Differential Diagnosis &Intervention for Non-Verbal Learning Disorders (NLD)

PPA Annual ConventionJune 14, 2000 9 AM to 12 Noon

Neuropsychological Framework for Diagnosis of Learning

Disorders

Disorders of the Left-Hemisphere Disorders of the Frontal Lobes Disorders of the Motor Strip Right-Hemispheric Learning Disorders

– Autism– Aspergers– NLD

Autism: DSM-IV Criteria

Marked impairment in use of multiple nonverbal behaviors

Failure to develop peer relationships Lack of seeking to share enjoyment & interests Lack of social or emotional reciprocity Qualitative impairments in communication Restricted, repetitive & stereotyped patterns of

behavior & interests

Aspergers: DSM-IV Criteria

Qualitative impairments in social interaction same as defined for Autism

Restricted, repetitive & stereotyped patterns of behavior & interests same as defined for Autism

No clinically significant delay in language No clinically significant delay in cognitive

development

NLD: DSM-IV Silent

PDD-NOS– Impairment of reciprocal social

interaction– Impaired verbal and non-verbal

communication skills– Stereotyped behavior, interests &

activities– Category includes “atypical autism”

NLD: DSM-IV Silent

LD-NOS– Includes problems in reading, math &

written expression that significantly interfere with academic achievement

– NLD encompasses a broad range of skill set difficulties which result in academic and social deficits

History of NLD in Research Literature

Johnson & Myklebust (1967)– Nonverbal disorders of learning. In Learning

Disabilities: Educational Principles and Practices. New York: Grune & Stratton.

Wechsler Verbal > Performance by 12 points or more

Johnson & Myklebust (1967)

Academic weaknesses are rooted in deficits in perception & visual imagery

Deficits result in confusion in language processing & cognition

Confusion manifests in difficulties interpreting spatial, part to whole & causal relationships

Johnson & Myklebust (1967)

Difficulty forming visual images Focus on details Failure to grasp the complete picture Trouble interpreting non-verbal cues Significant difficulty perceiving &

interpreting social situations Awkward & slow development of motor

skills

Dormant Stage of NLD Research

1970’s Right To Education Laws parse out broad categories of exceptionality– 1970’s Mental Retardation significant focus of

attention with PARC decision

1980’s Shift to Learning disabilities– Diagnosis & placement issues– LD subtype research– Reading disabilities: The Reading War

Awakening Stage of NLD Research

1980’s Frontal lobe dysfunction: ADHD classification systems

1980’s Major inroads in Reading Research 1980’s Increased research attention to

disorders of written expression Late 1980’s Return to the Right Hemisphere

with work of Byron Rourke

Byron Rourke

1985 Neuropsychology of Learning Disabilities. Adaptive behavior of children who exhibit specific arithmetic disabilities and associated neuropsychological abilities. NY: Guilford Press.

1989 Nonverbal Learning Disabilities. NY: Guilford Press

Byron Rourke

1995 Syndrome of Nonverbal Learning Disabilities: Neurodevelopmental manifestations. NY: Guilford Press.

3 areas of deficit:– Neuropsychological deficits– Academic deficits– Social-emotional/adaptation deficits

Neuropsychological deficits

Tactile & visual perception Psychomotor coordination Visual attention Nonverbal memory Reasoning Executive function Pragmatic aspects of language

Academic deficits

Math calculationMath reasoningReading comprehensionWritten languageHandwriting

Social-emotional/adaptation deficits

Social perceptionPerception of nonverbal social

cuesSocial interactionAnxiety Depression

Overlapping Conditions

NLD is a discrete & separate diagnostic entity

Some symptoms of NLD, however, are similar to those described in other disorders of the right hemisphere.

NLD overlaps with Aspergers syndrome and some central processing disorders

Distinction Matter of Degree

Not seen in typical NLD presentation

– Severe speech prosody deficits

– Pronounced deficits with planning & organization

– Severe tactile-spatial deficits

Overlapping Conditions

Low functioning children diagnosed with Asperger’s syndrome may be more properly diagnosed as Autistic

Higher functioning children diagnosed with Asperger’s, may be more properly diagnosed with NLD

Classification Concerns

There is no formal provision under federal special education law recognizing the existence of nonverbal learning disability as a handicapping condition.

Common Characteristics of NLD

Precocious speech & language development

Verbosity at a young age Remarkable rote verbal memory Hyperlexia (word calling) Strong spelling from dictation

Strengths

Common Weaknesses of NLD

Verbal IQ > Performance IQ (12+ points) Poor writing & writing organization Math disability Poor coordination & balance Poor fine-motor skill Poor visual-spatial and part-to-whole

perception

Common Weaknesses of NLD

Difficulty comprehending novel material Poor pragmatic language skills Poor social interaction Withdrawal tendencies Hyper- to hypo-activity More interest in verbally naming objects

than exploring them

Brain Basis of NLD

Disruption to the right-hemisphere white matter connections

Forms basis for intermodal integration Synthesizer part of the brain

– Visual spatial analysis– Non-verbal social cues– Complex comprehension– Attention to verbal & non-verbal input

May be genetic or acquired

Risk Factors for NLD

50% NLD children have evidence of an antecedent prenatal or perinatal encephalopathic event

50% genetic predisposition 40% history of prematurity Radiation to the head predisposes Agenesis of the corpus callosum Hydrocephalus

Evaluation Clues on Cognitive Measures

Good Information & Vocabulary subtest scores Good rote, verbal memory for math facts Elevated Digits forward (rote verbal memory) Depressed scores on Comprehension &

Picture Arrangement (Social cognition) Depressed scores on Object Assembly (part-

to-whole visual-spatial organization)

Evaluation Clues on Achievement Test Measures: Reading

Strength in phonetic decoding of nonsense words (oral reading is strong)

Weakness in reading comprehension requiring:– Prediction of cause & effect– Ability to separate relevant from irrelevant detail– Inferential thinking

No trouble recalling what is read Good memory for read material

Evaluation Clues on Achievement Test Measures: Writing

Good spelling from dictation Poor spelling in expository writing Poor writing mechanics & organization Will sit & stare at the page; unable to organize

and communicate thoughts through writing Poor penmanship Failure to answer the question: Essay exams

Evaluation Clues on Achievement Test Measures: Math

Often exhibits strength in rote math facts recall

Trouble with math word problems; can’t separate relevant from irrelevant

Trouble with higher-level math conceptsParticular difficulty with geometry

Evaluation Clues on Achievement Test Measures: Knowledge

Often advanced knowledge of facts in Science

Typically poor performances on tests measuring knowledge of content in Social studies

Excels in geography bees but does poorly in Social Studies classes

Evaluation Clues on Language Tests

Strong verbal elaboration and word finding Weak listening comprehension Poor pragmatic language skills

– Social language– Getting the punch line in a joke– Literal translations of language– See things as “black & white”

Evaluation Clues on Visual Perceptual Tests

Poor scores on reversal tests (e.g. Jordan Left-Right Reversal Test)

Poor scores on Category Test (Reitan)Poor performances on Bender and

Developmental Test of Visual-Motor Integration

Low scores Trails A & B (Reitan)

Sample WISC-3 for NLD Student

Information = 17

Similarities = 10

Arithmetic = 8

Vocabulary = 16

Comprehension = 5

(Digit Span) = ( 9)

Verbal IQ = 107

VCI = 111 FDI = 93

Full Scale IQ = 83

Picture Completion = 7

Coding = 5

Picture Arrangement = 4

Block Design = 8

Object Assembly = 3

(Symbol Search) = (6)

Performance IQ = 72

POI = 75 PSI = 77Verbal > Performance by 35 points

Sample WIAT for NLD Student

Basic Reading 125

Reading Comprehension 80

Math Reasoning 75

Numerical Operations 65

Spelling 122

Written Expression 75

Listening Comprehension 85

Oral Expression 135

Process Assessment: Qualitative

Wechsler IQ– Watch for V>P split– Look at subtest patterns

Halstead-Reitan– Watch for depressed

scores on Category, TPT and Trails tests

Bender & VMI Pragmatic language

scales Childhood Autism Rating

Scales (CARS)

WIAT: Deficits– Reading comprehension – Listening comprehension

Woodcock-Johnson– Elevations on Word Attack– Poor scores on Math &

Written expression Social skills

– Piers-Harris– CPQ or MAPI– Child Behavior

Checklists

Educational Course

Elementary: May appear gifted due to strengths in rote memory, oral reading, and fact recall; often poor social skills & attention problems; may be hyperactive

Middle School: Deficits in complex comprehension, inferential thinking, writing and math become more debilitating; social withdrawal; hypoactivity & low arousal; depression

Instructional Methods

Reading: SDI’s for early literacy instruction

– May have initial difficulty learning to read due to misperception of symbol directionality

– Work on directionality perception

– Use synthetic, phonetic instruction

Instructional Methods

Reading: SDI’s for comprehension– SQ3R– Project READ Reading Comprehension Strand– Highlighting techniques– Consumable text books– Extra time to compensate for difficulties in complex

comprehension– Accept literal translations of language– Teach to look for main idea; key concepts; notes

Instructional Methods

Math: SDI’s for complex reasoning & calculation– Saxon math series– Teach using step-wise procedures– Rote verbal memory for steps– Extend time– Shorten assignments– Spot tutoring– Calculator

Instructional Methods

Writing: SDI’s for written expression– Teach touch typing at an early age– Teach rules: capitalization, punctuation, spelling,

grammar (step-wise procedures)– Teach key word note taking methods– Teach step-wise procedures for expository writing– Teach word processing after keyboard is mastered– Extend time/shorten written assignments– Oral tests instead of essay tests

Instructional Methods

Social Skills Training: Direct & Explicit Teaching– Skillstreaming curriculum (Arnold Goldstein & Ellen

McGinnis)– Role playing– Videotaping– Counteract withdrawal– Involvement in physical activity

Instructional Methods

Executive functions & higher level reasoning– Cannot shift gears; needs help with transitions– Perseverative behavior– Require direct eye contact– Preferential seating away from distractions– Avoid visually stimulating environments– Keep all possessions in one central place– Assist with organization

Observed problems: Language

No problem learning vocabulary word meanings

Problem with pragmatics– Cannot understand or express emotional intonation– Hyperverbal in social context; drone on relentlessly

over boring topics– Content of speech is simple & repetitive– Restricted range of interests (TV & computers)

Instructional Methods

Language Therapy– Pragmatics– Non-verbal language: Gestures, body language– Tone of voice– Jokes– Idioms, slang, play on words– Social language: Requires direct & explicit

instruction

Instructional Methods

General Teaching Considerations:– Part-to-whole, stepwise approach– Redundant, sequential teaching– Encourage participation in physical exercise– Explain everything verbally: This type of student

cannot read “body language”– Give practice for repetitive, motor skills– Tell student what to listen for when giving directions– Counter passivity & withdrawal (blends into

woodwork)

Recommended Reading: Neurology

Rourke, B.P. (ED) (1995). Syndrome of Non-Verbal Learning Disabilities: Neurodevelopmental Manifestations. Guilford Press.

Roman, M.A. (1998). The Syndrome of Nonverbal Learning Disabilities: Clinical Description & Applied Aspects. Current Issues in Education, 1 (1).

Semrud-Clikeman, M., & Hynd, G.W. (1990). Right hemispheric dysfunction in nonverbal learning disabilities: Social, academic and adaptive functioning in adults & children. Psychological Bulletin, 107, 196-209.

Recommended Reading: Teachers

Thompson, S. (1997). The Source for Non-Verbal Learning Disorders. LinguiSystems.

Foss, J.M. (1991). Nonverbal learning disabilities and remedial interventions. Annals of Dyslexia, 41, 128-140.

Recommended Reading: Counselors & Therapists

McGinnis, E. & Goldstein, A.P. (1997). Skillstreaming the Elementary School Child: New Strategies & Perspectives for Teaching Prosocial Skills. Research Press.

McGinnis, E. & Goldstein, A.P. (1997). Skillstreaming the Adolescent: New Strategies & Perspectives for Teaching Prosocial Skills. Research Press.

On-line Resources

NLD Line http://www.nldline.com/

OASIS http://www.udel.edu/bkirby/asperger/

NLD on the Web http://www.nldontheweb.org/ Social learning disabilities project at Yale

University http://info.med.yale.edu/chldstdy/research.htm

ASPEN of America http://www.asperger.org/

ASPEN http://www.aspennj.org/