Children who are gifted: Educational interventions and primary care management

INTRODUCTION — Individuals who are gifted have exceptional abilities in a particular domain or domains.

This topic review will discuss educational interventions for and the primary care management of children who are gifted. The characteristics and identification of giftedness are discussed separately. (See "Children who are gifted: Characteristics and identification".)

TERMINOLOGY — Individuals who are gifted have exceptional abilities in a particular domain or domains (eg, mathematics, music, athletics). In addition, they typically have high degrees of self-motivation, curiosity, perseverance, and enjoyment in developing and expressing their talents [1].

There is no universally accepted definition for giftedness, which can manifest in a variety of ways. Other terms that are used to describe giftedness include "outstanding talent," "gifted and talented," and "high-ability." (See "Children who are gifted: Characteristics and identification", section on 'Terminology'.)

The United States Department of Education (DOE) definition for giftedness is the most widely accepted by researchers and practitioners in the field of giftedness (table 1) [2]. The DOE definition is similar to that provided by the National Association for Gifted Children [3]. In the United States, most state boards of education provide definitions for gifted/giftedness, but the definitions may differ from the DOE definition [4]. The definitions used by individual states are available from the National Association for Gifted Children.

INTELLECTUAL GIFTEDNESS

General principles — The development of intellectual or school-house giftedness, like any form of giftedness, is a long-term endeavor, fostered by early identification, supportive and encouraging caregivers, and teachers and mentors who place high expectations on the student [5]. Students who are gifted need to be challenged to maintain interest and high achievement [6]. Those who are not sufficiently challenged may develop maladaptive behaviors, mental health conditions (eg, depression), and/or academic failure [7-9]. The underchallenged student may fail to develop good study habits and no longer be successful as academic challenges increase. When not challenged, the student who is gifted risks not developing the frustration tolerance and self-confidence that comes from approaching and mastering difficult material [7].

Given the variety of ways in which students can be gifted and the range of domain-specific abilities within a given student, educational interventions and strategies to challenge students who are gifted must be determined on a case by case basis. The "optimal match" is a curriculum that matches the child's cognitive abilities, maturity, and academic interests and is sufficiently challenging that it requires the child to work to succeed, but not so challenging that they become discouraged [10,11].

Factors to be considered in choosing an educational program include the student's pattern of strengths and weaknesses, the student's social and emotional maturity, the types of programming available through the local school system, the availability of programs outside of the school setting, and family resources [11]. The ultimate decision may represent a compromise based on the advantages and disadvantages of the available options.

There are few high-quality studies evaluating educational interventions or strategies for children who are gifted [12]. Educational practices that are used for children who are gifted have influenced general education practices and in some cases may have been derived from special education. As such, educational practices that are useful for children who are gifted are useful for a wide range of students [13-15]. These practices include:

●Recognition of individual differences

●Focusing on concepts rather than memorizing information or learning a circumscribed skill

●Using an interdisciplinary curriculum and theme-based studies (eg, teaching skills within a broad topic that may be of special interest to the student)

●Using alternative methods of assessment (eg, student portfolios or performance assessment)

●Using peers for teaching and learning

●Problem-based learning emphasizing metacognition (ie, the use of general or prior knowledge and skills to address new learning problems)

Guidelines for the education of students who are gifted suggest that such students [16,17]:

●Be provided with acceleration and enrichment experiences or activities (see 'Acceleration' below and 'Enrichment' below)

●Spend the majority of their school day with others of similar abilities and interests, whether this is part of a high ability group within their grade or in a higher grade

●Can be grouped with students not functioning at the same ability level, but primarily for nonacademic portions of the school day

Availability of interventions — The educational opportunities available for students who are gifted vary from community to community [7,18,19]. Programs and services for students are determined by state laws and policies and are funded at the state and local level. There is wide variation in funding and eligibility definitions [6,18,19]. Programming for students who are gifted may not be a priority in low-income communities or in communities where education is not valued. In such communities, programming for students who are gifted may not be offered by the local school district, even though students in that district may be in need of such programming.

In the United States, information about educational options for children who are gifted in a given state is available from the state's Department of Education website or local school boards and special education departments [20]. Individual state board of education definitions for giftedness are available through the National Association for Gifted Children [4].

Types of intervention — Programming for children with academic or intellectual giftedness must be determined on a case-by-case basis. Specific types of educational interventions or strategies include:

●Acceleration

●Enrichment

●Ability grouping

●Programs focusing on meta-cognitive skills and self-regulation

These interventions may overlap (ie, a program can be accelerated and enriched) [21].

The evidence about the relative merits of different types of programming is largely inconclusive [22]. However, in experimental and controlled studies, acceleration and enrichment have been beneficial in increasing academic achievement [11,23-25]. The learner who is gifted typically benefits most from both acceleration and enrichment.

Acceleration — Acceleration is the practice of allowing the student who is gifted to learn at their own pace. It can occur for one or multiple academic areas and with or without advanced grade placement. With accelerated programming, the usual curriculum may be taught at a faster pace or the student may be permitted to skip formal instruction on the material that they already know. The student may be placed in a higher grade for one or several classes, may be allowed to skip a grade, or may be allowed to complete coursework in less time than it takes other students (eg, to complete high school in less than the typical four years) [7].

Acceleration assumes that children who are gifted learn faster than their peers, but that they learn in the same way (ie, that they are qualitatively similar). This question remains open [26]. Nevertheless, in experimental and controlled studies, acceleration has been associated with improvement in educational progress (sustained interest and involvement in academic activities with high-levels of academic success) of students who are gifted [6,23,27,28]. Acceleration also may raise educational standards for students who are not gifted [14,29].

There are concerns that acceleration may affect the student's social adjustment and that the student may fail to participate in extracurricular activities or find a peer group with classmates who are chronologically older [11]. However, there is no evidence that acceleration is detrimental to the social or emotional adjustment of students who are gifted when the acceleration is well planned [10,28,30,31].

Factors to be considered in determining whether acceleration should be undertaken for an individual student include intelligence quotient (IQ), academic skill level (eg, academic ability level should be above the mean of the desired grade level), social and emotional maturity to interact with older peers, and whether the child is receptive to acceleration [10]. Information about the policies regarding acceleration in individual states of the United States is available through the Institute for Research and Policy on Acceleration.

Grade skipping — Grade skipping (also known as double-promotion) is a broad-based form of acceleration that does not take into account the student's specific pattern of abilities or the possibility that students who are gifted learn in different ways than students who are not gifted [21]. Advanced grade placement without other interventions does not guarantee an appropriate educational experience.

The major concern with grade skipping is that it places students who are gifted with students who are physically more advanced and also may be different socially and emotionally. Grade skipping is often avoided for fear of causing social maladjustment. Research findings about social maladjustment are mixed but suggest that decisions about grade skipping should be made on a case-by-case basis [21]. Grade skipping may be an option for a student who is moderately gifted (ie, full scale IQ 130 to 144) who is a rapid learner with a good memory, but should probably be avoided for students who are profoundly gifted (ie, full scale IQ >160) who would need to be placed with children significantly more advanced in age to match their intellectual skills.

Enrichment — Enrichment is the practice of increasing the depth and breadth of content. Enrichment can occur by providing higher-level texts or exposure to other media that explore the topic in greater depth and/or make connections to other disciplines. Enrichment may allow the student to increase their knowledge in a subject area, allow the student to participate in special projects related to the course (eg, reports, presentations), or teach the student creative or other critical thinking skills that may or may not be related to the course content [17,21].

Enrichment can be beneficial to various students, not just those who are gifted [17,18]. However, it may not be appropriate for students who are markedly advanced [11]. Asking students who are profoundly gifted to complete additional work at a level that does not challenge them intellectually does not enhance growth, teach perseverance, require the development of study skills, or combat boredom.

Ability grouping — Ability grouping refers to using test scores or other measures of achievement to assign students with similar abilities to learning groups [6]. Students of similar abilities can be placed in self-contained classrooms for students who are gifted, grouped together within a classroom (or across grades) for specific subjects, or enrolled in schools designed for students who are gifted (eg, magnet schools, science and math schools, private schools that require achievement or IQ testing for admission) [6,21].

Ability grouping has not been studied sufficiently to draw firm conclusions. In meta-analyses of evaluations of self-contained classes for children who are gifted, ability grouping without curriculum modifications (eg, enrichment or acceleration) resulted in minimal or no gains [27,32]. Simply learning alongside peers of similar ability does not provide the stimulation needed by the child who is gifted. However, when combined with appropriate curriculum modifications, ability grouping was associated with improved performance on standardized tests [27]. Ability grouping within the classroom does not appear to affect the educational outcomes of students who are not gifted who are not placed in the high-ability group [18]. (See 'Acceleration' above and 'Enrichment' above.)

Ability grouping must be distinguished from "cooperative learning." Cooperative learning places students into groups without regard to ability. It is commonly used in general education. Cooperative learning may not be effective for students who are gifted if the peer group is at a different ability level [25]. Students who are gifted can become bored or domineering when placed alongside less able peers.

Out-of-school programs — Some programs for children who are gifted occur outside of the regular classroom. Programs for students who are gifted may meet on weekends or during the summer. Such programs are a type of ability grouping because the classes are only open to students who are gifted, who may qualify through a "talent search" [21]. Acceleration, enrichment, or a combination of both can be used in these out-of-school programs. Out-of-school programs may or may not connect with the student's experience during the academic year [18]. (See 'Acceleration' above and 'Enrichment' above.)

Meta-cognitive skills and self-regulated learning — Metacognitive skills and self-regulated learning are additional approaches that may be of value for some students who are gifted [6,21,33-36]. Meta-cognitive skills use prior knowledge, or knowledge from several disciplines, to solve complex and novel problems. Self-regulated learning skills are the skills required by students to plan, monitor, and evaluate their own learning. The student is taught to become aware of their attitude towards learning (curiosity, persistence, self-confidence), and develop the skills of choosing their own goals, planning the steps needed to reach the goal, and verifying success in executing the plan.

Social and emotional development — Educational programming for children who are gifted can address social and emotional development through [6]:

●Ensuring time to learn with others of similar abilities

●Providing opportunities to explore areas of interest with a variety of peers

●Provision of mentoring or coaching to cope with the stress, criticism, and social demands of high achievement

●Developing approaches to help students who are gifted support one another (eg, group interventions that provide direct instruction in conflict resolution, decision making, and leadership)

Special populations

Profoundly gifted — Students who are profoundly gifted may be under-challenged even in a program for students who are gifted [11,21,37]. They may not find their appropriate level of challenge until they reach college. Grade skipping generally should be avoided for students who are profoundly gifted who would need to be placed with significantly older peers to match their intellectual skills. (See 'Grade skipping' above.)

Gifted with learning disorder — Some students can have both giftedness and a learning disorder (LD). These students perform in advance of expectations in their gifted academic areas and below cognitive expectations in their area of LD. Services for students who are gifted and also have an LD ideally should include a combination of enrichment and/or acceleration in the academic area of strength and remediation (eg, special education services) for the areas of weakness [38]. This may result in grade level asynchronies within the student's educational program. (See 'Acceleration' above and 'Enrichment' above and "Specific learning disorders in children: Educational management", section on 'Quality instruction for learning disorders'.)

The accommodations and interventions for LD that are available through special education should be made available to the student who is gifted and has LD, but only if the developmental demands in the areas of weakness are appropriate to the student's ability level. As an example, it may not be appropriate to place a student who is gifted and has LD into a class for students with LD, because the student who is gifted with LD may perform better than the students with LD who are not gifted. The student who is gifted with LD may best be served by providing supports and services in a general education setting. (See "Specific learning disorders in children: Educational management".)

Children who are gifted and have LD may not qualify for special education services if the school does not recognize their area(s) of weakness as a LD [39]. This may occur if the child's level of function in one academic area is within the average range for their age or grade, even if it is substantially lower than their general cognitive ability. (See "Specific learning disorders in children: Evaluation", section on 'Determination of service eligibility'.)

A detailed discussion of educational interventions for students who are gifted with coexisting LD is beyond the scope of this topic review but can be found in the following references [3,38,40].

NONACADEMIC GIFTEDNESS — The literature provides little guidance about how to address the needs of children who are gifted in nonacademic domains. Giftedness in areas such as art, music, athletics, and other domains generally is addressed by professionals trained in these domains. The approach for a particular child will vary depending upon the professional who takes on the mentoring or teaching role.

ROLE OF THE PRIMARY CARE PROVIDER — The primary care provider can play an important role in identifying giftedness and coexisting conditions and providing anticipatory guidance and support to families with a child who is gifted [6,7]. This section will focus on the provision of anticipatory guidance and support. The role of the primary care provider in identification of giftedness is discussed separately. (See "Children who are gifted: Characteristics and identification", section on 'Role of the primary care provider'.)

Children who are gifted, particularly children who are profoundly gifted (ie, intelligence quotient >160), pose special challenges to families. Similar to families of children with disabilities, it is important for families of children who are gifted to ensure that demands and expectations for the child are commensurate with the child's underlying ability levels to avoid secondary social, emotional, or behavioral problems. The primary care provider can support the family by providing anticipatory guidance to promote a healthy balance for the family as a whole, monitoring the child who is gifted for specific vulnerabilities, and helping the family find appropriate educational programming for their child.

The primary care provider's awareness of the special concerns of children who are gifted and their families can help children who are gifted to succeed. Like all children, children who are gifted are more likely to succeed if their needs are understood and addressed.

Anticipatory guidance

For the child — It is important for the primary care provider to help the child who is gifted to understand how they are different from other children and to value those differences. Nonetheless, children who are gifted should understand that they are expected to:

●Complete activities of daily life and respect and follow the household's rules of conduct

●Have friends and have fun

●Perform well at school, both in terms of academic function and classroom participation behaviors

For the family — Families play a central role in developing the talents of a child who is gifted; they serve as the child's initial teachers and can nurture the child's curiosity [7]. However, fostering the abilities of children who are gifted may require time, energy, and financial resources [7,10]. Families may feel pressured to provide enriched experiences and may feel burdened by the time and financial commitment required. Parenting and living with a child who is gifted can be challenging, particularly if the child has a coexisting condition, such as a learning disorder [25]. The pressures on the child who is gifted to succeed can be a significant stressor for the family. Siblings of the child who is gifted may receive less attention from the caregivers.

Families may need guidance about how to manage the differences imposed by giftedness and to normalize their experience of feeling inadequate to the task of raising a child who is gifted. The caregivers may not feel prepared to address the child's asynchronous development, internal drive, perfectionism, questioning authority, or atypical social preferences. The primary care provider can provide information and anticipatory guidance to help with these challenges.

Important aspects of anticipatory guidance for caregivers and siblings of children who are gifted include [10,11,20]:

●Provision of information about identification practices, educational, and programming options (see "Children who are gifted: Characteristics and identification", section on 'Identification' and 'Types of intervention' above)

●Demystification of giftedness

●Assurance that most children who are gifted have good psychosocial adjustment (see "Children who are gifted: Characteristics and identification", section on 'Emotional characteristics')

●Guidance about how to manage the differences imposed by giftedness

•Asynchronous development.

•Internal drive (eg, wanting to spend excessive time on areas of interest); the caregivers can set time limits to help the child balance the area of interest with other important aspects of childhood (eg, having friends and having fun).

•Perfectionism and its attendant frustration (encourage them to help the child set realistic goals, focus on the process rather than the outcome, and to value the lessons learned from their mistakes) [6,41].

•Atypical social preferences (eg, older children, adults); contact with other children who are gifted of the same age is a major benefit of special programs for children who are gifted. (See 'Social and emotional development' above.)

•More frequent questioning of authority; when the caregiver's authority is questioned, they can respond with something like: "I have to do my job. My job is to make sure that you perform well in all areas of life, not just those that you prefer."

●Letting caregivers know that it is normal to feel inadequate or ill-equipped to raise a child who is gifted; there is no single best way to raise a child who is gifted, as long as the caregivers set clear and high expectations and are invested and responsive (eg, respect the child's questions, provide interesting experiences, etc) [6,42]

●Helping caregivers avoid resentment of the child who is gifted by their siblings who are not gifted (by encouraging them to consider each of their children as unique, with individual strengths and weaknesses rather than gifted/not gifted, and encouraging them to spend designated special time with each child)

●Helping caregivers to understand that, despite their differences, children who are gifted should be expected to participate in family and community life, to respect household rules, to participate in tasks, chores, etc; this is true no matter how much time is dedicated to talent development or how sophisticated the child is at arguing that they need not comply with ordinary rules of conduct

●Helping caregivers to understand that students who are gifted may lack motivation for learning; rewarding the process of learning and developing intrinsic motivation for learning is an important goal for students who are gifted and students who are not gifted alike [43]:

•Caregivers can support autonomy by allowing the student some say in how to manage the demands of life, not just formal learning

•Caregivers can support competence by helping the student see their own progress and development in a talent or area of interest, instead of simply comparing themselves to other same-age students

•Caregivers can support social relatedness by encouraging the student to develop peer relations in areas outside their talent(s), as well as in areas of talent

Assessing program quality — The following questions can help caregivers assess the child's current programming and help decide if evaluation and specialized or gifted programming is needed:

●Does the child enjoy school?

●Is the child learning new information or simply repeating topics already mastered?

●Are academic strengths as well as weaknesses noticed in the student?

●Does the teacher know the child, and does the teacher know what the child can really do?

●Is the school able to be flexible in matching educational programs to the child's interests and needs?

●Does the school offer educational acceleration, enrichment, or ability grouping?

Monitoring for vulnerabilities — Although children who are gifted generally have good emotional adjustment, they have particular areas of emotional vulnerability. It is important for the primary care provider to monitor for these problems and make referrals to mental health providers as necessary.

These vulnerabilities include [6,7,41]:

●Sensitivity, emotional intensity, loneliness, and social isolation (particularly for those with intelligence quotient >160) (see "Children who are gifted: Characteristics and identification", section on 'Social characteristics')

●Maladaptive perfectionism, which may lead to anxiety or depression (see "Children who are gifted: Characteristics and identification", section on 'Emotional characteristics')

●Asynchronous development in social, emotional, and intellectual domains (see "Children who are gifted: Characteristics and identification", section on 'Developmental characteristics')

●Maladaptive behaviors and academic failure if not sufficiently challenged and supported (see 'General principles' above)

Additional information about balancing psychosocial health with giftedness is available in reference [44].

Advocacy — The primary care provider may be able to provide information or resources about programs to help the student who is gifted explore their interests in greater depth and to interact with peers who have similar interests and abilities. (See 'Resources' below.)

Practitioners who are familiar with local school districts and programs may be able to help caregivers negotiate with school personnel to determine the optimum interventions for their child [7,10].

OUTCOME — Longitudinal studies of children identified as intellectually advanced in elementary school indicate that, as a group, they continue to achieve at relatively high levels of competence [7]. However, there is individual variation. Opportunities for education and mentoring, socioeconomic conditions, individual social skills and motivation, and participation in talent development programs may affect long-term outcomes [21,45,46]. Programs for children who are gifted vary across the United States, and outcomes of individual programs are difficult to generalize [47]. Although participating in gifted programming is strongly correlated with success later in life, it is not clear whether this success is related to gifted programming or to personal and family factors [48].

Most children who are gifted do well as adults. However, they do not necessarily make major contributions to their particular domain or achieve eminence in a field [46,49]. Above the level of 120, intelligence quotient appears not to predict adult eminence [50].

Students who are gifted can and do drop out of school. The number of students who are gifted who drop out is unclear because of the limited number of quality studies and the varying definitions of giftedness [51]. However, students who are gifted may be over-represented among high school dropouts. In one study of gifted high school drop-outs, the reasons for dropping out varied, but not liking school was a major factor [52].

The long-term course of nonacademic talents (eg, music, chess, athletics) is variable. It depends upon the social value placed upon the talent, opportunities for expert instruction, and the child's dedication [7].

RESOURCES — Resources for clinicians and families are provided in the table (table 2).

SUMMARY

●Terminology – Individuals who are gifted have exceptional abilities in a particular domain or domains (eg, mathematics, music, athletics). The United States Department of Education definition for giftedness (table 1) is the most widely accepted by researchers and practitioners in the field of giftedness. (See 'Terminology' above.)

●Intellectual giftedness – The development of giftedness is a long-term endeavor, fostered by early identification, supportive and encouraging caregivers, and teachers and mentors who place high expectations on the student. Students who are gifted need to be challenged to maintain interest and high achievement. Those who are not sufficiently challenged may develop maladaptive behaviors, mental health conditions (eg, depression), and/or academic failure. Lack of challenge can inhibit the development of self-confidence and lead to poor study habits. (See 'General principles' above.)

The educational opportunities available for students who are gifted vary from community to community. (See 'Availability of interventions' above.)

Educational programming for children with academic or intellectual giftedness is best determined on a case-by-case basis. In experimental and controlled studies, acceleration and enrichment have been beneficial in increasing academic achievement. (See 'Types of intervention' above.)

Services for students who are gifted and also have a learning disorder ideally should include a combination of enrichment and/or acceleration in the academic areas of strength and remediation for the academic areas of weakness. (See 'Gifted with learning disorder' above.)

●Nonacademic giftedness – Giftedness in areas such as art, music, athletics, and other domains generally is addressed by professionals trained in these domains. The approach for a particular child will vary depending upon the professional who takes on the mentoring or teaching role. (See 'Nonacademic giftedness' above.)

●Role of the primary care provider – The primary care provider can play an important role in providing anticipatory guidance and support to the child who is gifted and their family. The primary care provider also can monitor the child who is gifted for vulnerabilities associated with giftedness. (See 'Role of the primary care provider' above.)

●Outcome – Longitudinal studies of children identified as intellectually advanced in elementary school indicate that, as a group, they continue to achieve at relatively high levels of competence. However, there is individual variation. (See 'Outcome' above.)