Understanding Nonverbal Learning Disabilities

Understanding Nonverbal Learning Disability
Binyamin Goldman, PsyD

Definition
A nonverbal learning disability (NLD) is a developmental brain based disorder that impairs a child's capacity to perceive, express, and understand nonverbal (nonlinguistic) signs.
The disorder is generally expressed as a pattern of impaired functioning in the nonverbal domains, with higher functioning in the verbal domain.

Definition
The neuropsychological deficits associated with this disorder constrain children's capacity to function in the academic, social, emotional, or vocational domain and lead to a heterogeneous set of neurobehavioral symptoms.
The brain dysfunctions affect children's behaviors, their social interactions, their feelings about themselves and others, and their emerging personality patterns--all of which may manifest as symptomatic behaviors.

Discovery
Johnson & Myklebust (1967)
Coined the term nonverbal learning disability
Referred to a residual group of children who did not have verbal language problems but did have a range of symptoms that interfered with their school functioning
Initially used the term “disorders of social imperception,” referring to: “a child’s … lack of ability to understand his social environment, especially in terms of his own behavior.”
Concluded that these children have a hard time understanding the meanings of other people’s social cues

Prevalence
NLD estimated at 5-10% of LD clinical sample (Rourke, 1989)
Population prevalence of LD around 10% (Pennington, 1991)
Overall NLD population prevalence= 0.1-1.0%

Gender Ratios
Reports have changed over time
1960’s- 5:1 (Rourke, 1989)
1970’s- 2.8:1 (Rourke & Strang, 1978)
1989- 1:1 (Rourke, 1989)
Changes thought to be due to shifting gender roles

Rourke’s Hierarchical System

Primary Assets
Simple motor skills
Simple, repetitive motoric skills are generally intact, especially at older age levels (middle childhood and beyond).
Auditory perception
After a very early developmental period when such skills appear to be lagging, auditory-perceptual capacities become very well developed.
Rote material
Repetition and/or constancy of stimulus input - especially through the auditory modality, but not confined to it - is well appreciated.
Repetitious motoric acts, including some aspects of speech and well-practiced skills such as handwriting, eventually develop to average or above-average levels
(Rourke, 2008)
(Rourke, 2008)

Secondary Assets
Attentional skills
Deployment of selective and sustained attention for simple, repetitive verbal material (especially that delivered through the auditory modality) becomes very well developed.
(Rourke, 2008)

Tertiary Assets
Memory
Rote verbal memory and memory for material that is readily coded in a rote verbal fashion becomes extremely well developed.
Verbal Assets: Speech and Language
Following an early developmental period when linguistic skills appear to be lagging, a number of such skills emerge and develop in a rapid fashion. These include excellent phonemic hearing, segmentation, blending, and repetition.
Very well-developed receptive language skills and rote verbal capacities are evident, as are a large store of rote verbal material and verbal associations, and a very high volume of speech output.
All of these characteristics tend to become more prominent with advancing years.
(Rourke, 2008)

Academic Assets
Following initial problems with the visual-motor aspects of writing and much practice with a writing instrument, graphomotor skills (for words) reach good to excellent levels.
Following initial problems with the development of the visual-spatial feature analysis skills necessary for reading, good to excellent single-word reading skills also develop to above-average levels.
Misspellings are almost exclusively of the “phonetically accurate” variety: that is, the type seen most often in normal spellers.
Verbatim memory for oral and written verbal material can be outstanding in the middle to late elementary school years and thereafter.
(Rourke, 2008)

Primary Deficits
Tactile perception-
Bilateral tactile-perceptual deficits are evident, often more marked on the left side of the body.
Deficits in simple tactile imperception and suppression may become less prominent with advancing years, but problems in dealing with complex tactile input tend to persist.
Visual perception-
There is impaired discrimination and recognition of visual detail and visual relationships, and there are outstanding deficiencies in visual-spatial-organizational skills.
Simple visual discrimination, especially for material that is verbalisable, usually approaches normal levels with advancing years. Complex visual-spatial-organizational skills, especially when required within a novel framework, tend to worsen relative to age-based norms.
(Rourke, 2008)

Primary Deficits
Complex psychomotor skills-
Bilateral psychomotor coordination deficiencies are prominent; these are often more marked on the left side of the body. These deficits, except for well-practiced skills such as handwriting, tend to increase in severity with age, especially when they are required within a novel framework.
Novel material-
As long as stimulus configurations remain novel, they are dealt with very poorly and inappropriately.
Difficulties in age-appropriate accommodation to, and a marked tendency toward over-assimilation of, novel events increase with advancing years.
There is an over-reliance on prosaic, rote (and in consequence, inappropriate) behaviors in such situations. The capacity to deal with novel experiences often remains poor and may even worsen with age.
(Rourke, 2008)

Secondary Deficits
Attention-
Attention to tactile and visual input is poor.
Relative deficiencies in visual attention tend to increase over the course of development, except for material that is programmatic and over-learned (e.g., printed text).
Deployment of selective and sustained attention is much better for simple, repetitive verbal material (especially that delivered though the auditory modality) than for complex, novel nonverbal material (especially that delivered through the visual or tactile modalities).
The disparity between attentional deployment capacities for these two sets of materials tends to increase with age.
(Rourke, 2008)

Secondary Deficits
Exploratory behavior.
During early phases of development, there is little physical exploration of any kind. This is the case even for objects that are immediately within reach and could be explored through visual or tactile means.
A tendency toward sedentary and physically limited modes of functioning tends to increase with age.
(Rourke, 2008)

Tertiary Deficits
Memory-
Memory for tactile and visual input is poor.
Relative deficiencies in these areas tend to increase over the course of development, except for material that is programmatic and overlearned (e.g., spoken natural language).
Memory for nonverbal material, whether presented through the auditory, visual, or tactile modalities, is poor if such material is not readily coded in a verbal fashion.
Relatively poor memory for complex, meaningful, and/or novel verbal and nonverbal material is typical.
Differences between good to excellent memory for rote material and impaired memory for complex material and/or that which is not readily coded in a verbal fashion tend to increase with age.
(Rourke, 2008)

Tertiary Deficits
Concept-formation, problem-solving, strategy-generation, and hypothesis-testing/appreciation of informational feedback.
Marked deficits in all of these areas are apparent, especially when the concept to be formed, the problem to be solved, and/or the problem-solving milieu(x) is/are novel or complex.
Also evident are significant difficulties in dealing with cause-and-effect relationships and marked deficiencies in the appreciation of incongruities (e.g., age-appropriate sensitivity to humor).
Most noticeable when formal operational thought becomes a developmental demand (i.e., in late childhood and early adolescence), relative deficits in these areas tend to increase markedly with advancing years, as is evident in the often widening gap between performance on rote (overlearned) and novel tasks.
(Rourke, 2008)

Linguistic Deficits
Speech and language.
Mildly deficient oral-motor praxis, little or no speech prosody, and much verbosity of a repetitive, straightforward, rote nature are characteristic.
Content disorders of language, characterized by very poor psycholinguistic content and pragmatics (e.g., “cocktail party” speech) and reliance upon language as a principal means for social relating, information gathering, and relief from anxiety.
"Memory" for complex verbal material is usually very poor, probably as a result of poor initial comprehension of such material.
All of these characteristics, except oral-motor praxis difficulties, tend to become more prominent with advancing years.
(Rourke, 2008)

Academic Deficits
Graphomotor
In the early school years, there is much difficulty with printing and cursive script; with considerable practice, handwriting often becomes quite good. However, some avoid practice and remain deficient in such skills.
Reading comprehension
Reading comprehension is much poorer than single-word reading (decoding).
Relative deficits in reading comprehension, especially for novel material, tend to increase with advancing years.
(Rourke, 2008)

Academic Deficits
Mechanical arithmetic and mathematics
There are outstanding relative deficiencies in mechanical arithmetic as compared to proficiencies in reading (word-recognition) and spelling.
With advancing years, the gap between good to excellent single-word reading and spelling and deficient mechanical arithmetic performance widens.
Absolute level of mechanical arithmetic performance only rarely exceeds the Grade 5 level; mathematical reasoning, as opposed to programmatic arithmetic calculation, remains poorly developed.
(Rourke, 2008)

Academic Deficits
Science
Persistent difficulties in academic subjects involving problem-solving and complex concept-formation (e.g., physics) are prominent.
Problems in dealing with scientific concepts and theories become apparent by early adolescence.
The gap between deficiencies in this type of complex academic endeavor and other, more rote, programmatic academic pursuits widens with age.
(Rourke, 2008)

Psychosocial/Adaptational Deficits
Adaptation in novel situations
There is extreme difficulty in adapting to (i.e., countenancing, organizing, analyzing, and synthesizing) novel and otherwise complex situations.
An over-reliance on prosaic, rote (and, in consequence, inappropriate) behaviors in such situations is common.
These characteristics tend to become more prominent and problematic with advancing years.
Social competence.
Significant deficits are apparent in social perception, social judgment, and social interaction skills; these deficits become more prominent and problematic as age increases.
There is a marked tendency toward social withdrawal and even social isolation with advancing years.
(Rourke, 2008)

Psychosocial/Adaptational Deficits
Psychosocial disturbance
Often characterized during early childhood as afflicted with some type of acting-out or other "externalized" disorder, such children are very much at risk for the development of internalized forms of psychopathology.
Indications of excessive anxiety, depression, and associated internalized forms of psychosocial disturbance tend to increase with advancing years.
Activity level
Children who exhibit the syndrome are frequently perceived as hyperactive during early childhood. With advancing years, they tend to be characterized as normoactive and eventually hypoactive.
(Rourke, 2008)

The Three Domains

Factors Affecting the Phenotype

Possible NLD Phenotypes

Locating the Deficit

Processing a Social Situation

The Neurological Perspective
History and Models

Early Studies
Generally pursued a hypothesis of right hemisphere dysfunction
Focused on brain-damaged individuals who displayed symptoms similar to NLD
Major validity questions:
No uniformity among samples
No precise way to identify type or location of brain lesion
(Palombo, 2006)

Early Studies
Applied various labels to their cohorts:
Disorders of social imperception(Johnson & Mykelbust, 1967)
Left hemisyndrome(Denckla, 1978)
Nonverbal learning disability (Rourke, 1989; Johnson, 1987)
Social-emotional learning disability (Denckla, 1983; Voeller, 1986)
Right parietal lobe syndrome/developmental learning disability of the right hemisphere(Weintraub & Mesulam, 1982)
Right hemisphere deficit syndrome (Voeller, 1986)
Right hemisphere deficit syndrome (Semrud-Clikeman & Hynd, 1990)
(Palombo, 2006)

Rourke and Finlayson (1978)
GL +2
GL
GL -2

Group 2
(relative arithmetic weakness)
Groups 1 & 3
Performed worse on visuospatial skills measures
Performed better on rote verbal and auditory processing measures
Performed worse on rote verbal and auditory processing measures
Performed better on visuospatial skills measures
Visuospatial measures: Nonverbal WISC subtests, Target Test (requiring drawing a pattern from memory)
Rote verbal & auditory processing measures: Peabody Picture Vocabulary Test, Speech-Sound Perception Test, Auditory Closure Test

Concluded that the arithmetic deficit group represented a distinct population with a unique profile of neurological assets and deficits
Suggested that the difference between that group and the other two had to do with brain hemispheres
This group’s difficulties were due to dysfunction in the right cerebral hemisphere
The other group’s difficulties were related to left hemisphere skills

Rourke (1987)
Found the NLD neuropsychological profile in children with other neurological conditions such as hydrocephalus, moderate to severe head injury, congenital absence of the corpus callosum, and post-radiation survival of childhood cancer.
Commonality of this group not right hemisphere dysfunction, but white matter damage or dysfunction

White Matter

White Matter
Sends the messages through the grey matter
If grey matter like the computer, white matter like the cables
White from the myelin

Rourke’s White Matter Model
NLD occurs when there is a problem with:
the white matter
in the right hemisphere
Adverse conditions in early childhood are more likely to affect right hemisphere processing abilities because:
The right hemisphere contains a greater proportion of white matter to grey matter than does the left hemisphere
The right hemisphere is dominant in infancy
(Rourke, 1987; Rourke et al., 2002)

Hemispheric Specialization
“Localization”-
Broca (in 1861) and Wernicke (in 1876)
Hypothesized specific areas of the cerebrum that are responsible for specific functions
Shaped the historical understanding of brain functioning
(Palombo, 2006)

“Lateralization”
Differs from the concept of localization in that: “laterality is relative, not absolute, because both hemispheres play a role in nearly every behavior.”
For example:while the left hemisphere is especially important for producing language, the right hemisphere plays some role as well.
(Kolb & Whishaw, 2001, p. 180)

“Lateralization”
This means that just because many NLD symptoms appear to be the products of right hemisphere dysfunctions, that does not necessarily mean that the left hemisphere and subcortical regions do not also contribute to those problems
(Palombo, 2006)

Left Hemisphere
More specialized for
Utilizing information already learned
Processing verbal language
Verbal manipulation of numbers
Logical, analytical thinking
Dealing with details
Right Hemisphere
More specialized for
Novel learning
Nonverbal reasoning
Spatial construction, visual perception
Music ability
Global, gestalt-oriented analysis

(Mesulam, 2000, p. 80)

Specializations of the Right Brain
1. Complex and Nonlinguistic Perceptual Tasks
Auditory abilities to recognize pitch and melody
Visual discrimination such as the ability to recognize faces, identify complex geometric shapes
Visual-Spatial abilities necessary for depth perception, spatial location, mental rotation, visual perspective taking
Visual-Motor abilities such as tracing mazes and block design
Spatial memory to recall complex spatial relationships
Time perception
Many of these abilities are essential to successful social communication.
(Palombo, 2006, p. 45)

2. Paralinguistic Aspects of Communication
Decoding: the ability to read social signs such as facial expressions and vocal intonation
Encoding: the ability to form mental representations of those signs and store them in memory
Processing: understanding what the signs communicate within the context in which they occur
Expression: retrieving the sign from memory and producing it through some motor output

3. Spatial Distribution of Attention
Very little research exists with regard to how this function relates to the problems displayed by children with NLD.

4. Emotion Perception
Processesing the perception of affect states
Coordinating the expression of emotional tone through paralinguistic communication
Identifying the emotion behind others’ prosody and facial expressions
Modulating affects involved in the development of social skills
(Semrud-Clikeman & Hynd, 1990; Mesulam, 2000)

The Two Axes Interpretation
Anterior
-Executive Functions
-Motor Output
Right Hemisphere
-Novel/Global/Coarse
-Divergent/Discordant
-Fluid Abilities
Left Hemisphere
-Routinized/Detailed/Local
-Convergent/Concordant
-Crystallized Abilities
Posterior
-Sensory Input
-Comprehension

Developmental Profile
NLD Through the Lifespan
(from Thompson, 1997)

Infant and Toddler Years
Does not explore the world motorically
Speech and language develop early
Wants a verbal label for everything
No strong evidence of non-motoric developmental delay
Appears “drunk” in early attempts to walk
Does not automatically assume a position of balance when set down after being held
Clings to objects and people for balance
Constantly bumps into things
(Thompson, 1997)

Preschool Years
Exceptional rote verbatim memory skills
Extremely verbose, perhaps talking “like an adult”
Early reading skills, strong letter and number recognition and spelling skills
Understands statements and readings very literally, views things as black and white
Poor gross motor development and motor planning skills
(Thompson, 1997)

Middle School Years (11-14)
is often excluded, teased, and persecuted at school
is misunderstood by both teachers and peers
has difficulty meeting age-appropriate behavioral expectations; these difficulties may be misattributed to "emotional" issues
has problems with work and study habits; these problems may be misattributed to "motivational" issues
has visual-spatial-organizational difficulties, difficulty using a locker, can't find his way around campus, is often lost or tardy

High School Years (15-18)
by high school, peer tolerance usually increases; one or two close friendships may develop (or continue)
If an Individualized Education Program has been put into place to accommodate the student, academic achievement, which typically drops in middle school, makes an encouraging comeback; if no IEP, this student is at risk for dropping out of school
still thinks in concrete and literal terms
is slow to date and interact with the opposite sex

High School Years
early job experience performance problems are common
has difficulty learning to drive, can't coordinate the use of a manual shift
is socially immature; may be seen as a "nerd" or "weird" by classmates
has low self-esteem; is prone to depression, withdrawal, anxiety, and suicide

Social Development

Theory of Mind
The ability to attribute intentions, desires, beliefs, and other mental states to oneself or to another
Enables one to make sense of and predict the behavior of others
Well-developed theory of mind is the foundation of social competence
Severe deficit in this area is considered a central characteristic of autism
(Baron-Cohen, 1997)

Theory of Mind
What about children with NLD?

Theory of Mind
False-Belief Test
Child
No studies of False-Belief Test performance for kids with NLD

Theory of Mind
Children with NLD:
Have difficulty with reciprocal exchanges
Are socially immature
Are argumentative & socially disruptive
Have difficulty maintaining friendships
Are often rejected by their peers

Theory of Mind
BUT… clinical data suggests that:
These children typically desire friends and relationships with others
They are capable of deception and imaginary play
They are able to understand that others have beliefs and intentions
(Palombo, 2006)

Don, age 11, complained bitterly to his therapist that kids continually teased him. When asked what they said, he reported that they accused him of being cruel and sadistic to his beloved cat. They said that he enjoyed hurting the pet or that he had set fire to his cat’s tail, none of which was true. His response was to protest loudly that he was not that kind of person and would never do such things to his pet. However, his reaction only inflamed the other kids, inciting them to escalate their teasing

Theory of Mind
Why are these children so often helpless to defend themselves against taunting?
Where is the deficit?

Don could not get beyond the literal meaning of what his peers said; he could not see through their remarks to discern their motives. Once these motives were pointed out to him, he was able to take what the other kids said as a “joke” and respond with his own brand of humor.

Differential Diagnosis
Is NLD Really Different from Asperger’s?

NLD vs. AS
NLD and AS are very similar in behaviors, NP profiles, and comorbid conditions
“The process of differentiating the characteristics of AS, and NLD, and a pragmatic language disorder arguably may be the most challenging diagnostic task in developmental –behavioral pediatrics.” (Stein, 2008)
Lack of agreement on core definitions of both disorders. (Palombo, 2006)

Rourke suggests that the two should not be dissociated (Rourke, et al., 2002)
The two are not mutually exclusive (they belong to different classification systems) and often co-uccur .(Klin, 2008)
Children with AS have NLD, but many children with NLD don’t have AS (Palombo, 2006)
AS has more stereotypic behaviors and restricted interests, greater impairment of sense of self, theory of mind

Is NLD on “The Spectrum?”
?
?

Interventions

3 Levels of Intervention

Psychomotor and Perceptual Motor Deficits
Remedial interventions
Specific training/practice in handwriting accuracy and speed
Direct instruction in functional perceptual skills such as:
Reading facial expressions
Understanding gestures
Reading maps and graphs
(From: Telzrow & Bonar, 2002)

Compensatory interventions
Extended time for completing written work
Handwriting aids such as a word processor or scribe
Providing multiple choice rather than essay questions when testing content knowledge
Organizing worksheets with a limited number of well-spaced prompts
Providing teacher-prepared lecture guides to minimize need for note-taking
Use of oral or written directions and explanations instead of visual maps and schemas

Instructional/therapeutic interventions
Adapted physical education with emphasis on developing functional recreational activities
Early and sustained training and practice in keyboard skills
Occupational therapy to enhance perceptual and psychomotor deficits

Arithmetic Deficits
Remedial Interventions
Direct instruction in computation using verbal mediation to rehearse sequential steps
Color-coded arithmetic worksheets to cue right-left directionality
Direct instruction in organizational schemas and checking strategies
Preteaching/reteaching to reinforce and distinctions relationships among concepts

Arithmetic Deficits
Compensatory Interventions
Graph paper to assist in column alignment when completing arithmetic problems
Use of a calculator or matrix of arithmetic facts
Chapter summaries or study guides
Rehearsal strategies that rely on verbal mnemonic devices
Instructional/Therapeutic Interventions
Strategy training in specific skill areas, such as written expression
Graphic organizers, especially with sequential/ linear components

Problem-Solving Skills
Direct instruction and rehearsal of appropriate responses in various situations
Reference list of rote “rules” to direct behavior
Problem-solving instruction and practice

Interpersonal Skills
Direct instruction in social pragmatic skills, such as making eye contact, greeting others, and requesting assistance
Teaching strategies for making and keeping friends
Vocational guidance toward careers that minimize interpersonal skill requirements
Choosing structured, adult-directed, individual or single-peer social activities over unstructured or large group events

Social and Interpersonal Skills
Social skills training using published curricula
For best results: target critical skills, match training to individual behavioral deficits/excesses, train in naturalistic settings, and use functional approach to generalization
Interpersonal rules, social stories, and social scripting
Pragmatic language therapy to address skills related to topic maintenance, verbal self-monitoring, and appropriate social communication

Psychosocial Adjustment Problems
Self-monitoring to reduce symptoms of inattention and impulsive behavior
Investigation of other features of NLD syndrome in preschool/primary age children who display ADHD
Relaxation skills to compensate for pervasive anxiety
Increasing access to pleasant events to address depressive symptoms

Psychosocial Adjustment Problems
Educator/parent awareness training concerning risk for depression and suicide
Student insight counseling about NLD features, interventions, and prognosis
Cognitive behavioral interventions to enhance positive self-schema and reduce cognitive distortions

Classification
Depends on the state and district
Almost no state has NLD as a SLD
Most NLD children receive services, if at all, based on other conditions or seek an AS diagnosis.

References (partial)
Palombo, J. (2006). Nonverbal learning disabilities: A clinical perspective. New York: W. W. Norton & Company
Rourke, B. (1989). Nonverbal learning disabilities: The syndrome and the model. New York: Guilford Press.
Telzrow, C. & Bonar, A. (2002). Responding to students with nonverbal learning disabilities. Teaching Exceptional Children, 34 (6) pp 8-13
Thomoson, S. (1997). The source for nonverbal learning disorders. East Moline, IL: LinguiSystems.

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Understanding Nonverbal Learning Disabilities

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Understanding Nonverbal Learning Disabilities — Presentation Transcript