Dr. Devon MacEachron\'s Blog

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The term “executive function” often comes up when we talk about weaknesses displayed by twice-exceptional learners. Some parents even describe their child as having an “executive function disorder” or “disability.” But there’s really no such thing. You won’t find it as a stand-alone diagnostic category in the Diagnostic and Statistical Manual for Mental Disorders (DSM-5). And it isn’t a disability category recognized in educational settings for an IEP or 504 plan.

Executive function (EF) is a broad concept comprising many skills, including: inhibitory control; flexible thinking and the ability to “shift set,” emotional control; the ability to self-monitor; working memory; planning and organizing; time management; organization of materials; task initiation; and task completion. Perhaps the best way to visualize it is as the brain’s “control center.”

A child may have weaknesses in certain aspects or subskills within executive function, and not in others. Rarely do they have weaknesses in all. The child’s specific weaknesses may be associated with a disorder like ADHD or an Autism Spectrum Disorder (ASD). Or they may not. It’s quite possible to have executive function weaknesses and not meet criteria for a specific disability of any kind.

Children with ADHD often display executive function weaknesses in inhibitory control. They’re impulsive and act without thinking. Sometimes their impulsivity flows into the emotional arena and they aren’t able to control their responses before acting. They may be overly sensitive or too quick to anger. They often have difficulty self-monitoring their work and are prone to “careless errors.” Weak working memory (e.g. forgetting what one is supposed to be doing while doing it) is a hallmark of ADHD. A poor sense of time combined with difficulty delaying immediate gratification for long term rewards can result in poor task initiation, time management, and task completion.

Children with ASD usually present with a slightly different pattern of executive function weaknesses. Flexible thinking is a challenge. They tend to get “stuck” on ideas and ways of doing things, demonstrating rigid thinking. It can be difficult for them to “shift set.” Key aspects of shifting set include the ability to make transitions, tolerate change, problem solve flexibly, switch or alternate attention between tasks, and change focus from one task or topic to another. Mild deficits in shifting may compromise problem solving and result in a tendency to get stuck or focused on a topic or problem, whereas more severe difficulties can be reflected in perseverative behaviors and marked resistance to change. Poor emotional control and emotional dysregulation are also typically present in children with ASD.

Of course a child may have both ADHD and ASD, with executive function weaknesses characteristic of both.

I’ve also worked with children who do not have a formal disability diagnosis but have immature executive functions. These are children who forget to hand in their homework, leave long-term assignments to the last minute, and neglect to check their work before turning it in. As I write this I wonder – does this describe most teens?

The executive functions are housed in the frontal lobe of the brain. This is one of the last areas to develop as children mature.

But we don’t have to wait for skills to develop on their own. We can explicitly teach them.

Some schools incorporate this kind of teaching in their academic programs. A parent told me that the 6th  grade at their suburban public school is “all about executive function.” Of course one would ideally not wait until college, but there are entire programs and courses in executive function at colleges like Landmark and Lynn University. I’m not a huge fan of summer programs purporting to teach executive function skills as most of what needs to be learned should be practiced during the school year in a natural setting.

In the absence of a school program, most families have to tackle the issue outside of school. Parents can try to teach their child themselves (awfully tough for many families) or hire someone to do so. A whole industry has grown up in the last 10-15 years of executive function coaches or tutors. As there isn’t a license required to call oneself an “executive function coach,” and there is no standard of qualifications, I’m afraid it’s a “buyer beware” situation. To find a good coach, ask around and get a referral. A good one can make a world of difference.

Coaching usually works best when implemented on a regular basis over a fairly long period of time (months, at least). There’s no “quick fix” for most problems. The child should be involved with the coach in setting goals, practicing skills, monitoring progress, and ultimately becoming more independent as they are gradually “weaned” of support. A child of any age can benefit from strengthening the executive functions, but I feel it’s especially important to try to get such skills under your child’s belt before they go to college. For students with executive function weaknesses, college can be a perfect storm.

What can parents do? Be proactive and give your child the benefit of explicit teaching. Try not to get frustrated with your child’s EF weaknesses, but rather see them as an area in need of support.

Resources:

Executive Skills in Children and Adolescents, Third Edition: A Practical Guide to Assessment and Intervention by Peg Dawson and Richard Guare. This is, in effect, a manual for how to assess and teach executive function skills. I used this as my guide when I taught my son. Also by the same authors: Smart but Scattered: The Revolutionary “Executive Skills” Approach to Helping Kids Reach Their Potential.

Anything by Seth Perler an executive function coach par excellence who is also knowledgeable about 2e learners. Subscribe to his blog, take a look at his “Toolkit,” and listen to his interviews on TiLT Parenting (e.g. A Master Class in EF). 

Last week I gave a presentation at a conference on twice-exceptionality run by a terrific organization called Twice Exceptional Children’s Advocacy. My talk was on how parents can uncover their children’s strengths and interests, and help them develop their talents towards future careers and passions. I like giving talks about this topic because I believe strongly in the importance of developing children’s strengths, not just focusing on their weaknesses.

During the Q&A, I was challenged by a parent who described the idea of talent development as “pie in the sky” for her family. Another asked how to uncover strengths in a child who is non-verbal (not capable of spoken language). Another described a child who requires a full-time aide to manage explosive and disruptive behaviors. I believe these parent’s children may all be on the Autism spectrum. Because I don’t typically work with children who suffer from such severe symptoms, I felt ill-prepared to address their concerns. I’ve felt badly about it all week. So let me try.

It’s sad but true that individuals with Autism are woefully underemployed as adults. The employment rate among adults with autism is reported to be about 15-25%. A whopping 75-85% are unemployed. Your child has a better chance of being employed as a young adult if they have a learning disability (95%), speech/language impairment (91%), and even low IQ/intellectual disability (74%).

No wonder parents of 2e students with ASD are worried about their children’s chances of having a career. But the statistics I just quoted are for all individuals with autism – not specifically those who are twice-exceptional. About 50-70% of individuals with autism have an intellectual disability. I don’t know what percentage of individuals with autism would be considered twice-exceptional. But I’ve got to believe that unemployment couldn’t be as pervasive for twice-exceptional adults with autism, given all the talents they have to share.

What are the opportunities for twice-exceptional individuals with autism? Famous media portrayals include Dr. Shaun Murphy in The Good Doctor tv show, most of the characters on the show Silicon Valley, Temple Grandin and Dan Akroyd. Individuals with autism may be especially good systematizers, have amazing attention to detail, and excel at visual thinking. Careers in computer programming, engineering, drafting, photography, mechanics, animation, accounting, inventory control, and statistics, may be good fits. Careers for nonverbal individuals with autism could include data entry, sorting, hand crafts, and assembly. Individuals with autism tend to not be as good at the social aspects of work and should generally avoid careers and workplaces placing a high value on social skills (e.g. marketing, sales). Workplaces that are tolerant of or seek out neurodiversity are more likely to provide a welcoming environment.

There is a growing awareness in the business world of the contributions individuals with autism can make in the workplace, and an effort to provide opportunities. A Wall Street Journal article this fall described a company called Daivergent that connects contractors on the autism spectrum with clients in need of their skill sets. Microsoft implemented an Autism Hiring Program in April 2015. Software corporations SAP, HP, and New Relic have dedicated autism hiring programs. An article on companies hiring adults with autism described several more.

I’m not arguing that opportunities abound, but there are some and they are increasing.

How can parents help their child with ASD identify interests and develop the skills needed to pursue a career? I don’t think talent development is a pie in the sky notion for anyone. We all have strengths and interests, and the twice-exceptional are gifted with more strengths than most. The key with a child who has a more impairing kind of autism is for parents and other professionals to look especially hard. Consider: What does the child like to do with his or her free time? What are his or her interests? What does he or she dislike? When and on what does he or she hyperfocus? In what areas is he or she gifted? Once the child’s strengths and interests are identified, deliberate efforts can be made to further develop the child’s talents. Simultaneously, any areas of weakness (e.g. behavioral) can be addressed through therapy and skill building.

Reach out for help. Organizations like Asperger Works, tools like Autism Speaks’ Spectrum Careers Toolkit, and coaches and advisors (e.g. www.integrateadvisors.org.) are available to help. In New York City, an organization called Spectrum Services has specialists who provide coaching for launching individuals with ASD into adulthood and employment placement.

It isn’t easy – especially for parents with children who have more extreme symptoms of autism. But I believe that there is always something we can do to try to help prepare our children for the future.

Where does the concept of overexcitability come from?

Overexcitability was introduced to psychology by Polish psychiatrist Kazimierz Dabrowski in the 1960’s as part of a “Theory of Positive Disintegration.” The theory proposed that psychological tension and anxiety are necessary to achieve the highest levels of personal and moral growth. Hence these “disintegrative” processes (tension and anxiety) were seen as “positive.” Dabrowski believed that some people have more “developmental potential” than others, and that high intelligence (giftedness) and overexcitability were predisposing factors.

So what exactly is overexcitability?

Dabrowski defined overexcitability as a heightened physiological experience of stimuli resulting from increased neuronal sensitivities that cause a person to experience life more intensely and to feel the extremes of joy and sorrow more profoundly. He called it a “tragic gift.”

He outlined five forms which have been elaborated by others over the years:

Psychomotor overexcitability manifests as a capacity for being active and energetic. It can include loving to move and being physically active, restlessness, speaking quickly, frequent impulsivity in action, and having high stamina.

Sensual overexcitability manifests as increased pleasure from the senses (e.g. tastes, smells, textures, sounds, and sights) and, conversely, extreme negative reactions to unpleasant sensations. It can include an exceptional dislike for particular stimuli or sensations, like the sensation of a shirt’s tag on one’s neck or the texture of certain foods.

Intellectual overexcitability manifests as an extreme desire to seek understanding, gain knowledge, and analyze and categorize information. It can include asking a lot of questions, being a quick thinker and observer, love of ideas and theoretical analysis, and the search for truth.

Imaginational overexcitability manifests as an intensified play of the imagination and vividness of imagery. It can include fantasizing, day-dreaming, a craving for novelty, and dramatization.

Emotional overexcitability manifests as a capacity for feeling emotions intensely and deeply. It can include being highly sensitive, empathetic, anxious, sad, lonely, nervous, fearful, having a heightened sense of responsibility, and a tendency toward self-examination.

What’s the link between giftedness and overexcitability?

Dąbrowski’s followers suggest that the gifted disproportionately display overexcitabilities, positive disintegration, and hence the potential to attain higher levels of personal and moral growth. The notion was popularized in the gifted education and research communities by Michael Piechowski initially in the 1970’s, Sal Mendaglio, who edited the book Dabrowski’s Theory of Positive Integration (2008), Susan Daniels and Michael Piechowski, who edited Living with Intensity (also published in 2008) and by Linda Silverman of the Gifted Development Center in Colorado, who worked with Piechowski and others on the development of the Overexcitability Questionnaire II, a self-report form widely used as a research instrument. You can try it out yourself by following the link.

I think parents find the concept appealing because it links giftedness and experiences and behaviors that could otherwise seem problematic or dysfunctional (like melt-downs over labels in clothes and extreme emotional reactivity), suggesting these are just part of the child’s gifted temperament. I personally found solace in the idea when my daughter was hypersensitive as a young child. However I have seen parents who take it to an extreme by attributing everything to only one aspect of their child’s profile (their giftedness), and ignoring areas of challenge that need to be addressed.

Is a link validated by the research?

I don’t think so. But I may get in trouble with my friends and colleagues in the gifted community for saying so. The idea that overexcitabilities are higher in the gifted has so captured the imagination and loyalty of researchers, practitioners, and parents that it has, in effect, become accepted as an article of faith or ideology. Practically every website and book written for parents on the social and emotional aspects of giftedness promulgates the view. There’s very little debate about it in the presentation to the public – it’s simply accepted as truth. That’s why I’m writing about it. It bothers me when everyone jumps on the same bandwagon without questioning where it’s going. Also, I have a problem with the idea that the gifted are more capable of attaining higher levels of moral and personal growth than the non-gifted.

Let’s look at the research literature:

On the “pro” side, in 1984 Colangelo and Piechowski summarized the literature, noting that overexcitabilities were consistently present in the gifted. Falk and Miller conducted a literature review of 28 studies in 2009, reporting that gifted individuals were significantly more overexcitable than the non-gifted, especially in the Emotional, Intellectual, and Imaginational areas. In Taiwan, Kuo and Chang (2013) concluded that gifted persons are significantly overexcitable. Many professionals involved in counseling the gifted (e.g. Linda Silverman, Ann Marie Roeper, Susan Daniels) have cited their personal professional experience as evidence that the gifted are more intense, sensitive, and overexcitable.

On the “con” side, in 2006 Mendaglio and Tillier conducted a literature review and concluded that gifted groups did not significantly outscore non-gifted groups. When Pyrt (2008) analyzed the effect sizes (strength) of the relationships reported in research studies he found most to be “small” and “trivial.” The only relationship that had a decent-sized effect was with Intellectual overexcitability. Jane Piirto, a researcher who’s made overexcitabilities her primary research focus, has administered the overexcitability questionnaire to over 600 gifted students, and who personally organized three of the first Dabrowski conferences in the U.S., was an “early adopter” but has grown skeptical over time. In an article titled “21 Years with Dabrowski Theory” she wrote that almost all the studies conducted have had small numbers of participants, making conclusions suspect, and that the only consistent finding has been for Intellectual overexcitability. A 2014 meta-analysis conducted by Daniel Winkler focused on answering the question: “Do the gifted have greater excitabilities than the non-gifted?” He did find a relationship between Intellectual overexcitability and giftedness. For the Emotional and Imaginational overexcitabilities he found that more studies failed to find a relationship than succeeded. The findings for Sensory overexcitability were deemed “insufficient.” And he reported that no studies conducted in the United States have found that the gifted have greater Psychomotor overexcitability.

I agree that the data indicates a link between giftedness and Intellectual overexcitability, but this doesn’t impress me.  I expected it. When you look for a relationship between two things that are conflated – like height and basketball prowess – you are likely to find one. The Big Five Factor Model of Personality, which has been strongly validated by the research, has a factor called “Openness” which is near identical to the concept of Intellectual overexcitability. Openness is the degree of intellectual curiosity that a person has. Of course it is associated with giftedness, and of course Intellectual overexcitability is associated with giftedness as well. As for the other excitabilities, it seems the evidence is just not there.

Why, then, is there such a strong ideology built up around this notion?

This makes me wonder why the gifted community has been so dogmatic about its belief in overexcitabilities, despite the lack of empirical evidence. It may be that people decided they liked the idea when it was just a hypothesis and haven’t kept up with the research findings. It was striking how fast thought-leaders in the gifted community jumped on the wagon when the hypothesis was first popularized in the 1980’s, despite a near total lack of any evidence at the time. I think it could also be due to the “halo effect.” Professionals in the gifted community want to see the people they work with through a positive lens. For parents, the idea that their child is oversensitive as part of their giftedness and that’s a good thing may be more appealing than an additional diagnosis of AHDH or Asperger’s or anxiety. Finally, we all want to think that pain and suffering will prove, in the long run, to be for the best. We want to believe it, and so we do.

Why does this matter, and what should parents do?

It matters because making the assumption that a gifted child is more excitable because they are gifted and that it’s fine (even good) to be that way can focus attention away from challenges that need to be addressed. Let’s remove the halo of giftedness, and look at the whole child. The potential for a child to realize their potential and to grow into a happy and productive (and personally and morally developed) member of society is increased when we support both their strengths and their weaknesses.

Mindfulness meditation has enjoyed a tremendous surge in popularity in the past decade. The practice has moved from a largely obscure Buddhist concept founded about 2,600 years ago to a mainstream psychotherapy and educational construct.

What is Mindfulness Meditation?

It’s a technique of meditation that focuses awareness on breathing and encourages positive attitudes to distracting thoughts and feelings that are not ignored, but are rather acknowledged and observed nonjudgmentally as they arise to create a detachment from them and to gain insight and awareness. It involves training attention and awareness in order to bring mental processes under greater voluntary control. It promotes metacognitive awareness. Mindfulness meditation is a western adaptation of Vipasna, or mindful breathing meditation, with influences from other methods.

Other forms of meditation include: transcendental meditation, in which one sits in lotus position and chants internally with the goal of “enlightenment;” Kundalini meditation in which one tries to channel an upstream of energy and experience an altered state of consciousness; Qi Gong meditation from ancient China which utilizes breathing, movement, and posture to circulate energy through the bodies “energy centers;” and Zazen Zen Buddhist meditation, a straight-backed, seated meditation in which one aims to forget all judgmental thoughts, ideas, and images.

One of the main influencers behind the popularity of mindfulness meditation in the west is John Kabat-Zinn. Dr. Kabat-Zinn has written a number of best-selling books including: Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness; Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life; and Everyday Blessings: The Inner Work of Mindful Parenting. He approaches mindfulness as a scientist (PhD in molecular biology, MIT) and has published scientific articles in peer-reviewed journals (e.g. Journal of the American Medical Association) on mindfulness in medicine. His Mindfulness-Based Stress Reduction (MBSR) program, developed in 1979 at the University of Massachusetts Medical School, has been used in hospitals and health clinics to help patients improve the quality of their lives.

What has my personal experience been with it?

My 26-year old 2e son got me into it. He gave me Full Catastrophe Living for Christmas and we did an 8-week self-guided MBSR meditation course based on Kabat-Zinn’s teachings. We’d text each other when it was time to meditate then text again afterward and call to chat about the experience. I also took a 6-week online course from Mindful Schools for educators. I still feel like an amateur! In my experience this is not something one can read a book about or take one course and immediately implement successfully. I think that’s one reason it’s called a “practice.” You have to practice a lot to get it down and even then you may lose direction. My son, who has been practicing on a daily basis for several years now, feels it is very helpful for improving his attention and focus (he has ADHD) and for reducing anxiety and a tendency to ruminate on negative thoughts. He thinks one of the biggest challenges with implementing it as a “treatment” is that teaching and coaching methods are not standardized and one often doesn’t know if one is “doing it right.”

How could it help 2e learners?

Mindfulness meditation could help 2e learners who have ADHD, autism, anxiety, and/or depression. The following benefits are mentioned:

• Improved attentional control and focus. Boosts to working memory.
• Stress reduction.
• Less emotional reactivity and emotional dysregulation.
• Reduced rumination via disengagement from perseverative cognitive activities.

Is it effective?

A 2017 article was published by science reporter Brian Resnick on Vox.com called: Is mindfulness meditation good for kids? Here’s what the science actually says. Resnick read more than a dozen studies — including systematic meta-reviews, which accounted for thousands of other papers — analyzing the research on mindfulness in both children and adults (there was much more research available on adults). He writes: “The evidence for mindfulness in adults is limited but promising” – especially for anxiety, depression, and stress reduction. He found less evidence for children, in part because there were so few studies.

Dr. Erica Sibinga, a pediatrician  at Johns Hopkins, conducts well-controlled trials using mindfulness in Baltimore’s poorest public schools. She and her colleagues recently conducted a randomized clinical trial with 300 fifth- to eighth-graders. Half the students got mindfulness instruction for 12 weeks. The other half got 12 weeks of health education and were the study’s controls. The results were quite strong: depression, anxiety, self-hostility, coping, and post-traumatic symptoms moved from “concerning levels” to “normal levels.”

A 2014 review published in Frontiers in Psychology found, across 24 studies (11 which had not been published in peer-reviewed journals), that mindfulness improved measures of cognitive performance but had less impact on stress and coping.

A second 2014  meta-analysis published in Education Psychological Review looked at 15 studies of school meditation programs and found “school based meditation is beneficial in the majority of cases,” but “the majority of effects of meditation upon student outcomes are small.”

And a third meta review, published in the Journal of School Psychology in August 2017, compiled 72 mindfulness studies of youth both in and outside of classroom settings. They found “universally small, positive therapeutic effects” for attention, introspection, and emotion regulation.

Overall, the evidence suggests that mindfulness does appear to have a positive effect for children, especially on anxiety and cognitive measures. The studies suggest that it is most beneficial for children who are disadvantaged or at-risk, and may not be as effective for children who are closer to a “normal” baseline. I feel our 2e children are “at-risk” and stand to benefit.

How do you teach a child how to do it?

Some schools incorporate the teaching of mindfulness in the school day. Mindful Schools  and MindUP are great programs designed for implementation in schools. Parents might be able to find a local private instructor, parent/child, or child-centered course to enroll in. They might find a therapist to engage their child in mindfulness-based therapy. There are numerous apps designed for children including Headspace for Kids and Mindfulness for Children. Parents willing to develop their own knowledge and skills might “home school” their child in mindfulness. Practitioners suggest that however a parent chooses to teach their child mindfulness, parents who also practice it themselves tend to have the greatest impact on their children.

Recommendation: 

I often recommend mindfulness meditation to the families of 2e learners I work with, as I do think it can help. I am concerned, though, that instruction and methodology can be a bit vague and many families may not know how best to go about it. Also, it’s not a “quick fix” but more of a “lifestyle change” requiring a  significant commitment to see results. I feel that the most benefit is gained when some rigor is put into implementation (e.g. scheduled daily family practice, instruction and ongoing guidance by a trained professional). Practice makes perfect!

What is sensory integration and sensory integration therapy?

Sensory integration refers to the process by which the brain organizes and interprets external stimuli such as touch, movement, body awareness, sight, sound, and gravity. Sensory integration therapy is an occupational therapy intervention that uses individually tailored  activities in an effort to facilitate adaptive responses and functional behaviors. The therapy sessions typically involve months to years of 1-3 times per week, 30-60 minutes sessions and some homework.

Practitioners of sensory integration therapy propose that there is something called “sensory integration dysfunction” or “sensory processing disorder” that impairs the central nervous system, affecting the vestibular, proprioceptive, and/or tactile systems. The vestibular system provides sensory input to the brain about the body’s movement through space. Ostensible signs of vestibular impairment include poor posture and dyspraxia (difficulty planning motor activities). Therapy intended to stimulate the vestibular system might include swinging, rolling, jumping on a trampoline, or riding on scooter boards. The proprioceptive system provides sensory input from the muscles and joints. Proprioceptive impairment is said to be revealed by the presence of stereotyped body movements, such as flapping one’s hands or rocking one’s body back and forth. Impairments in the tactile system are supposed to be evidenced by over- or under-sensitivity to sensory stimuli. Activities to stimulate the proprioceptive or tactile systems might include “smooshing” the child between gym pads or pillows to provide “deep pressure,” brushing the child’s body, providing “joint compression” by repeatedly tightening the joints at the wrist or elbow, and playing with textured toys.

The goal of sensory integration therapy is to remediate sensory difficulties so the child’s overall functioning will improve over time, and allow the child to process and react to sensations more efficiently.

Is there really such a thing as a “Sensory Processing Disorder?”

Practitioners of sensory integration therapy are the sole users of the terms “sensory processing disorder” and “sensory integration dysfunction.” The prevailing view in the broader scientific community is that “sensory symptoms” are ill-defined for purposes of diagnostic categorization and also for identification of a course of treatment or intervention. Sensory “issues” are seen as a nonspecific indicator of neurodevelopmental immaturity rather than as a distinct disorder.

In 2012 the American Academy of Pediatrics (AAP) issued a policy statement recommending that pediatricians not use sensory processing disorder as a diagnosis. The AAP left the window open for therapy by adding that while there may not be a diagnostic category, occupational therapy using sensory-based therapies “may be acceptable as one component of a comprehensive treatment plan.”

Why would sensory integration therapy be recommended for a child with Asperger’s/autism?

Many children with Asperger’s and autism have “sensory issues,” such as over-sensitivity to touch, sounds, smells, tastes, brightness, and movement. They may have trouble tolerating scratchy clothing, shirt tags, or “squishy” substances on their skin. They may be overly sensitive to loud noises or very picky about what they eat. They may evidence repetitive motor acts such as hand flapping. These difficulties can make ordinary situations overwhelming, create extreme stress, and trigger meltdowns. In fact, the latest edition of the American Psychiatric Association’s diagnostic manual, the DSM-5, lists sensory problems as a criteria for autism diagnosis.

Similar symptoms may occur with other neurodevelopmental and behavioral problems, especially ADHD and anxiety. My daughter, who has both, had sensory integration therapy. She couldn’t tolerate labels in clothing and loud noises (automatically flushing toilets were to be avoided at all costs). After a family vacation to Disneyland where she was overwhelmed by the noises and smells, she said “that would have been a great vacation except for that awful theme park.” For the most part, she’s outgrown her sensitivities. And I think she would have outgrown her sensitivities without a year of OT. But many children with autism continue to have sensory issues of one kind or another throughout their lives.

Is there a sound theoretical argument for sensory integration therapy? 

Not really. A major limitation with sensory integration theory is the dearth of evidence for its main tenet, which is that the integration of sensory input is necessary for higher level functioning. This tenet is based on the outmoded view that the development of the child mirrors the evolutionary development of the species. The argument is that sensory systems arose relatively early in the evolutionary history of humans and were a prerequisite for the emergence of more complex cognitive skills. The vestibular, proprioceptive, and tactile systems are thus said to reside in the “primitive” subcortical pathways that need to develop before the formation of more advanced cortical systems. There is no sound scientific basis for this idea, and it sounds a lot like the specious arguments made by Brain Balance Centers (see my Myth Busters Blog on that topic). Rather, the functional organization of the nervous system is better conceptualized as a co-occurring and interactive network of cortical and subcortical systems that mediate voluntary and involuntary responses to stimuli. As such, a linear model that posits that one system must reach some prerequisite level of development in order for a “higher” system to function properly is just inaccurate.

In some of the sensory integration literature biological theories are complemented by hypothetical constructs such as “inner drives” for self-actualization, “sensory deprivation and/or overload,” and “sensory defensiveness.” These constructs do not have any demonstrated scientific basis or even clear definition that would permit their valid and reliable measurement.

O.K. So maybe there’s not much scientific logic to support the theory. But does it work anyway?

Does sensory integration therapy help children with Asperger’s/autism? 

Many parents think it does. Many colleagues who I respect think it does. More colleagues who I respect think it doesn’t. The research evidence (so far) is rather unconvincing.

I took a close look at four analyses published since 2012. Lang, et. al.  reported in 2012 in the journal Research in Autism Disorders that when 25 studies were analyzed, 3 studies suggested it was effective, 8 studies found mixed results, and 14 reported no benefits. Not very compelling. Many of the studies (including the 3 that found positive results) had “serious methodological flaws” (e.g. no experimental design), precluding any valid conclusions. The authors concluded: “There is insufficient evidence to support the use of sensory integration therapy for children with ASD.”

Case-Smith and Scaff reported in 2014 in the journal Autism that among 5 studies, 1 was a case study so could not be generalized, 1 found no treatment effect, and the other 3 had mixed results. Of the 3 with mixed results, one utilized scientifically rigorous methodology (e.g. a control group). The findings from that study were positive according to parent and teacher report: children who received sensory integration therapy had a greater reduction in ASD symptoms. However, the authors cautioned: “additional rigorous trials using manualized protocols for sensory integration therapy are needed to evaluate the effects for children with autism spectrum disorders.”

Barton, et. al.  reported in the journal Research in Developmental Disabilities in 2015 on the findings from 30 studies. They concluded that there was so much heterogeneity in implementation, measurement, and study rigor that not much could be ascertained. They wrote: “The research on sensory-based treatments is limited to insubstantial treatment outcomes, weak experimental designs, or high risk of bias. Although many people use and advocate for the use of sensory-based treatments and there is substantial empirical literature on sensory-based treatments for children with disabilities, insufficient evidence exists to support its use.”

Finally, there is a chapter on sensory integration in the 2015 book  Controversial Therapies for Autism and Intellectual Disabilities: Fad, Fashion, and Science in Professional Practice by Foxx and Mulick. In addition to reporting in detail on prior studies, the authors report their own review of  data from 2011-2014. When they analyzed 10 studies, 3 were single-subject (one child) studies that did not show any benefit. 4 studies reported positive results but were criticized as “speculative at best” because they did not randomly assign children to groups and examiners were not “blinded” to group assignment. The 2 studies that did utilize sound scientific methodology provided inconclusive results, The authors conclude that sensory integration therapy has “limited scientific support,” but note that it “remains popular despite professional ethical guidelines that call for the use of evidence-based practice.” In other words, they feel it’s unethical for professionals to recommend sensory integration therapy because its not an evidence-based practice.

Why do families engage in sensory integration therapy if the evidence is so scanty? 

In an online survey about 60% of parents of children with ASD reported that their children engaged in a course of sensory integration therapy.

Why do they do it given the weak scientific evidence?

Maybe they haven’t looked at the science. Maybe they were convinced by the pseudoscientific arguments. Maybe they hope scientific research will someday catch up with practice and show it to be efficacious. Maybe they relied on a story from a friend or a friend of a friend that was convinced it helped their child. I think this happens a lot. Or maybe parents are so desperate to do anything to help their child they will grasp at straws.

Recommendation: While it probably won’t do much, if you want to do sensory integration therapy as one part of a comprehensive treatment plan, there’s probably no harm in proceeding. But please don’t divert time, money, and attention away from therapies that are scientifically validated as effective.

 

What is it? In 2006 Dr. Robert Melillo – a chiropractor – entered into a partnership with his nephew to launch the Brain Balance franchise model. Since then, over 130 franchises have been purchased across the country. The concept is based on Dr. Melillo’s book: Disconnected Kids: The Groundbreaking Brain Balance Program for Children with Autism, ADHD, Dyslexia, and Other Neurological Disorders. He describes his program as a “non-medical and drug-free approach” based on “cutting edge brain science” for achieving “optimum body and brain balance.” He argues that kids who have learning or behavioral issues have “inadequately developed sensory and motor systems” and because “the brain is built from the bottom up,” sensory and motor work must be done “before any higher learning, behavioral or academic changes can truly happen.”

He addresses this presumed deficit with “motor” exercises (e.g. rhythm and timing, primitive and postural reflexes, eye-muscle balance) and “sensory” exercises (e.g. hearing, vision, smell, taste, touch). Academic skills are also (briefly) addressed. The sensory, motor, and academic work is all condensed into 3 one-hour sessions per week at a center. Your child is taught by a “coach” – an unlicensed person who need have no background in education, health, occupational therapy, chiropractic, or any related field. A blogger who got details from a former center employee insider’s perspective reports that “most staff are very young (21/22 on average), with no real relevant qualifications, and there’s a high turnover; most don’t stay longer than a few months. That could be partly because of the wages; $10 an hour.”

In addition to the 3 hours per week your child gets at a center, the program includes nutritional recommendations and exercises to be done at home.

Most families are advised that their child requires two 3-month sessions at a cost of $6,000 per session, plus several hundred dollars for the assessment and proprietary nutritional supplements (including KidGenius vitamins “that help promote brain growth!”). Total cost is approximately $13-14,000. Cost per session works out to about $182/hour, of which the coach gets approximately $10. None of the cost is covered by health insurance.

Can it help? Let’s break the question down into what part (s) of it work, and for who?

Let’s start with “who.” I’m skeptical that children with all the different issues they claim to treat can be helped with the same basic treatment. A blog titled Total and Utter Neurobollocks states: “They claim to effectively treat pretty much any developmental disorder under the sun, including autism, ADHD, Asperger’s, Tourette’s and dyslexia, without the use of any drugs. This is because all these disorders are (apparently) caused by an “underlying functional imbalance or under-connectivity of electrical (brain) activity within and between the right and left sides of the brain.” Any alarm bells ringing yet? They should be. Whenever someone comes along with a miracle-cure for a range of unrelated conditions, and has come up with the equivalent of a Unified Field Theory of neurodevelopmental disorders, something must be a bit fishy.”

There are also multiple parts of “it” to consider – sensory motor exercises, academic skills tutoring, and dietary changes each would be expected to have different effects (if any). Some aspects of the program’s interventions might prove helpful to individual children. I’m all for good nutrition, academic skills tutoring, and parents spending quality time exercising with their children, for example. But there is no indication that the core theoretical basis of the program – that sensory-motor exercises will “balance” the brain and improve “functional connectivity” – has any basis in fact. That aspect of the program is based on speculation, not on credible evidence.

One parent, Natalie Hanson, chronicled her family’s experience in a blog. She wrote: “We went into it very hopeful.” “So…he’s a chiropractor. Whatever. If the program works, who cares?” Two years later she wrote: “many of you have reached out via the blog and via email for guidance about whether to pursue Brain Balance for your children. It’s so hard to hear your stories and your desperation, which (in many cases) mirrors our own.” But, “knowing what we know now, I don’t think we would do it again… The most valuable thing we’ve done is remove gluten and dairy from our kids’ diet, and get their genome mapped so that we can address underlying issues with their biochemistry through food, supplements, and ultimately medications.” Later that year she wrote: “I continue to get so many questions about Brain Balance from hopeful parents. I would just like to reiterate again that I WOULD NOT recommend investing in this program for your kids. It is extremely expensive, and the results are fleeting at best. You’re better off changing their food habits and finding other ways to address the behaviors. I know this may be unpopular for those of you looking for answers, but these programs are not what you’re looking for – what they are promising is, sadly, too good to be true.”

Dr. Harriet Hall, a retired family physician who writes about pseudoscience and questionable medical practices on the website Science-Based Medicine, wrote a critical review, saying she was initially skeptical because “miraculous results are reported (“He spoke for the first time!”),” but says the biggest red flag is that they claim their program is “clinically proven,” yet they provide mostly testimonials as evidence. Anecdotal reports do not provide evidence of the efficacy of a treatment. Dr. Hall examines the one research study then mentioned on the website in which “They speculate that ADHD is related to a “functional dysconnectivity,” hemispheric imbalance, subcortical dysfunction, a lack of temporal coherence, and a difference in arousal level between the hemispheres. They provide no evidence that these are characteristic of ADHD or were present in their subjects, or that their treatments specifically changed any of them. They assumed an underactive right hemisphere (it was not clear why) and they provided interventions that they assumed (without any supporting evidence) ought to remedy the alleged imbalance.”

When I checked the Brain Balance website for listings of research I found that several articles and a few studies are now listed. Some sound astonishingly compelling. A 2013 randomized control study (that part sounded good!) reports the “elimination of ADHD symptoms in 81% of participating children after completing a 12 week program.” As if that weren’t enough, 60% also achieved a two-grade level academic increase and 35% achieved a four grade level increase in academic skills! Sounds too good to be true, doesn’t it?

The lead author was Dr. Gary Leisman. I googled his name, and the fifth hit that shows up is a Finding of Scientific Misconduct published by the NIH in 1994. Apparently, this “authority” falsely claimed to have earned an M.D. degree he never earned, to have been a professor of neurology at Harvard Medical School (he had no such affiliation), and to have been awarded 13 U.S. Patents (he never was). Since that time, he has been working in Cuba and Israel.

Other articles include tenuous links to Brain Balance methodologies from some solid research findings. For example, the finding that children with autism have higher than normal connectivity between certain areas of the brain was extrapolated to “lend further support to the Brain Balance theory of Functional Disconnection…The Brain Balance Program combines customized sensory-motor and cognitive activities to repair the miscommunication.”

Why isn’t their more research? Well, first of all, neuroscience has moved far beyond the simple left brain/right brain dichotomy. Furthermore, the idea that diverse conditions are caused by a disconnection syndrome between the two hemispheres is preposterous enough to fail to get research funding.

Why don’t the people making money from Brain Balance programs fund some research? Melillo has argued that Brain Balance is too busy treating patients to do rigorous scientific studies. How convenient.

Can it hurt? Yes – your pocketbook.

What should parents do? Spend their time and money on treatments that are efficacious. Dietary changes, academic skills tutoring, exercise, and maybe even some sensory-motor therapy – depending on the child’s needs – provided by someone trained and licensed to provide it (a good occupational or physical therapist, for example).

I was asked to write an article on this topic for TECA (Twice Exceptional Children’s Advocacy), an online community providing service and program directories and information about advocacy. I decided to enlist the help of Benjamin Meyer, a therapist specializing in young adults with NVLD and Asperger’s in the workforce. Here’s what we wrote:

By Benjamin Meyer, LCSW and Dr. Devon MacEachron, PhD

You did it! Your child has finally received an acceptance letter to a college or university and is beginning his or her first steps toward adult life. All your hard work navigating the treacherous path of diagnosis, remediation, social skills training, OT, PT, gifted programming, IEP’s and 504’s has paid off. You deserve a lot of credit for all that you have done to guide your child through the process, and you certainly deserve to celebrate!

While high school has come to an end, it is important to keep in mind that even after college, your child may face challenges related to their disabilities. These can include identifying and finding a career they enjoy, adapting to the world of employment, making friends with peers, and adult dating. Many young adults with learning differences are unemployed or underemployed due to the more nuanced social and executive functioning demands of the workplace, The National Center for Learning Disabilities reports that only 46 percent of work-age adults with an LD are employed (Cortiella, 2014) . “Failure to launch” has become a national epidemic, with many young people returning home to live with their parents due to challenges with the professional and social demands of adulthood. Your high school grad will be at an advantage if they take a few practical steps while in college to prepare for the “real world”.

Young adults in our practices often identify specific challenges at work related to their learning profiles. The dyslexic who chose engineering or architecture due to his gifted visual-spatial skills may find that slow speed and miscalculations made in math problems hinders his ability to complete tasks efficiently. The ingenious marketing professional with ADHD may experience difficulty organizing her ideas into action plans. The gifted writer with Asperger’s Syndrome or NVLD may struggle to hold regular employment due to difficulties reading their peers’ body language. Young adults who plan in advance for a career or job that will be a good fit for their unique profiles are most likely to be successful transitioning to the world of work.

Finding the Sweet Spot

When deciding on a career, young adults can search for the “sweet spot” where their strengths, interests, and values coincide (see diagram). The blue circle represents strengths. These should include intellectual talents as well as people skills, executive function, willingness to work hard, artistic, musical, and any other abilities. The green circle encompasses interests: sports, outdoor activities, academic subjects – any and all interests the individual may have. Lastly, it is important to identify and “own” the personal values that can impact career satisfaction. These include: how important a flexible work schedule is, how much social interaction is desired at work, the hours one is willing to work, desire for autonomy and independence versus taking direction from a boss, whether one enjoys working on a team, being outdoors versus in an office building, how important a high salary is, how important it is have a high prestige position, whether one wants to be considered an expert or authority, how important it is to feel one is helping others or making the world a better place. Values go in the yellow circle. By identifying the key factors that influence career success and happiness, young adults can begin to see which careers might fall within their “sweet spot.”

Acknowledging and Factoring in Areas of Challenge

While students are searching for their “sweet spot,” they will also benefit from being honest with themselves about their challenges. There are certain skills that are important in practically any job. Relating to colleagues, keeping your emotions in check, taking initiative, and having an organizational system are a few of them. There are also specific skills required in different fields, e.g. math skills for an actuary or writing skills for a journalist. If the student feels they have a weakness in an area important to a career they feel they would like to pursue, they can work on developing those skills while still in college. For example, they might learn to create an organizational system with a coach or work with a therapist on professional social skills. The student will also benefit from consulting with professionals who are in the field they are considering, especially those who have a similar profile of strengths and weaknesses. This will help them assess how suited their specific strengths and weaknesses are with the demands of the job and will aid in identifying some strategies for compensating for their weaknesses. Internships and mentorships are ideal opportunities to practice compensation strategies while building on strengths, experience and expertise.

Case Studies

Jacob is a verbally gifted 2e student with nonverbal learning disability interested in becoming a social worker. He realizes that he may find meeting documentation requirements challenging due to executive functioning deficits, while also facing obstacles reading nuances in body language from colleagues and employers. On the other hand, his strengths in writing and verbal skills will help him to produce well-written progress notes and describe cases in detail. As is the case for any 2e student, expressing specific strengths to potential employers during and after the interview process is a critical skill for landing a good job. Twice-exceptional students have exceptional strengths and these can be a major attraction to employers. But prospective employers may not know what those are until the applicant articulates them in a clear and concise way, convincing the employer of their value. Jacob needs to sell his verbal and writing skills. At the same time, he should anticipate concerns about weaknesses and consider addressing them up front. If a prospective employer knows that Jacob has NVLD and what NVLD means, they might be concerned about Jacob’s organizational abilities. Jacob would be wise to highlight in the interview process that he worked on developing a unique filing system at his last job, and explain how this skill will help him be an effective social worker.

Neil is a brilliant mathematician and visual-spatial thinker with Asperger’s and ADHD. He struggled with attention and making friends in college, however he successfully identified a strong interest and talent in architecture. Neil knows that he will no longer have access to a note taker, extra-time on tests, and academic coaches to help him stay on task in the work world. Also, an understanding of business social skills will be critical for him to engage effectively with clients in this field. During his last two years of college, Neil decided to work with a therapist building business-savvy social skills. During the summer when he is interning at an architecture firm he intends to consult with a business organizational coach and mentor who understands some of the demands he is likely to face in an architecture career. When Neil interviews for full-time jobs after college he may request “reasonable accommodations” that will not create an excessive burden for the employer. These could include extra filing space, access to a computerized organizational system, and a co-worker to accompany Neil to organizational meetings and provide professional feedback, etc.

Caroline is a 2e student who is dyslexic and has ADHD. She wants to be a journalist. She hit some road-bumps along the way in college from her ADHD and as a result it took her 6 years to graduate. She’s decided she needs to address this up-front in her interviews by explaining that she has ADHD, what happened, and what she learned from it (e.g. how to be organized, how much she cares about learning). When she mentions her ADHD she intends to emphasize that she thinks it is part of the reason she is so creative as a journalist and point to examples of creative stories she has published. But she doesn’t think her dyslexia will negatively impact her future work because she knows to get her pieces edited for spelling and grammatical errors. So she’s not planning on mentioning that exceptionality.

Does Your 2e Learner Have to “Tell All?”

It depends. In an ideal, open-minded, accepting-of-neurodiversity world one would be up-front about such things. No one wants to end up in a position that’s a bad fit. On the other hand, although they legally cannot discriminate, prospective employers may be concerned about hiring someone who brings challenges along with them. Many people don’t know about twice-exceptionality and may not get that one can be gifted and have a disability. We recommend the student decide in advance how much information would be in their best interests to divulge. The decision of what to share may be influenced by how overt the student’s weaknesses are. If you can’t hide it, own it. The decision may be influenced by the culture in the specific career field or company. Technology firms and academia tend to be more open-minded to differently-wired people. Traditional businesses like manufacturing and law may be less so. Of course if the student does decide to share, thought should be given to how to frame such information in the most informative light.

When a 2e student is proactive in preparing for future employment during the college years, their chances of success are greatly improved. These steps can include: researching and selecting a career that fits well with their unique profile of strengths, challenges, and values; working to address organizational and “soft skills” deficits while still in college; and finally deciding what and how much to self-disclose. Although 2e young adults may face challenges adapting to the workforce, they can be proactive about creating strategies for overcoming these boundaries, especially if they start doing so during the college years.

Benjamin Meyer, LCSW is a bilingual psychotherapist who provides psychotherapy and coaching services to young adults with High-Functioning Autism and Nonverbal Learning Disorder post-college in New York City. Dr. Devon MacEachron, PhD is a psychologist with expertise in twice-exceptional learners who provides psychological assessment and educational planning services to children, young adults, and their families in New York City.

Works Cited

Cortiella, C. &. (2014). The State of Learning Disabilities: Facts Trends and Emerging Issues . New York, NY : The National Center for Learning Disabilities.

Many parents wonder if their child will grow out of the problems that plague them as a child: their dyslexia, math disability, writing challenges, weak executive function, ADHD, or Asperger’s. I’m asked this question quite often by successful adults who are initially surprised their children are struggling, but when interviewed carefully about their own early years admit to having experienced similar challenges. But now they are a successful adult, so they must have grown out of it. Right?

Not necessarily. The short answer to whether most children grow out of these challenges is: probably not. At least not completely. But the demands in the world around them (their day-to-day environment) do change, and as they move through school and career they can be more selective about the kinds of things they choose to do, electing to do things they’re good at and avoiding things they’re not. So their dyslexia or ADHD or Asperger’s might not negatively impact the quality of their life very much as an adult, and may even become an advantage. But they still have it.

Adults diagnosed with dyslexia as children, even if they benefit from years of reading and writing remediation, tend to remain poor spellers and slow readers. I see this every day in my dyslexic husband who reads one book to my ten, though we spend the same amount of time reading every day.

For ADHD, some of the research suggests that children with ADHD simply have delayed brain maturation (by 3-5 years), but that they will eventually catch up with their peers. Unfortunately this may not happen until well past puberty and into college. I get dozens of calls every year from families of college freshmen with ADHD who are spinning out of control in the area of executive function. I often feel that students with ADHD would benefit from being “redshirted” to give their frontal lobe a chance to catch up with their peers’. Redshirting is a practice used most often in athletics of postponing entrance into kindergarten of age-eligible children in order to allow extra time for physical growth, making the children bigger and stronger thus more competitive athletically than their grade-peers. But it would be hard to “redshirt” our ADHD children for 3-5 years!

Anyway, rather than completely growing out of it, it seems that most children with ADHD grow up into adults with ADHD. The American Academy of Family Physicians reports that two-thirds of children with ADHD continue to grapple with symptoms (at some level) throughout adulthood. Their symptoms may present significant challenges, or they may not – depending on the circumstances. Some adults with ADHD only demonstrate impairing symptoms when they are anxious or depressed. Or when they’re hurrying. Or when they have to work on a long-term project. Or when they haven’t been getting enough exercise lately.

The environment and the individual’s physical state are both critical factors determining whether symptoms will be problematic or not. This is true for other medical conditions as well. If you have Type-II diabetes how you eat influences whether your symptoms manifest and whether your condition will appear to be dormant or you will have to use insulin for treatment. Adults with ADHD can try to choose careers (environments) that are well-suited to their needs. I can’t imagine either of my own children functioning very effectively if they were required to sit quietly at a desk all day doing routine work. Fortunately, they’ve gravitated to the fast-changing worlds of tech and media start-ups. In these environments they find it easy to stay attentive and focused. They can get up and move around. And they’ve learned that they’re more focused when they take care of their physical states by exercising, meditating, getting enough sleep, and eating right.

Children with Asperger’s still retain autistic brain differences as adults and gravitate to professions that fit their profiles. Hans Asperger wrote: “We can see in the autistic person, far more clearly than with any normal child, a predestination for a particular profession from earliest youth. A particular line of work often grows naturally out of their special abilities.” The adult with Asperger’s working as a physics professor or in Silicon Valley may be perceived as eccentric, but not necessarily as having a “disability.” The right environment can bring out the best aspects of a unique profile and downplay the worst.
Even during the school years, a child’s symptoms may manifest differently depending on the demands of the environment. A dyslexic child may experience significant challenges in elementary school when they have to read written text, hand-write responses, and are marked off for spelling errors. But when they’re in high school and can listen to text through voice software, type responses, and use spell-check, things can get a lot easier. A child with a math disability who struggles to recall math facts and has slow math calculation fluency may have a lot of trouble in elementary school when math is mostly about arithmetic. But when they reach high school and college when it’s more about problem-solving and fluid reasoning, they may excel.

So, children don’t usually grow out of it, but they may not be troubled by the different way their brain is wired when the demands of the environment change. In fact, having a differently wired brain may confer distinct advantages.

Books like: The Dyslexic Advantage: Unlocking the Hidden Potential of the Dyslexic Brain by Dr.’s Brock and Fernette Eide; The ADHD Advantage: What You Thought Was a Diagnosis May Be Your Greatest Strength, by Dale Archer, M.D.; and The Way I See It: A Personal Look at Autism & Asperger’s by Temple Grandin, M.D. point out the advantages that being wired differently can confer. This is not just “feel-good” pop-science – there is some serious research uncovering real strengths in thinking associated with each of these diagnoses.

If orange is the new black, maybe having a “disability” is the new superpower.

The term twice exceptional, sometimes shortened to “2-E,” is being used more and more often to describe high-ability learners who also have learning difficulties. These are smart students who have dyslexia, ADHD, Asperger’s, or some other learning weakness or disability that gets in the way, at times, of their ability to learn and perform at their ability level. It’s a terribly frustrating situation for all involved!

The word “exceptional” is used because it communicates the idea that these students have abilities at the extreme end of a range. Exceptional by definition means uncommon, deviating widely from the norm.

The word “twice” refers to the exceptionalities being in two areas: one in an area of strength and the other in an area of weakness. Jason, who has verbal ability at the 99th percentile yet cannot not read or spell anywhere near grade level due to his dyslexia is twice-exceptional. Melissa, a science and technology whiz who knows seemingly everything one could possibly know about cell phones and satellites, yet can’t connect well with others due to her Asperger’s, is also 2-E.

But thinking of a student as just twice-exceptional is often an oversimplification. Many students have more than one area of significant strength and more than one area of significant weakness within their cognitive profile. They are not just twice-exceptional, but rather thrice or more! This happens because both strengths and weaknesses tend to occur in clusters (known as co-morbidities in disability jargon).

Just taking ADHD, it is estimated that 50-90% of people who have ADHD also have some other weakness/disability such as a learning disability, anxiety, depression, or bipolar. And this is the same for strengths – it is quite common for a 2-E student to have strengths in more than one area. Sarah has four areas of weakness: ADHD, dyslexia, math disability and anxiety. But she has three gifted-level strengths: verbal reasoning, fluid reasoning, and creativity. Among the students I’ve assessed there are many more children like Sarah who have multiple exceptionalities on both sides of the equation than who have just two.

Does a student have to be identified as “gifted” to be twice-exceptional?

I feel it depends on what one means by “gifted.” Global measures of intelligence like IQ are composites of many different abilities including verbal, visual-spatial, fluid reasoning, memory, processing speed and other abilities. 2-E learners might not test as globally gifted because their areas of weakness can bring down their overall IQ score. Yet they still have significant (exceptional) areas of strength. I consider a student to be gifted – to be “exceptional”- if they have a significant strength in one cognitive area related to learning and higher-order reasoning. They don’t need to be “globally gifted” and good at everything to be gifted in my book. I certainly consider a student who is exceptionally strong at higher order math thinking and fluid reasoning yet makes frequent careless errors and has slow math fluency to be gifted. In fact that profile describes the kind of “arithmetic weak/math talented” sort of student who may be in remedial math in lower grades, yet is capable of excelling in higher level math classes in high school and college math ld.

How “disabled” does a bright student need to be to be twice-exceptional?

Just how weak do their weaknesses need to be? Some academicians, educators, and others feel that unless a student is performing below the average level of his/her peers (and this can be defined as low as the 25th percentile), they do not have a disability. I disagree, and so do many professionals who have experience with gifted learners. Students are expected to perform academically at their ability level. That is what IQ tests were originally designed to do: predict academic performance based on ability. If there is a significant gap between ability and achievement, that’s a problem that needs to be addressed.

Twice-exceptional learners are complex and fascinating. They have enormous potential, but it may be hidden from view. Underachievement is a high risk. Frustration is a given. Anxiety and depression are common side-effects.

If you think your child might be twice-exceptional, one of the greatest gifts you can give them is of understanding.