Alena Foong

Institute of Mental Health, Singapore

Too Bright to Fail, Too Complex to Fit: Twice-Exceptionality in an Adolescent with ADHD, Autism, and Complex Mood and Behavioural Dysregulation

---

Biography

Dr Alena Foong is a fourth-year psychiatry resident at the Institute of Mental Health (IMH), Singapore. She holds an MD from the University of New South Wales (UNSW). With a strong clinical interest in child/adolescent psychiatry, Dr Foong has rotated through child/adolescent units during her training as well as in her earlier years as a medical student. 

Abstract

Twice-exceptional (2e) individuals possess high cognitive ability alongside one or more neurodevelopmental or psychiatric conditions, yet clinical and educational services typically assess giftedness and disability within separate frameworks, obscuring both intervention priorities and prognosis. We present a 13-year-old girl with attention-deficit/hyperactivity disorder and autism spectrum disorder, with cognitive testing in the extremely high range, who developed progressive mood and behavioural dysregulation over eighteen months, including recurrent self-harm, suicidal ideation, and escalating aggression culminating in an emergency psychiatric admission. Sequential diagnoses of major depressive disorder and oppositional defiant disorder were added despite trials of an SSRI, stimulant medication, and an antipsychotic, with limited sustained improvement. Multidisciplinary review suggested her presentation reflected the interaction, rather than the simple sum, of her exceptionalities: high intelligence masking early distress, autism-related rigidity intensifying oppositional behaviour, and a coercive parent-child cycle reinforcing dysregulation. Applying an operational definition of twice-exceptionality reframed the case as a comorbidity effect requiring integrated, rather than sequential, management. Drawing on evidence from a strengths-based, talent-focused school programme that produced sustained cognitive, emotional, and social growth in 2e students, we argue that psychiatric management of twice-exceptional youth should incorporate strengths-based strategies alongside standard pharmacological and psychotherapeutic approaches, rather than defaulting to purely deficit-oriented treatment. This case highlights the need for assessment and management models that account for the interactive effects of giftedness and disability in this under-recognised population.