Patient Presentation
An 8-year-old female came to clinic for her health supervision visit. She was doing well and but was having problems with her math and some reading. She said she really liked school and her friends and teachers, but it was hard for her to do the work sometimes. Her mother explained that the teachers were concerned enough that they had initiated an educational evaluation for her. “They think she can do better but I see how she works. It takes a long time and I’m not sure she actually is reading but seems to fill in the words that could be correct. Like she was reading a Star Wars book. The word was empty but she read empire. Her papers are really messy and I can see why the math would be hard. Her numbers are all over the page, ” the mother explained. “I also don’t understand it because they tested all the kids last year and now she is in the gifted and talented class too. I’m not sure what to think,” the mother said. The past medical history showed that she had been evaluated for possible attentional problems at age 6 but was not found to have attention deficit disorder.
The pertinent physical exam had normal vital signs and her growth was around the 75%. Her physical examination was normal.
The diagnosis of a healthy female who was identified as gifted and talented in school but also with learning problems. The pediatrician recommended to continue the evaluation at school and also offered that if needed there were psychologists in the area that could also help. “She’s doing well socially and developing pretty normally, so that is good. She’s really verbal and has lots of energy and that is also a strength. There are some kids that are both gifted or talented but they also have problems learning. They are called twice-exceptional because they have traits at both ends of the spectrum. They learn or do some things exceptionally well, but they also are exceptional in that they have problems learning too. I don’t know if that is your daughter but the evaluation will help. Let me know about the school evaluation and if you need more help as well,” she offered.
Discussion
“Gifted individuals are those who demonstrate outstanding levels of aptitude (defined as an exceptional ability to reason and learn) or competence (documented performance or achievement in top 10% or rarer) in one or more domains.” Domains for giftedness include:
- Intellectual
- Creative
- Artistic
- Leadership
- Specific field – language arts, mathematics, science, etc.
Giftedness is usually not screened for in young children, but may be screened for in early elementary school for potential differentiated educational programs. A review of giftedness and how it can present can be found here Individuals with developmental or intellectual disabilities are screened for using a number of standardized tools in healthcare, childcare and educational settings. They often, but not always, are identified relatively early in life and individual therapies initiated. A review of potential etiologies for intellectual disability can be found here
Learning Point
“Twice-exceptional individuals are those who have high cognitive ability in one or more areas and a coexisting disorder or disability.” While either giftedness or disability is considered a neurotypical exceptionality, for these individuals they have both and therefore are twice-exceptional (2E).
The overall prevalence of 2E individuals is estimated to be 300,000 – 360,000 in the US. However, the numbers are based on small sample sizes and 2E is very likely under-identified. Individuals may be not/underidentified because their giftedness is less frequently identified and only their disability is seen, the belief by professionals that individuals cannot have both exceptionalities, their giftedness masks their disabilities, and similar issues. Masked abilities/disabilities are a common problem. They may not be identified because they “don’t qualify” on broad educational testing. Their scores are “bad enough” or ‘they aren’t failing” and may not qualify for special education interventions. They also may not qualify for gifted and talented programs because their scores are not high enough because of their disability. This is sometimes referred to as a skewed profile where on testing the individual does very well in some areas and very poor in others. It is only since 2004 that the US Federal Government acknowledged 2E.
The most common disorders identified along with giftedness in 2E are autism spectrum disorder, attention deficit disorder, emotional disturbances and specific learning disorders. Specific learning disorders include:
- Oral expression
- Listening comprehension
- Written expression
- Basic reading skill
- Reading fluency skill
- Reading comprehension
- Mathematics calculation
- Mathematics problem-solving
Of these, reading problems are the most common.
2E individuals are less likely to receive the educational and psychology interventions they need because they aren’t identified, or only some services are provided (ie they receive special education services but not gifted and talented services). Services for 2E individuals are not different than conditions where the emphasis is on using the individual’s strengths of the individual to help augment and improve the weaknesses. These can include specific educational interventions, psychological support, physical therapy, occupational therapy, speech therapy, etc. Increasing awareness of 2E, increased or universal screening for giftedness, along with additional review and questioning for why a student may be underachieving or failing in school may help identify and get the 2E individual the services they need to be successful.
Questions for Further Discussion
1. What are common child development screening tools and how are they best used?
2. What are common screening tools for giftedness?
3. What services for gifted students does your local school district provide?
Related Cases
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Learning Disabilities .
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Twice-Exceptional Learners: Who Needs to Know What? – Megan Foley-Nicpon, Susan G. Assouline, Nicholas Colangelo, 2013. Accessed December 11, 2023. https://journals-sagepub-com.proxy.lib.uiowa.edu/doi/10.1177/0016986213490021
Gilman BJ, Lovecky DV, Kearney K, et al. Critical Issues in the Identification of Gifted Students With Co-Existing Disabilities: The Twice-Exceptional. SAGE Open. 2013;3(3):215824401350585. doi:10.1177/2158244013505855
LeBeau B, Schabilion K, Assouline SG, Foley Nicpon M, Doobay AF, Mahatmya D. Developmental milestones as early indicators of twice-exceptionality. Neurobiol Learn Mem. 2022;194:107671. doi:10.1016/j.nlm.2022.107671
Gifted LD. Accessed December 11, 2023. https://www.ldinfo.com/gifted_ld.htm
Dyslexia | Dyslexic Advantage – Dyslexia | Dyslexic Advantage. Accessed December 11, 2023. https://www.dyslexicadvantage.org/
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 
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