Gifted Issues Discussion homepage Forums Twice Exceptional Inattentive ADHD in gifted girls

Out of the blue my D22 requested a reference from her doctor for ADHD testing. This was a surprise for us and at first this did not make any sense. She is 2 grades skipped, 4.0, 36 ACT kinda kid. Never any complaints from school, mature, reliable, etc. Before shelling out some insane amount of money we decided to have a talk and what she is saying makes some sense and warrants visit for an assessment. Now here is my concern. If we, her parents, never ever noticed any struggles related to this, it is quite possible she is compensating quite intense for any deficiencies she might have related to ADHD. How would we find doctors to make sure they can account for it. Have anyone dealt with a child who never exhibited any symptoms but actually had ADHD, just covered up/compensated? I started to read on it and looks like it will be really hard to diagnose due to her having no issues (on the surface) related to ADHD. I would appreciate any words of wisdom! I just don’t want misdiagnosed child. If she has ADHD we want it to be addressed this year, before she goes to college…

A few angles I would offer on this:

Most importantly, something is causing her to feel a level of distress. It may be ADHD, or it may be something else. If I recall correctly, your DD is a mid/late teen right now, which is a challenging age developmentally for anyone. So more than looking specifically for an ADHD evaluation, I would keep an open mind about what it is that currently makes her feel she is having difficulty regulating her attention/focus. For example, it may be emotional in basis, it may be physical/organic (which can also feed into emotional), or it may be neurocognitive (such as ADHD). Plus any/all of these may be amplified by the public health crisis that we all have been living through for the past year and a half. This requires a thoughtful intake interview with an experienced evaluator (e.g., neuropsychologist, child/adolescent psychiatrist), starting from what she has been experiencing over the years, what is bringing her concerns to the fore at this specific moment, and how she perceives her principal area of need.

I took the liberty of scanning some of your previous posts, and noticed that historically, not only has she been an exceptionally bright and compliant child, but she has also been reserved about her interior life, so it isn't that surprising that she may have been trying to manage this on her own so effectively that even her parents did not see signs of struggle. Please be gentle with yourselves!

This also may not be quite as expensive as you are anticipating, precisely because there are no academic concerns. Neuropsychological evaluations (which are typically the direction one goes especially when attempting to tease out a subtle diagnosis like ADHD in a gifted individual) often can be at least partially covered by insurance if you first obtain a referral/preapproval from your primary care provider. The main thing is to emphasize that it is -not- an academic concern, but a medical concern, such as with recently-reported changes in her ability to focus, or feelings of anxiety regarding meeting her own expectations, or whatever the actual symptoms she is reporting are. Insurance companies typically will -not- pay for learning disability evaluations (because public school districts are responsible for those, for any child who resides in-district, even if they attend another school).

Alternatively, you could start from the school district, and request an initial evaluation, with concerns regarding regulating attention, and perhaps executive functions/organization (these are typical ADHD concerns). Depending on your state, the district may or may not be able to decline to evaluate; in some states, the bar is fairly high for rejecting parental requests, while in others, districts routinely reject requests when the student is performing at or above average. If the district evaluates, this would be at no cost to you beyond whatever you are already paying in taxes. Keep in mind, however, that the client in this case is actually the district, whereas in a clinic-based eval, you are the client. Most school-based practitioners do, of course, view the child as their primary client, ethically, but they may experience institutional factors that affect what they are able to do, as well as resource limitations for some of the pricier computer-based assessments. But a good school-based psychologist can generate an evaluation (comparable but not entirely identical) on a par with that of a good clinic-based neuropsychologist. (Full disclosure: I'm a school-based evaluator.)

And with regard to the difficulty of identifying a well-compensated disorder, my thoughts would be that, first, there is a point at which a neurocognitive profile is sufficiently well-compensated that it really isn't pathological any more. That point is generally when it doesn't interfere with major life functions, and it doesn't cause distress to the individual. It appears that whatever is going on doesn't, on the surface, interfere with major life functions, but that it is actively causing distress.

Secondly, a good neuropsychological evaluation will involve objective performance measures that are designed to isolate specific neurocognitive functions as much as possible, to reduce the confounding effect of compensatory strategies (or interference from cross-domain weaknesses). For ADHD, there are a number of computer-based tools that have a pretty good track record in this regard. In addition, a skilled evaluator will look for interpretive patterns across multiple instruments, both computer-based and in other formats, and may be able to pick up on subtle effects.

Mainly, it will be important that the evaluator have a strong rapport with your DC, and experience with how gifted young people mask or compensate for their challenges. And an open mind.

Thank you Aeh for the thoughtful response. You pinpointed my thoughts on this subject beautifully. My main struggle is with determining if what she is experiencing is normal response to 18 months remote learning fatigue, teenage angst (she is indeed 15 year old rising senior) and underchallenging environment; or this is truly a manifestation of some underlying neuro-atypical condition, as you stated. We are going to test her, even if only to reassure her concerns are heard and we taking it seriously, but since we are investing time and money (not the most important, but still) I want to get the best possible care and educate myself before this process to make sure I can trust the results and not second guess it and have to go for second evaluation 1 to 3 months later. I’ve already heard from couple of places and they sound exactly the same. I am waiting on the third call and will have to make this decision.

You gave a good point to emphasise the medical side and not the educational issues while discussing our concerns. We will not get school involved, as they were mostly useless in any other instances and will go private testing route.

It is still very strange to me that she is not showing any signs of unable to mange day to day activities, beyond usual teen procrastination. If she is able to sit through ACT test, pull 36 on it and move on without meltdown (and PSAT testings) should this be a sign that she is OK? Yes, she is messy to the point of my husband losing his mind every time he visits her room, but he has OCD and I am OK because I cannot stand cleaning myself, so this is normal and not a manifestation of ADHD in my book. She does procrastinate on her school work, but I would be too if it is boring and uninspiring, but then she pulls all As, gets state level awards and manages multiple leadership responsibilities, all with being 2 years younger than her peers. So I am at loss here with my assessment. Maybe she is just burnt out? I looked up these initial assessment forms for parents and I literally cannot answer any of these except “I don’t know” and “Everything looks fine to me”. I guess I am frustrated at the moment, trying to wrap my head around this and once I have a plan, I’d be more with the program. My husband do have undiagnosed ADHD (we don’t have to test him for it, anyone can see it :)), so definitely family history there too.

A brief anecdote: one of my dearest friends, a research scientist, only identified that she had ADHD-I midway through working on her doctorate. Until that time, her compensatory strategies had been sufficiently well-developed that she was able work without supports or interventions.

Your DD may not be able to articulate what change she’s perceiving, or she may not be comfortable doing so openly as she explores her feelings. What my friend described sounded quite akin to ambiguous loss, whereby she had to grieve the expectation she had held about her potential level of sustainable professional function. Your DD might benefit from some time with a therapist to unpack her intuition, even aside from the evaluations. It’s been a tough year for everyone.

MorningStar, your current state of confusion is quite understandable, but also exactly the reason that going ahead with an evaluation may give you all some more peace of mind. At the moment, you have a lot of questions and ambiguity, but you also know two things: 1), your DC feels there is a problem; and 2), no one really knows what it is. The purpose of the evaluation is to assure your DC that her concerns are taken seriously (as you note), and to try to bring clarity to what "it" is (and thus to help guide any helpful responses).

As a parent myself, I know that quite often we feel that we should be able to identify and solve our children's problems, so I totally understand the frustration of not even being able to pinpoint -if- there is an observable problem, let alone what it is. But it may be that this is something that is evident only internally, and, in any case, this is why you are hiring a professional. If it were something you could easily figure out yourself, you would have already done so!

And on that same note, one of my relatives by marriage discovered that they were dyslexic while completing a master's degree that involved analyzing brain imaging -- of dyslexic persons. Up until then, they had compensated quite effectively by using their exceptional oral language and social reasoning skills to absorb content by listening, and to talk their way out of all lengthy writing assignments.

(FWIW, that's also how my color blind parent learned he was red-green color blind--in medical school, while learning about color blindness.)

One of the factors contributing to distress for learners with focal disabilities is the awareness of the gap between what they "should" be able to do and how they actually perform. This occurs commonly for learners of generally average ability who have specific learning disabilities, but since, in my observation, the magnitude and nature of the gap is far more critical than the absolute level of performance, the intensity of this distress can be correspondingly far greater for gifted learners--even those who are also high performers.

Your DC has clearly not reached her true instructional zone (on a purely academic level) even now (or she wouldn't be maintaining all As while routinely procrastinating), which suggests that her true potential is far higher than that implied by two years of acceleration. That doesn't, btw, mean that this is a flawed placement. In fact, it appears that it is exactly right for illuminating growth needs in some other areas that will likely be crucial to her long-term health and happiness, while not also penalizing her academic record. But the point is, the gap between her internal feeling of what "should" be easily accomplished and the amount of effort she puts into accomplishing it may well be significantly larger than it appears from the outside.

It's hard to add to aeh's wealth of wisdom, but a couple of quick thoughts from the parent of two teens with inattentive ADHD (and a cornucopia of other Es ).

If you can, find a psychologist with real experience of highly-gifted teens. Every provider of every kind I ever talked to all assured me, "Of course I've worked with tons of gifted kids". No, no they hadn't. They'd works with tons of bright kids, that top 20th percentile who are always at the top of the class. Different group, different need - and totally different compensation skills. So I recommend asking some very specific questions about the kinds of HG kids they've worked with, how they found them different to assess, and what they did differently to tease out the challenges in the face of such powerful ability to hide them. If they can't articulate any of this, I'd guess they don't have actual HG experience.

As aeh notes, there are a lot of things that can affect attention and look like inattentive ADHD, including especially anxiety, but also auditory processing. And the impact of other LDs being increasingly hard to compensate for can also trigger existing ADHD, making it suddenly become a much bigger problem and much harder to manage.


Nope. My elder (17) is the more extreme for both gifted and ADHD. It's extraordinary what he can pull off - and what he can't. Inconsistency is the core of the ADHD beast, and it's very confusing as a parent or a teacher. But surely if you did this, then you could easily do that?!!" No, they actually can't, they really just can't. The level of effort required can be achieved when the stars and planets are in perfect alignment and you throw in some extremely high intrinsic motivation for this specific task, but this is not sustainable.

I found Russell Barkley immensely helpful for understanding the particular weirdnesses of inattentive ADHD; for instance: http://www.russellbarkley.org/factsheets/WhatCausesADHD2017.pdf


Final thought - any chance your husband's ADHD is of the more visible, externally-manifested hyperactive/impulsive type? Because that will look extremely different from inattentive, and could be contributing to your confusion. I didn't really even know the inattentive kind existed before I started this journey, so it took me a long while to wrap my head around the idea that my kids had ADHD, despite looking so utterly different from friends and family with ADHD.

Best of luck to you. I hope the assessment goes well and your DD finds the support she's looking for.

Excellent observation.

Well said, Platypus101!

Thanks all for giving me food for thought. I think I calmed down slightly We playing phone tag with her pediatrician for now, so hopefully we can finally connect with him Monday.

I did talk to her some more about her concerns and still thinking it is not really a manifestation of ADHD but most likely the dreaded disengagement symptoms of her being bored out of her mind combined with all year remote instructions, that provided minimal stimulation for her.

She went for a month to Gov school for engineering and had no problems managing her day to day activities and work load. She was actually very engaged and happy.

However, one thing that does slightly concerning and was questionable in my mind is her sleeping needs that seems to be a lot. I was watching it carefully since I couldn’t pinpoint why it is bothering me, but now I am thinking if there is some underlying psychological issues, maybe this is how her brain recharging from working in “overdrive”. Anyhow, testing in our future for sure.

For finding testers - you all nailed it as far as responses from testers “they have lots of experience with gifted :)) I will have to go back to each of them and drill them some more on that…

Just a question to confirm this isn't a typo - is your daughter 22, or is this DD number 2?