The Role of Clinical Psychologist

“There are many myths that continue to surround the needs of twice-exceptionality, and we need to continue to educate others to dispel those myths.”

As clinical psychologists, our role is to provide psychological and   educational testing, and counseling for children and their families. Our job is to understand the developmental trajectories and expectations across areas of functioning (i.e., behavior, self-regulation, cognitive, academic, and social), differentiate typical versus atypical development, and provide recommendations for accommodation, intervention, and growth in the home, at school, and in the community. We are trained to fit psychological and behavioral profiles into boxes, called diagnoses, and recommend “treatment” based on the particular diagnosis and associated challenges. However, what if a child does not fit into a specific diagnostic box? What if a child has strong abilities? What if a child has both advanced and delayed development? In what box does that fit?

As psychologists who work primarily with gifted and talented individuals, we see this situation frequently—it is called twice-exceptionality. In essence, the silent question often asked about these individuals is “What is wrong with this student?” With 2e, the diagnostic box, although important, is not the ultimate focus—the needs and the strengths are equally, if not more, important. We also ask “What is right with this student?” to find the hidden strengths the student is using to compensate. In this way, the multidimensional needs (i.e., advanced curriculum, intervention for learning and processing deficits, and support for improved self-regulation and executive functioning) become the focus.

Asynchrony (i.e., uneven development) is typical among gifted individuals, but what if that asynchrony is taken to an extreme and spans a wide range? Abilities well above average, along with others that are average or even below average, create challenges for 2e children as they struggle to make sense of their unique pattern of strengths and weaknesses. Parents face challenges with ups and downs of behavior and emotion related to 2e issues, seeing maturity and yet immaturity at the same time. Educators wonder how to address the needs, or perhaps misattribute the student’s behaviors to lack of motivation or interest, rather than to skill weaknesses. Psychologists see discrepancies in test scores and typically report “relative weaknesses” that are average or better in some cases, leading them to suggest the child will be fine because they do not show any “true” deficits on an absolute scale. These are some of the challenges with understanding, identifying, “diagnosing,” and serving the 2e population.

Historically, 2e individuals have struggled with an area of weakness that may be below, at, or even above grade level. Often, their weaknesses are not addressed in the school setting because “they are doing fine” or “meeting minimum grade requirements” in one or more subjects, according to teacher comments and reports. In addition, these students are sometimes defined by their strengths (“they are exceptional in math”), whereas their weaknesses go unrecognized or are not seen as relevant. Psychologists may overlook the needs of 2e students when they see precocious youth who speak well and describe clear explanations for their unusual patterns and a plan to address them. Yet, despite saying the right things, their performance continues to be limited by their disability without accommodation even as they are doing “fine.” A primary reason 2e students’ weaknesses are overlooked and missed is because their strengths and weaknesses cancel each other out, and they are seen as “average.” Part of this critical issue resides in the lack of awareness of the concept of twice-exceptionality and the myths that gifted individuals are strong across subjects and cannot be both advanced and behind at the same time.

Twice-exceptional (2e) individuals, according to the new definition put forth by the National Twice-Exceptional Community of Practice (2e CoP), evidence both exceptional ability and disability. Having a shared and accepted definition of twice-exceptionality, which indicates how twice-exceptionality may present and highlights the need for and types of intervention, will allow psychologists to provide clear information to parents about the characteristics of 2e students and their needs. The new definition, which affirms what many have called twice-exceptionality, states that 2e individuals may demonstrate unexpected low performance that can be at or even above grade level and still indicate a disability. This aspect has been frequently overlooked by schools since the implementation of the Individuals with Disabilities Education Act (IDEA) revisions in 2004, as schools have often looked for absolute low performance and students meeting a low-level “cut score” for qualification, rather than the relative weakness that this new definition affirms. This shared definition supports the legitimacy of a group of students who are often marginalized due to their strength areas and ability to compensate for their learning and processing weaknesses.

After decades of working with this population and reading hundreds of testing reports from school, clinical, and neuropsychologists, we have become aware of a critical question: How can psychologists and educators understand the profile of a child who has exceptional strengths and weaknesses, if one is never trained in understanding this profile, nor given information about the best practices that support the growth and development of these individuals? That is our charge as psychologists who work with gifted and 2e students—to understand and educate others to understand the unique needs of the 2e population. We must strive to share knowledge and advocate for the needs of the 2e. We must help psychologists understand that relative weaknesses are true weaknesses and must be addressed so that a 2e student can demonstrate his or her abilities with lessened impact of his or her disabilities. We must ensure that 2e students’ performance and grades result from their abilities and are not limited by their disabilities. We must provide clear recommendations to help these students thrive both in school and beyond.

How can these atypical patterns of strengths and weaknesses be identified? What methods must be used to find them and to identify appropriate interventions? Comprehensive assessment by clinical or school psychologists is critical for understanding the complex profiles of 2e students. Response to Intervention (RtI) services can be very useful for 2e students when their weaknesses are noticeable to their teacher and identified as needing intervention. Unfortunately, for reasons described above, many 2e students are not recognized as needing such interventions because they are performing adequately compared with grade-level peers. Increasing teachers’ knowledge about 2e students may begin to increase identification of these needs and result in more 2e students receiving support for their learning and processing challenges. However, when only academic or performance-based methods are used to determine RtI eligibility, a 2e student can perform adequately because of his or her strengths and compensatory skills, leading him or her to be often overlooked for RtI services in a typical classroom situation.

With comprehensive psycho-educational testing, the patterns of 2e students can be identified, along with needed interventions, even when performance is at or above grade level. According to the U.S. Department of Education (USDOE),

. . . IDEA requires the use of a variety of assessment tools and strategies to gather relevant functional, developmental, and academic information about the child, and prohibits the use of any single measure or assessment as the sole criterion for determining whether a child is a child with a disability . . . (Letter to Delisle, 2013, DOE 13-008520r)

Although significant discrepancies in scores across different domains can illuminate challenges that may be overlooked in the classroom because of adequate performance, clinical observations can also indicate areas of concern and point to possible interventions. Finding visual or auditory processing difficulties or weaknesses in visual-motor or impulse control development can help parents and teachers understand the ups and downs of a 2e student’s day-to-day performance in a different light.

Comprehensive evaluations help find the students whose needs are complex and cannot be recognized by a teacher saddled with the pressure to help all children reach grade level. Clinical and school psychologists can provide another level of assessment, using multiple tools that can work in tandem with teachers and taking advantage of the expertise of both disciplines to best identify, understand, and meet the needs of 2e students in the classroom setting. With knowledge of the unique skills pattern, a teacher can help a child use the strength areas to compensate for weaker areas, allowing the student’s abilities to shine. Without knowledge of 2e students and the usefulness of comprehensive assessment, educators may focus only on performance-based assessment and see “average” or “grade-level” performance, thus overlooking the special needs of the 2e population. Newer school psychologists unfamiliar with 2e students may only be exposed to performance-based measures for eligibility determination and may lack the skills to identify 2e students.

In addition to the challenges of explaining and classifying 2e children and adolescents more accurately, increasing access to services has long been an issue for the 2e student. Since the reauthorization of the IDEA in 2004, 2e individuals have had a difficult time qualifying for Individual Education Programs (IEPs) and Section 504 Plans to receive needed intervention and accommodation. In a recent letter to State Disability Directors dated April 17, 2015, USDOE Special Education Director Melody Musgrove stated,

. . . we continue to receive letters from those with children with disabilities with high cognition . . . expressing concern that some local education agencies (LEA) are hesitant to conduct initial evaluations to determine eligibility for special education services and related services for children with high cognition . . . remind each LEA of its obligation to evaluate all children, regardless of cognitive skills, suspected of having one of 13 disabilities . . . (OSEP Memo 15-08)

A widely accepted definition, along with clarifications from the USDOE such as Letter to Delisle and Letter to State Special Education Directors, can help identify legislative priorities and language that can be used in future revisions of IDEA to assure 2e students are not excluded from needed services. Currently, students seen as achieving at “grade level” are routinely denied evaluation and needed services, and clearer language in future IDEA revisions about 2e students are needed. Even when a 2e student is evaluated and a severe discrepancy between ability and achievement exists (sometimes 30 points—2 standard deviations—or more, for example), a 2e student is often not identified as having a learning disability because of “adequate” performance. As a result, many do not receive the required intervention and thus, underachieve, experience low self-esteem, suffer from anxiety and depression, and may even drop out of high school, leaving college out of reach.

Having a cohesive definition and understanding that is accepted by all stakeholders beyond those who specialize in this population will help legitimize this group’s needs and will hopefully lead to more training and increased success in identifying and serving this population to help the 2e student achieve commensurate with his or her abilities. We, as well as our colleagues around the United States, see the issue of lack of recognition of disability and inability to qualify for special education and 504 designations as some of the most critical issues facing 2e students today. These issues profoundly affect a 2e student’s daily life as well as the trajectory of his or her social, emotional, identity, and academic development.

Although the 2e CoP definition captures the complexity of 2e students and their needs, it will no doubt have critics. There are many myths that continue to surround the needs of twice-exceptionality, and we need to continue to educate others to dispel those myths. Furthermore, we need to continue to advocate at the local, state, and federal levels to ensure that 2e students are receiving a free and appropriate education (FAPE), and that their legal rights to accommodations and interventions, despite their advanced skills, are preserved and acted on. It is hoped that this definition, when accepted by allied professionals, organizations, and stakeholders, will help increase the advocacy efforts and increase the likelihood that 2e students will receive services they are entitled to receive under FAPE and IDEA guidelines. With increased understanding of the potential of 2e students and their complex profiles and needs gained through ongoing professional development, all stakeholders can better advocate for the specialized educational opportunities and simultaneous supports necessary for 2e students to overcome challenges on the way to academic success and social and emotional well-being.