By: Debra Johnson, MS, OTR/L

Many parents who contact me for OT services begin the conversation by saying that they aren’t really sure whether OT can help them or not. They are struggling, searching for answers and may have had others tell them they are over-reacting or that their child will outgrow the problems. During the initial evaluation these parents are able to identify their primary concerns often related to motor coordination, learning difficulties and behaviors. They then may state “but he’s so smart” or “but she is so creative.” When asked to name their child’s strengths a parent might list intelligent, clever, good problem solver, quick learner, excellent memory, compassionate, sensitive or make other comments about natural abilities. In many cases, the child is struggling at school while parents and teachers believe that the child could succeed “if he really wanted to.” This pattern of strengths and weaknesses is often indicative of a child being gifted or twice exceptional. These children can benefit greatly from OT services to support their development, facilitate positive self image and make the most of their natural abilities.
Most occupational therapists are able to easily address disabilities that impact child development but are not familiar with the needs of gifted children. Giftedness is often thought of in terms of high IQ or high creative ability (such as musical or artistic abilities). Assessment of giftedness is often difficult and much debated in the gifted education community. Most experts agree that in terms of IQ gifted individuals score 130 or above on standardized tests. IQ scores fall on a bell curve with 95% of the population having scores that range from 70 to 130. This means that only 2.5% of the population falls at either end of the bell curve with scores below 70 or above 130. As one expert pointed out to me, the needs of either group are equally different from the norm whether they fall at the lower 2% or the upper 2%. Many researchers have noted that as the level of giftedness moves farther from the norm so do the social/emotional needs, especially for young children.
Recent research on giftedness has identified that gifted individuals face many unique concerns including issues such as asynchronous development and heightened processing of information referred to as “overexcitabilities” (as defined by K. Dabrowski). Asynchronous development refers to the child being “out of sync” in development within the child, compared to age peers and compared to intellectual or emotional development expectations. Overexcitabilities refers to areas of heightened processing and intensity noted in gifted children and adults and includes increased psychomotor activity level, heighted sensory sensitivity, intellectual drive, imaginational creativity and emotional sensitivity.
Gifted children also tend to exhibit specific characteristics that can often be misunderstood or identified as “disordered” such as perfectionism, obsessions or persistence in a topic, tendency to question authority, preference for older companions/adults, high energy level and competitiveness. It is important to fully understand these issues related to giftedness in order to treat gifted children appropriately in OT. For example, asynchronous development refers to the wide spread in developmental skills that can occur for a young gifted child who, at the age of 7, may be able to read and understand language at a 12 year old level, do puzzles at a 9 year old level but have the fine motor or visual motor coordination of a 6 year old. This often results in great frustration for the child as they may struggle with a functional task such as handwriting. The child may become very frustrated with his own attempts at writing, becoming angry at what he perceives to be imperfect writing and exhibit what appear to be immature emotional reactions to handwriting tasks or avoidance of the task altogether.
“Twice exceptional” is a term that is applied to gifted children who also have special needs related to learning disorders, attention deficits, physical impairments or mental disorders. Often referred to as “2E”, these children may present with high intellectual or creative abilities as well as impairments related to a diagnosis of any one or multiple developmental concerns. A 2E child may have dyslexia, Tourette’s, Asperger syndrome or ASD, ADD/ADHD, OCD, Bipolar disorder, sensory processing disorder or any other condition. Gifted children who are visually or hearing impaired or physically disabled are also considered 2E. They warrant special attention and understanding of the “big picture” in order to benefit fully from what OT can offer them.
Twice exceptional children face even more challenges as they are typically very aware of how they differ from their peers and may develop a lack of confidence in their own true abilities as a result of failure in many areas of task performance. Intellectually they know they are smart and capable but then they experience difficulty in one or more areas. Some children develop a poor self image and internalize that they are “stupid” or otherwise inferior as a result of their failures. Some gifted children withdraw from challenges because their perfectionism drives them to be good at everything the first time. These children will withdraw from activities and pursue only those activities they can succeed at and may even excel at. It is not uncommon for adults to then comment that the child just needs to “try harder” or “apply themselves” to meet the challenges. Many adults erroneously assume that if the child excels in one area of performance he should excel in all areas. Yet, it is more common to see a child who is gifted in one or two areas of development (for example math and music) but then be average or perhaps lag behind in others (such as language skills). It has also been noted that many gifted children are able to mask their disabilities due to heightened intellectual skills and functional abilities, compensating for or hiding poor performance in specific areas. This can result in increased levels of stress and anxiety, distorted self image and poor coping skills for meeting higher level developmental challenges.
Occupational therapists are in a unique position to help both gifted and twice exceptional children meet their true potentials. A thorough OT evaluation can help to identify areas of twice exceptionality, such as impaired visual processing, poor executive function skills or motor coordination disorders. Gifted children have been identified as being more likely to have a sensory modulation disorder and perhaps more likely to have dyspraxia than the general population. OT is crucial in helping to identify whether a child has a sensory processing disorder and helping the child and family cope with sensory differences or modulation disorders that interfere with daily activities or providing treatment to address sensory based motor coordination disorders.
Play based therapy approaches that use “the just right challenge” can develop skills and foster the child’s self image and sense of competency. Opportunities to meet challenges in the therapy setting allow the child to develop more appropriate coping skills and reduce negative effects of perfectionism. Sensory and play based therapy can address motor coordination issues, perceptual skills and executive functions. Use of specific programs such as The Alert Program, social stories, picture or word schedules, and behavior programs help the child learn self regulation and develop appropriate coping skills. Parent education regarding sensory processing differences, sensory accommodations and sensory diets help the parents to better understand their child’s unique needs and ease stress at home surrounding a sensitive child’s behaviors.
When children present with twice exceptionality it is important that the child be viewed as being gifted AND having ADD (or whatever the issue is) not gifted BUT having ADD. Putting the condition in the context of the giftedness allows the therapist to address all the child’s needs as related to functional skills. Incorporating information from the fields of gifted education and research, occupational therapists can develop a treatment plan and recommend strategies to support functional skills utilizing the child’s strengths and accommodating for the areas of weakness. Being knowledgeable in gifted issues allows the OT to better educate the parents on the child’s needs and help the parents become better advocates for the child. Through direct intervention to address skill development and support emotional well being and parent education for better understanding of the child’s needs, OT can help gifted and 2E children realize their unique gifts and develop their talents for future endeavors.
Our Featured Contributor: Debra Johnson, MS, OTR/L
About the author: Debra Johnson, MS, OTR/L is the owner of STEPS for Kids, Inc in Yorkville, IL. She has been an OT for 22 years and worked in a variety of settings from pediatrics to geriatrics. She is passionate about providing quality care for children with a focus on remediation, education and wellness. As the parent of a gifted child with unique needs, Debra has a special interest in helping gifted and twice exceptional children and their families. Visit STEPS for Kids, Inc at www.rightstepsforkids.com
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