in the study were signifi-
out ADHD, however, were similar on self-reported intel-
cantly impaired on at least five of the eight executive function
ligence, anxiety, popularity, and physical self-concept.
measures despite their cognitive strengths; overall, dually
Foley-Nicpon et al. charged that the connection between
diagnosed children were substantially impaired in work-
ADHD and happiness in gifted students warrants further
ing memory, processing speed, and auditory verbal memory
examination.
 200 D. R. MULLET AND A. N. RINN
Comorbidities
Evidence suggests that dually diagnosed children have
higher rates of comorbidities than their gifted peers with-
out ADHD. Antshel et al. (2007) reported higher rates of
major depression, generalized and separation anxiety disor-
ders, social phobia, and conduct disorder in gifted children
with ADHD than without. Antshel and colleagues pointed
out that high rates (greater than 50%) of conduct disorder and
major depression observed in gifted children with ADHD
warrant further examination to rule out comorbidities as a
cause of academic underachievement. Brown et al. (2011)
found significant cooccurrences of one or more psychiatric
disorders including depression, obsessive–compulsive disor-
der, and Asperger’s syndrome in dually diagnosed children.
Cordeiro et al. (2011) observed at least one additional comor-
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bid mood, learning, or behavior disorder in eight of the
10 dually diagnosed children in their study.
Dual Diagnosis and Academic Performance
Though academic underachievement has been cited as a
concern for gifted students with ADHD, only a few empir-
ical studies have examined this problem. In a case study,
Zentall et al. (2001) compared learning and motivational pro-
files of three groups of boys: (a) gifted boys with ADHD,
(b) gifted boys without ADHD, and (c) nongifted boys
with ADHD. They noted that gifted boys with ADHD were
more likely to underachieve, avoid homework, and experi-
ence difficulty initiating tasks and staying on task. Cordeiro
et al. (2011) used a multidisciplinary approach in their case
study of 15 gifted children referred for behavior or learn-
ing difficulties. The children completed a comprehensive set
of psychiatric, psychological, and pedagogical assessments
including tests of intelligence, ADHD, and psychiatric dis-
orders. Ten participants had the dual diagnosis. All 10 dually
diagnosed children showed significant academic impairment,
and seven of those 10 performed poorly on standardized tests
of reading, writing, or math. Brown et al. (2011) reported
similar reading achievement scores for gifted children with
and without ADHD, but the gifted children with ADHD
scored lower on a math achievement test. Gifted students
with ADHD may repeat grades more often. Antshel et al.
(2007) observed a 20% retention rate for gifted students
with ADHD in comparison to gifted peers without ADHD.
Similarly, Brown et al. (2011) found gifted children with
ADHD more likely to have been retained a grade, to be
placed in a special education setting, or to have received aca-
demic tutoring. Foley-Nicpon, Allmon, Sieck, and Stinson
(2011) noted that gifted students with ADHD may succeed
or even excel academically until demands exceed their ability
to compensate with intelligence, creativity, or talent.
Creatively Gifted with ADHD
Cramond (1994) assessed creativity in children with
ADHD and ADHD in highly creative children. Children
with ADHD performed more than one standard deviation
above the test mean on elaboration, defined as a style of
creative response that involves adding substantial detail to
an idea. Further, Cramond (1994) reported that 26% of
the highly creative children also met the screening crite-
ria for a diagnosis of ADHD, despite teachers’ reports of
normal levels of inattention, hyperactivity, and impulsiv-
ity. Zentall et al. (2001) likewise found that gifted students
with ADHD demonstrated more creative ability than gifted
students without ADHD. Healey and Rucklidge (2006) com-
pared creatively gifted children with and without ADHD
and found that ADHD occurred more frequently among cre-
atively gifted children: 40% of creatively gifted students
displayed significant levels of ADHD symptomology ver-
sus 9% expected in the general population. Healey and
Rucklidge (2006) noted that full-scale IQ, working mem-
ory, and executive functioning were equivalent in creative
children with and without ADHD, yet creative children with
ADHD were impaired in processing speed and reaction time
compared to their peers without the diagnosis. Parents of
creative children with ADHD rated their children higher
on inattentiveness and hyperactivity, but neither parent nor
teacher ratings indicated cognitive impairment. The authors
concluded that what distinguishes creative children from
children with ADHD may be their higher ability to process
and use information they cannot selectively filter.
Fugate et al. (2013) compared creativity and working
memory in gifted students equivalent in fluid intelligence,
with and without ADHD. Despite poorer working memory,
gifted students with ADHD were substantially more creative
than gifted peers without ADHD. Forty-one percent of dually
diagnosed students scored at or above the 90th percentile and
more than half scored at or above the 70th percentile on the
Torrance Tests of Creative Thinking (Torrance, 1966, 2006).
A compelling finding was the negative relationship between
working memory and creativity in both groups; poorer work-
ing memory was associated with higher creativity. Fugate
and colleagues (2013) noted that their finding contradicts
previous evidence of a positive association between working
memory and creativity. Fugate et al. concluded that dually
diagnosed students’ inability to filter peripheral cues may
enhance creative performance. Notably, Fugate et al.’s evi-
dence of a positive relationship between intelligence and
creativity challenges the threshold concept, or the idea that
the positive relationship between intelligence and creativity
disappears above a threshold IQ of 120 (Torrance, 1962).
Stability of Dual Diagnosis
Cordeiro et al. (2011) reported consistent psychopatho-
logical attributes and functional impairments across settings
in dually diagnosed children. Antshel et al. (2008) analyzed
longitudinal data from cohorts of gifted youths with and
without ADHD and found at the 4.5-year follow-up, 78% of
youths in the ADHD cohort had maintained ADHD status.

IQ was equally stable over time in both cohorts, and gifted
youth with ADHD were no more likely to lose gifted status
than gifted peers without ADHD.
Familial Patterns
Antshel et al. (2007) compared family histories of ADHD
in first-degree relatives of gifted children with and without
ADHD. ADHD was more common in the families of gifted
children with ADHD. Twenty-three percent of first-degree
relatives of gifted children with ADHD met diagnostic cri-
teria for ADHD compared to 5.6% of first-degree relatives
of gifted children without ADHD. Similar rates have been
reported in nongifted individuals with ADHD.
Perceptions of Others
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Investigations into others’ perceptions of dually diag-
nosed children have reported varied findings. Edwards
(2008) observed that parents of gifted children with ADHD,
not their teachers, identified the children as underachieving.
Chae et al. (2003) reported that 13.2% of their sample of
gifted children were rated by parents and teachers as hav-
ing ADHD according to a behavior checklist, yet did not
meet clinical criteria for a diagnosis of ADHD. Chae et al.
suggested that gifted children might be rated impulsive or
inattentive by parents and teachers when they fail to focus
on routine tasks. Similarly, Antshel (2008) found that parents
of gifted children with ADHD rated their children higher in
psychopathology and dysfunction than did parents of gifted
children without the diagnosis. Brown et al. (2011) pointed
out that parents are often told by educators and practition-
ers that ADHD does not occur in gifted children and thus
may be reluctant to accept a dual diagnosis. For example,
Wood (2012) noted that parents and teachers of gifted chil-
dren referred for ADHD evaluation indicated only average
levels of concern for inattention, hyperactivity, and exec-
utive function. Willard-Holt et al. (2013) reported gifted
college students’ accounts of struggling to have their ADHD
validated. The parents of one dually diagnosed student in
Willard-Holt et al.’s study denied the validity of her disabil-
ity. This created in the student a misconception that all adults
denied her ADHD diagnosis. Another dually diagnosed stu-
dent explained that she was never recognized as having
ADHD as a child because she was quick to grasp concepts.
These findings underscore how important it is for practi-
tioners to understand the characteristics of ADHD and their
presentation among gifted children (Reis, Baum, & Burke,
2014).
Foley-Nicpon, Assouline, and Colangelo (2013) surveyed
317 educators on their familiarity with ADHD in gifted stu-
dents and found that 49% of respondents had specific famil-
iarity, 36% had some familiarity, and 15% had either passing
or no familiarity. Regarding their experience working with
gifted students with ADHD, 22% of respondents indicated
extensive experience, 39% indicated moderate experience,
GIFTEDNESS AND ADHD 201
31% indicated some experience, and 8% indicated no expe-
rience. Gifted–talented specialists were more familiar with,
and experienced in, working with gifted students with
ADHD than classroom teachers, special education teach-
ers, or school psychologists. Foley-Nicpon et al.’s (2013)
findings are positive but they warrant further professional
development for classroom teachers, school psychologists,
and others who work with gifted children.
Neurobiological Patterns
Kalbfleisch (2001) used electroencephalography to com-
pare gifted and nongifted boys with ADHD on their neural
efficiency to shift between tasks. Interestingly, gifted boys
with ADHD were more impaired than nongifted boys with
ADHD when shifting between divergent thinking tasks.
Kalbfleisch contended that gifted children with ADHD
need help developing compensation skills that facilitate
transitions. Kalbfleisch’s findings help explain the hyper-
focused behavior described anecdotally in gifted children
with ADHD; because of their aptitude for higher-level
thinking afforded by high ability, it might be more diffi-
cult for these children to disengage from divergent think-
ing tasks. Kalbfleisch concluded that the propensity of
gifted boys with ADHD to maintain intense focus on tasks
involving higher-level thinking is a cognitive benefit of
ADHD.
ADHD AND GIFTEDNESS: DIFFERENTIAL
DIAGNOSIS
Given the possibility for both misdiagnosis and dual diagno-
sis, it is important to present information relevant in making
a differential diagnosis or a way to identify the presence of a
disorder or condition when multiple alternatives are possible
or appear possible.
Behavior checklists are often used to provide evidence
for a diagnosis of ADHD, yet a number of scholars believe
that relying on behavior checklists or behavioral mark-
ers is an insufficient way to identify ADHD in gifted
children (Budding & Chidekel, 2012). Behavior checklists
largely address the expression of behavior rather than the
cause of behavior. For example, whereas nongifted chil-
dren with ADHD generate kinesthetic and sensory activ-
ity when understimulated, gifted children with ADHD
generate cognitive activity instead (Zentall et al., 2001).
Such cognitive activity may be unobservable or subject
to misinterpretation if the accompanying physical behav-
ior is compliant; for example, a child engaged in imag-
inative thought may appear focused or attentive. Wood’s
(2012) exploratory study examined parent and teacher
perceptions of behaviors of gifted students with ADHD and
concluded that behavior rating scales failed to provide ade-
quate agreement for definitive dual diagnosis. Furthermore,
 202 D. R. MULLET AND A. N. RINN
discordance in parent and teacher ratings indicated that
symptoms might vary with context. Chae et al. (2003)
observed that behavior checklists resulted in significantly
more ADHD diagnoses than would be expected from clinical
evaluations.
A gifted student may have ADHD even when stan-
dardized measures of attention fail to indicate ADHD
(Foley-Nicpon et al., 2011). Brown et al. (2011) noted
that neuropsychological tests of executive function may
lack sensitivity to detect the full range of impairments
in gifted children with ADHD. Continuous performance
tests have also been found lacking sensitivity to detect
ADHD in gifted children. Chae et al. (2003) reported
that gifted children with and without ADHD performed
similarly on continuous performance tests; furthermore,
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gifted children with ADHD demonstrated fewer commis-
sion and omission errors and less response variability
than nongifted children with ADHD. Chae et al. sug-
gested that higher norms on continuous performance tests
might be necessary for detecting ADHD in gifted chil-
dren. Park et al. (2011) compared gifted and nongifted
children with ADHD on a visual–auditory continuous per-
formance test and found that gifted children with ADHD
performed better despite equivalent ADHD symptom sever-
ity; differences between the groups were more pronounced
on auditory variables. Park et al. concluded that predic-
tive validity of the continuous performance test was lower
for gifted children with ADHD than for nongifted children
with ADHD. Overall, these findings suggest that continu-
ous performance tests may fail to detect ADHD in gifted
children.
Comprehensive clinical and psychological evaluation
avoids confounding ADHD symptoms with ADHD-like
gifted behaviors (Brown et al., 2011; Cordeiro et al., 2011).
Teachers, parents, and diagnosticians should consider the
situation in which a child exhibits characteristics such
as inattention and impulsivity in order to more clearly
distinguish between behaviors associated with giftedness,
behaviors associated with ADHD, and behaviors associ-
ated with being twice exceptional. For example, if appro-
priate academic placement diminishes problem behavior,
or problem behavior only occurs in one setting, such as
school, but not in other settings (e.g., home, extracur-
ricular sports activities), ADHD may not be a concern.
Recently, the National Commission on Twice Exceptional
Students adopted a definition of twice-exceptional learners
that includes gifted students with ADHD. The new defini-
tion states that “identification of twice-exceptional learners
requires comprehensive assessment in both the areas of
giftedness and disabilities, as one does not preclude the
other” (Reis et al., 2014, p. 222) and advised identification
by professionals from both disciplines with knowledge about
twice-exceptionality.
INTERVENTIONS AND STRATEGIES IN
DEALING WITH A DUAL DIAGNOSIS
Most strategies and interventions for gifted children with
ADHD lack supporting evidence (Edwards, 2008), but
available evidence indicates that dually diagnosed children
respond well to targeted strategies. Though patterns of
behavior and cognitive impairment are similar in nongifted
and gifted children with ADHD, not all ADHD interventions
are appropriate for gifted children (Edwards, 2008).
Strength-Based Approaches
Hua, Shore, and Makarova (2014) contrasted deficit-focused
with strength-based strategies such as inquiry and problem-
based learning. Deficit-focused approaches, often driven by
Section 504 plans, help students cope with ADHD impair-
ments (Hua et al., 2014). Coping strategies may include
study habits, extra time on assignments, and breaking assign-
ments into smaller pieces. Gifted adolescents may feel stig-
matized by deficit-focused accommodations (Willard-Holt
et al., 2013). Furthermore, for dually diagnosed students,
typical strategies such as breaking tasks into simple parts
can cause frustration and inattentiveness (Moon, 2002). Hua
et al. (2014) argued that deficit approaches treat knowl-
edge as a commodity and may prevent dually diagnosed
students from connecting learning with deeper meaning.
Strength-based approaches, on the other hand, give pur-
pose and ownership to the student and enhance self-esteem.
Hua et al. (2014) asserted that inquiry-based learning in
the context of cognitive apprenticeship has strong posi-
tive effects on the academic outcomes of gifted students
with ADHD. Inquiry-based learning allows those students to
relinquish the underachiever identity, create a personal cog-
nitive framework around the problem, capitalize on idealism,
and assume new roles. Hua et al. (2014) believe, however,
that some teachers avoid strength-based strategies over worry
that students with ADHD, gifted or not, lack the requisite
organization and attention to succeed.
Talent development is a strength-based approach
with potential to improve long-term academic outcomes;
increased attention and persistence may help the student
overcome organizational problems (Zentall et al., 2001).
Edwards (2008) noted that gifted children with ADHD were
stimulated and engaged by tasks in their interest and talent
areas. Working in strength areas may induce hyperfocus
in dually diagnosed students; hyperfocus may orient the
student toward learning goals and thereby diminish barriers
to potential.
Fugate et al. (2013) argued that divergent thinking and
creativity may be compensatory strengths in gifted students
with ADHD and could be used to enhance educational
programming. Problem-based learning, creative writing,
 GIFTEDNESS AND ADHD 203

alternative assessments, and revisions of products for dif- Behavioral Strategies

ferent audiences are all strategies that demand divergent
Gifted individuals with ADHD are motivated by fear
thinking and may be particularly suited to dually diagnosed
of immediate negative consequences when performing
students.
uninteresting tasks and tend to procrastinate, often severely
(Brown et al., 2009). Behavioral interventions hold promise
Dually Diagnosed Students’ Perspective on What for gifted students with problem behaviors associated with
Works ADHD, such as procrastination and brinkmanship. The suc-
cess of behavioral interventions with gifted students may
Gifted elementary students with ADHD favored verbal
depend on the reinforcers; gifted students may prefer dif-
participation, hands-on involvement, and an active role
ferent reinforcers than are typically desired by nongifted
in the selection of tasks and learning conditions (Zentall
students (Foley-Nicpon et al., 2011).
et al., 2001). Edwards (2008) observed that gifted stu-
Single-subject research designs are useful when work-
dents with ADHD preferred strategies involving tasks that
ing with small, exceptional cohort groups such as twice-
were interesting, visual, purposeful, allowed movement, and
exceptional students (Walsh & Kemp, 2013) by allowing the
involved use of the computer. Most dually diagnosed stu-
application of a learning strategy while systematically col-
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dents preferred tasks that resulted in a tangible product,

lecting data on its efficacy (Simonsen & Little, 2011). The
possibly because such tasks have clear purpose. These stu-
reversal design, or ABAB design, is a single-case experiment
dents preferred to move freely around the classroom but
that involves the sequential application and withdrawal of an
also indicated a desire for structure and limited choices.
intervention to verify its effect. The ABAB design begins
Teachers can enhance learning by incorporating appropri-
with a baseline phase (A) followed by a treatment phase (B),
ate ways to move around the classroom into the curriculum.
a return to baseline (A), and another treatment phase (B).
Although computer use can be beneficial, parents indi-
An ABAB experiment could be used to study the effect of a
cated that overuse of the computer could lead to their
self-management strategy on the on-task behavior of a gifted
children’s anger and frustration; Edwards (2008) advised
student with ADHD. The teacher would begin by record-
setting time limits at the computer for gifted children with
ing baseline on-task behavior for several days (A). After
ADHD.
teaching the student how to apply the strategy, the teacher
would record on-task behavior with the strategy in place (B).
Classroom Strategies Finally, the teacher would repeat the baseline (A) and treat-
ment (B) phases. An effective strategy would be one that
Antshel et al. (2009) advised that teachers be aware of
improves the student’s behavior with each introduction of
discrepancies between ability and performance in gifted
the strategy.
students with ADHD and set expectations based on abil-
ity, not past performance. Zentall et al. (2001) empha-
sized the need for teachers not to limit assignments to Medical Intervention
rote, repetitive tasks because of the student’s need for
Katusic et al. (2011) reported similar rates of stimulant
challenge. Gifted elementary students with ADHD bene-
treatment, age at treatment onset, and treatment duration
fit from complex assignments, shorter assignments, more
in intellectually gifted, average, and below average chil-
direction, reminders and cues, frequent feedback, incen-
dren with ADHD. Grizenko, Zhang, Polotskaia, and Joober
tives for persistence, and performing a helper or leader
(2012) compared gifted, average, and below-average chil-
role. Zentall et al. found that the most helpful motiva-
dren with ADHD on their response to stimulant treatment
tional strategy for gifted boys with ADHD was a teacher’s
in a double-blind, placebo-controlled medical trial. Similar
individual attention and personal interest. Working mem-
response to treatment was observed across all participants,
ory deficits may pose a challenge for gifted students with
although the gifted children with ADHD presented less
ADHD during classroom discussions; writing out responses
severe symptoms than the other two groups. Grizenko et al.
in advance may help compensate (Willard-Holt et al., 2013).
(2012) suggest that stimulant treatment may be appropriate
Organizational cues such as graphic organizers and mem-
and helpful for gifted children with ADHD.
ory strategies were demonstrated to have long-term posi-
tive effects on dually diagnosed students’ working memory
(Whitaker et al., 2015). Further, dually diagnosed students
LIMITATIONS AND SUGGESTIONS FOR
benefited from additional time to complete assignments pro-
FUTURE RESEARCH
vided that the time was structured. Structural and organiza-
tional supports may improve access to higher-level reasoning
The empirical studies in our review varied in design and
abilities for these students when learning new concepts and
approach. The majority of studies were quantitative; others
behaviors.
 204 D. R. MULLET AND A. N. RINN
used mixed methods or were qualitative. A common lim-
itation involved the use of small or convenience samples.
Small samples limit statistical power and increase the like-
lihood of failing to detect significant effects. Findings based
on convenience samples cannot be generalized outside the
sample population because participants may differ system-
atically from the target class of interest in the general
population. For example, gifted students recruited from sum-
mer residential programs for high-ability students may differ
socioeconomically from gifted students who do not enroll
in those programs. Similarly, clinically referred samples
are more likely to represent persons with coexisting dis-
abilities (Fugate et al., 2013). Another common limitation
was lack of careful experimental control. Control varied
across studies and included comparison groups of gifted
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children with and without ADHD, gifted and nongifted chil-
dren with ADHD, or more than two groups. Several studies
excluded controls and, instead, compared participants with
published age-based norms. Overlapping gifted and ADHD
characteristics complicated research designs, making it dif-
ficult to rule out plausible alternative causes of observed
effects. Despite those limitations, it is important to recognize
that small populations, such as our population of interest,
offer few opportunities for rigorous statistical analyses or
experimental research designs. Smaller studies explore new
phenomena, offer preliminary findings, and suggest future
directions for research.
Definitions of giftedness and ADHD varied across
studies. Most used a full-scale IQ score of at least
120 to determine giftedness eligibility. Other studies used
General Intelligence Index, Verbal Comprehension Index,
or Perceptual Organization Index scores from the Wechsler
Intelligence Scale for Children (Wechsler, 1991). Other types
of giftedness such as creativity and talent were seldom inves-
tigated, and studies of highly gifted children with ADHD
were absent. Eligibility for an ADHD diagnosis varied across
studies and included behavior rating checklists, executive
functioning measures such as continuous performance tests,
and professional clinical diagnoses based on multiple assess-
ments.
Future research should address these noted limitations
to strengthen the conclusions drawn. Foley-Nicpon et al.
(2011) recommended further research into effects of gifted
programs such as acceleration on dually diagnosed students’
self-esteem and self-concept. Similarly, Antshel et al. (2007)
suggested further research into relationships between gifted
program participation, achievement, and social adjustment
of gifted students with ADHD. Remaining questions include
the effects of dually diagnosed children’s identity as gifted
on academic and social functioning (Foley-Nicpon et al.,
2012), differences between highly and moderately gifted
individuals with ADHD (Katusic et al., 2011), and the rela-
tionship between ADHD and other forms of giftedness such
as creativity and talent (Fugate et al., 2013). Questions also
remain regarding effects of multiple comorbidities in dually
diagnosed children. Antshel et al. (2007) recommended
longitudinal studies exploring how giftedness protects chil-
dren from ADHD over the course of development. Fugate
et al. (2013) recommended replication with a larger sample,
improved controls, and a wider range of IQ to better under-
stand the relationship between intelligence and creativity.
CONCLUSION
It is vital that ADHD remain a diagnosis of exclusion.
Though misdiagnosis is a recognized problem, giftedness
and ADHD also occur together. Characteristics shared
between ADHD and giftedness can make it difficult
to tell the two conditions apart. What is more, when
the two conditions coincide, they interact in unfamiliar
ways that blur distinctions and disguise both conditions.
Kaufmann, Kalbfleisch, and Castellanos (2000) noted that
gifted children’s overreliance on strengths inadvertently
obscures ADHD impairments and may lead to diagnostic
errors of omission. Accurate identification is challenging.
Distinguishing between giftedness, ADHD, and the combi-
nation of the two is not so much a need to identify symptoms
as it is to identify a fingerprint: a set of characteristics and
their interaction that, together, form the basis for a diagno-
sis. There is no one litmus test. Of the adults who make up a
child’s support structure, teachers most frequently find them-
selves in the position of concluding which students are likely
prospects for special educational programming. Teachers are
not trained diagnosticians, nor are they expected to make
diagnostic decisions. However, teachers frequently lack the
specialized training needed to recognize subtle distinctions
between gifted characteristics and ADHD symptoms when
the two overlap. In dually diagnosed children, giftedness
insulates the child from ADHD impairments to some degree.
This masking effect mitigates some observable ADHD char-
acteristics and can reduce the sensitivity of ADHD tests
when used with gifted children. Though research in this
area has increased, there remains an unmistakable need for
more empirical research. Future research should seek to
identify interactions between gifted and ADHD character-
istics and other comorbidities, evaluate the responsiveness
of dually diagnosed children to various interventions and
programs, examine the effects of professional training on
teacher perceptions, and give attention to highly gifted and
highly creative children with ADHD.
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AUTHOR BIOS

Dianna R. Mullet is a doctoral student in educational psychology at the University of North Texas. Her research
interests relate to special populations of gifted and talented students, including students with learning disabilities,
gifted females, and diverse groups of gifted students. E-mail: dianna.mullet@gmail.com

Anne N. Rinn, PhD, is an associate professor of educational psychology and coordinator of the Graduate Programs
in Gifted and Talented Education at the University of North Texas. Her research focus is on the social and emotional
needs of gifted and talented individuals. She has numerous scholarly publications in the fields of gifted educa-
tion and educational psychology and is an active member of the National Association for Gifted Children. E-mail:
Anne.Rinn@unt.edu