PPA NLD Presentation June 14, 2000


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PPA NLD Presentation June 14, 2000

  1. 1. Differential Diagnosis & Intervention for Non-Verbal Learning Disorders (NLD) PPA Annual Convention J une 14, 2000 9 AM to 12 Noon
  2. 2. Neuropsychological Framework for Diagnosis of Learning Disorders <ul><li>Disorders of the Left-Hemisphere </li></ul><ul><li>Disorders of the Frontal Lobes </li></ul><ul><li>Disorders of the Motor Strip </li></ul><ul><li>Right-Hemispheric Learning Disorders </li></ul><ul><ul><li>Autism </li></ul></ul><ul><ul><li>Aspergers </li></ul></ul><ul><ul><li>NLD </li></ul></ul>
  3. 3. Autism: DSM-IV Criteria <ul><li>Marked impairment in use of multiple nonverbal behaviors </li></ul><ul><li>Failure to develop peer relationships </li></ul><ul><li>Lack of seeking to share enjoyment & interests </li></ul><ul><li>Lack of social or emotional reciprocity </li></ul><ul><li>Qualitative impairments in communication </li></ul><ul><li>Restricted, repetitive & stereotyped patterns of behavior & interests </li></ul>
  4. 4. Aspergers: DSM-IV Criteria <ul><li>Qualitative impairments in social interaction same as defined for Autism </li></ul><ul><li>Restricted, repetitive & stereotyped patterns of behavior & interests same as defined for Autism </li></ul><ul><li>No clinically significant delay in language </li></ul><ul><li>No clinically significant delay in cognitive development </li></ul>
  5. 5. NLD: DSM-IV Silent <ul><li>PDD-NOS </li></ul><ul><ul><li>Impairment of reciprocal social interaction </li></ul></ul><ul><ul><li>Impaired verbal and non-verbal communication skills </li></ul></ul><ul><ul><li>Stereotyped behavior, interests & activities </li></ul></ul><ul><ul><li>Category includes “atypical autism” </li></ul></ul>
  6. 6. NLD: DSM-IV Silent <ul><li>LD-NOS </li></ul><ul><ul><li>Includes problems in reading, math & written expression that significantly interfere with academic achievement </li></ul></ul><ul><ul><li>NLD encompasses a broad range of skill set difficulties which result in academic and social deficits </li></ul></ul>
  7. 7. History of NLD in Research Literature <ul><li>Johnson & Myklebust (1967) </li></ul><ul><ul><li>Nonverbal disorders of learning. In Learning Disabilities: Educational Principles and Practices . New York: Grune & Stratton. </li></ul></ul><ul><li>Wechsler Verbal > Performance by 12 points or more </li></ul>
  8. 8. Johnson & Myklebust (1967) <ul><li>Academic weaknesses are rooted in deficits in perception & visual imagery </li></ul><ul><li>Deficits result in confusion in language processing & cognition </li></ul><ul><li>Confusion manifests in difficulties interpreting spatial, part to whole & causal relationships </li></ul>
  9. 9. Johnson & Myklebust (1967) <ul><li>Difficulty forming visual images </li></ul><ul><li>Focus on details </li></ul><ul><li>Failure to grasp the complete picture </li></ul><ul><li>Trouble interpreting non-verbal cues </li></ul><ul><li>Significant difficulty perceiving & interpreting social situations </li></ul><ul><li>Awkward & slow development of motor skills </li></ul>
  10. 10. Dormant Stage of NLD Research <ul><li>1970’s Right To Education Laws parse out broad categories of exceptionality </li></ul><ul><ul><li>1970’s Mental Retardation significant focus of attention with PARC decision </li></ul></ul><ul><li>1980’s Shift to Learning disabilities </li></ul><ul><ul><li>Diagnosis & placement issues </li></ul></ul><ul><ul><li>LD subtype research </li></ul></ul><ul><ul><li>Reading disabilities: The Reading War </li></ul></ul>
  11. 11. Awakening Stage of NLD Research <ul><li>1980’s Frontal lobe dysfunction: ADHD classification systems </li></ul><ul><li>1980’s Major inroads in Reading Research </li></ul><ul><li>1980’s Increased research attention to disorders of written expression </li></ul><ul><li>Late 1980’s Return to the Right Hemisphere with work of Byron Rourke </li></ul>
  12. 12. Byron Rourke <ul><li>1985 Neuropsychology of Learning Disabilities . Adaptive behavior of children who exhibit specific arithmetic disabilities and associated neuropsychological abilities. NY: Guilford Press. </li></ul><ul><li>1989 Nonverbal Learning Disabilities . NY: Guilford Press </li></ul>
  13. 13. Byron Rourke <ul><li>1995 Syndrome of Nonverbal Learning Disabilities: Neurodevelopmental manifestations . NY: Guilford Press. </li></ul><ul><li>3 areas of deficit: </li></ul><ul><ul><li>Neuropsychological deficits </li></ul></ul><ul><ul><li>Academic deficits </li></ul></ul><ul><ul><li>Social-emotional/adaptation deficits </li></ul></ul>
  14. 14. Neuropsychological deficits <ul><li>Tactile & visual perception </li></ul><ul><li>Psychomotor coordination </li></ul><ul><li>Visual attention </li></ul><ul><li>Nonverbal memory </li></ul><ul><li>Reasoning </li></ul><ul><li>Executive function </li></ul><ul><li>Pragmatic aspects of language </li></ul>
  15. 15. Academic deficits <ul><li>Math calculation </li></ul><ul><li>Math reasoning </li></ul><ul><li>Reading comprehension </li></ul><ul><li>Written language </li></ul><ul><li>Handwriting </li></ul>
  16. 16. Social-emotional/adaptation deficits <ul><li>Social perception </li></ul><ul><li>Perception of nonverbal social cues </li></ul><ul><li>Social interaction </li></ul><ul><li>Anxiety </li></ul><ul><li>Depression </li></ul>
  17. 17. Overlapping Conditions <ul><li>NLD is a discrete & separate diagnostic entity </li></ul><ul><li>Some symptoms of NLD, however, are similar to those described in other disorders of the right hemisphere. </li></ul><ul><li>NLD overlaps with Aspergers syndrome and some central processing disorders </li></ul>
  18. 18. Distinction Matter of Degree <ul><li>Not seen in typical NLD presentation </li></ul><ul><ul><li>Severe speech prosody deficits </li></ul></ul><ul><ul><li>Pronounced deficits with planning & organization </li></ul></ul><ul><ul><li>Severe tactile-spatial deficits </li></ul></ul>
  19. 19. Overlapping Conditions <ul><li>Low functioning children diagnosed with Asperger’s syndrome may be more properly diagnosed as Autistic </li></ul><ul><li>Higher functioning children diagnosed with Asperger’s, may be more properly diagnosed with NLD </li></ul>
  20. 20. Classification Concerns <ul><li>There is no formal provision under federal special education law recognizing the existence of nonverbal learning disability as a handicapping condition. </li></ul>
  21. 21. Common Characteristics of NLD <ul><li>Precocious speech & language development </li></ul><ul><li>Verbosity at a young age </li></ul><ul><li>Remarkable rote verbal memory </li></ul><ul><li>Hyperlexia (word calling) </li></ul><ul><li>Strong spelling from dictation </li></ul>Strengths
  22. 22. Common Weaknesses of NLD <ul><li>Verbal IQ > Performance IQ (12+ points) </li></ul><ul><li>Poor writing & writing organization </li></ul><ul><li>Math disability </li></ul><ul><li>Poor coordination & balance </li></ul><ul><li>Poor fine-motor skill </li></ul><ul><li>Poor visual-spatial and part-to-whole perception </li></ul>
  23. 23. Common Weaknesses of NLD <ul><li>Difficulty comprehending novel material </li></ul><ul><li>Poor pragmatic language skills </li></ul><ul><li>Poor social interaction </li></ul><ul><li>Withdrawal tendencies </li></ul><ul><li>Hyper- to hypo-activity </li></ul><ul><li>More interest in verbally naming objects than exploring them </li></ul>
  24. 24. Brain Basis of NLD <ul><li>Disruption to the right-hemisphere white matter connections </li></ul><ul><li>Forms basis for intermodal integration </li></ul><ul><li>Synthesizer part of the brain </li></ul><ul><ul><li>Visual spatial analysis </li></ul></ul><ul><ul><li>Non-verbal social cues </li></ul></ul><ul><ul><li>Complex comprehension </li></ul></ul><ul><ul><li>Attention to verbal & non-verbal input </li></ul></ul><ul><li>May be genetic or acquired </li></ul>
  25. 25. Risk Factors for NLD <ul><li>50% NLD children have evidence of an antecedent prenatal or perinatal encephalopathic event </li></ul><ul><li>50% genetic predisposition </li></ul><ul><li>40% history of prematurity </li></ul><ul><li>Radiation to the head predisposes </li></ul><ul><li>Agenesis of the corpus callosum </li></ul><ul><li>Hydrocephalus </li></ul>
  26. 26. Evaluation Clues on Cognitive Measures <ul><li>Good Information & Vocabulary subtest scores </li></ul><ul><li>Good rote, verbal memory for math facts </li></ul><ul><li>Elevated Digits forward (rote verbal memory) </li></ul><ul><li>Depressed scores on Comprehension & Picture Arrangement (Social cognition) </li></ul><ul><li>Depressed scores on Object Assembly (part-to-whole visual-spatial organization) </li></ul>
  27. 27. Evaluation Clues on Achievement Test Measures: Reading <ul><li>Strength in phonetic decoding of nonsense words (oral reading is strong) </li></ul><ul><li>Weakness in reading comprehension requiring: </li></ul><ul><ul><li>Prediction of cause & effect </li></ul></ul><ul><ul><li>Ability to separate relevant from irrelevant detail </li></ul></ul><ul><ul><li>Inferential thinking </li></ul></ul><ul><li>No trouble recalling what is read </li></ul><ul><li>Good memory for read material </li></ul>
  28. 28. Evaluation Clues on Achievement Test Measures: Writing <ul><li>Good spelling from dictation </li></ul><ul><li>Poor spelling in expository writing </li></ul><ul><li>Poor writing mechanics & organization </li></ul><ul><li>Will sit & stare at the page; unable to organize and communicate thoughts through writing </li></ul><ul><li>Poor penmanship </li></ul><ul><li>Failure to answer the question: Essay exams </li></ul>
  29. 29. Evaluation Clues on Achievement Test Measures: Math <ul><li>Often exhibits strength in rote math facts recall </li></ul><ul><li>Trouble with math word problems; can’t separate relevant from irrelevant </li></ul><ul><li>Trouble with higher-level math concepts </li></ul><ul><li>Particular difficulty with geometry </li></ul>
  30. 30. Evaluation Clues on Achievement Test Measures: Knowledge <ul><li>Often advanced knowledge of facts in Science </li></ul><ul><li>Typically poor performances on tests measuring knowledge of content in Social studies </li></ul><ul><li>Excels in geography bees but does poorly in Social Studies classes </li></ul>
  31. 31. Evaluation Clues on Language Tests <ul><li>Strong verbal elaboration and word finding </li></ul><ul><li>Weak listening comprehension </li></ul><ul><li>Poor pragmatic language skills </li></ul><ul><ul><li>Social language </li></ul></ul><ul><ul><li>Getting the punch line in a joke </li></ul></ul><ul><ul><li>Literal translations of language </li></ul></ul><ul><ul><li>See things as “black & white” </li></ul></ul>
  32. 32. Evaluation Clues on Visual Perceptual Tests <ul><li>Poor scores on reversal tests (e.g. Jordan Left-Right Reversal Test ) </li></ul><ul><li>Poor scores on Category Test (Reitan) </li></ul><ul><li>Poor performances on Bender and Developmental Test of Visual-Motor Integration </li></ul><ul><li>Low scores Trails A & B (Reitan) </li></ul>
  33. 33. Sample WISC-3 for NLD Student <ul><li>Information = 17 </li></ul><ul><li>Similarities = 10 </li></ul><ul><li>Arithmetic = 8 </li></ul><ul><li>Vocabulary = 16 </li></ul><ul><li>Comprehension = 5 </li></ul><ul><li>(Digit Span) = ( 9) </li></ul><ul><li>Verbal IQ = 107 </li></ul><ul><li>VCI = 111 FDI = 93 </li></ul><ul><li>Full Scale IQ = 83 </li></ul><ul><li>Picture Completion = 7 </li></ul><ul><li>Coding = 5 </li></ul><ul><li>Picture Arrangement = 4 </li></ul><ul><li>Block Design = 8 </li></ul><ul><li>Object Assembly = 3 </li></ul><ul><li>(Symbol Search) = (6) </li></ul><ul><li>Performance IQ = 72 </li></ul><ul><li>POI = 75 PSI = 77 </li></ul><ul><li>Verbal > Performance by 35 points </li></ul>
  34. 34. Sample WIAT for NLD Student <ul><li>Basic Reading 125 </li></ul><ul><li>Reading Comprehension 80 </li></ul><ul><li>Math Reasoning 75 </li></ul><ul><li>Numerical Operations 65 </li></ul><ul><li>Spelling 122 </li></ul><ul><li>Written Expression 75 </li></ul><ul><li>Listening Comprehension 85 </li></ul><ul><li>Oral Expression 135 </li></ul>
  35. 35. Process Assessment: Qualitative <ul><li>Wechsler IQ </li></ul><ul><ul><li>Watch for V>P split </li></ul></ul><ul><ul><li>Look at subtest patterns </li></ul></ul><ul><li>Halstead-Reitan </li></ul><ul><ul><li>Watch for depressed scores on Category, TPT and Trails tests </li></ul></ul><ul><li>Bender & VMI </li></ul><ul><li>Pragmatic language scales </li></ul><ul><li>Childhood Autism Rating Scales (CARS) </li></ul><ul><li>WIAT: Deficits </li></ul><ul><ul><li>Reading comprehension </li></ul></ul><ul><ul><li>Listening comprehension </li></ul></ul><ul><li>Woodcock-Johnson </li></ul><ul><ul><li>Elevations on Word Attack </li></ul></ul><ul><ul><li>Poor scores on Math & Written expression </li></ul></ul><ul><li>Social skills </li></ul><ul><ul><li>Piers-Harris </li></ul></ul><ul><ul><li>CPQ or MAPI </li></ul></ul><ul><ul><li>Child Behavior Checklists </li></ul></ul>
  36. 36. Educational Course <ul><li>Elementary: May appear gifted due to strengths in rote memory, oral reading, and fact recall; often poor social skills & attention problems; may be hyperactive </li></ul><ul><li>Middle School: Deficits in complex comprehension, inferential thinking, writing and math become more debilitating; social withdrawal; hypoactivity & low arousal; depression </li></ul>
  37. 37. Instructional Methods <ul><li>Reading : SDI’s for early literacy instruction </li></ul><ul><ul><li>May have initial difficulty learning to read due to misperception of symbol directionality </li></ul></ul><ul><ul><li>Work on directionality perception </li></ul></ul><ul><ul><li>Use synthetic, phonetic instruction </li></ul></ul>
  38. 38. Instructional Methods <ul><li>Reading : SDI’s for comprehension </li></ul><ul><ul><li>SQ3R </li></ul></ul><ul><ul><li>Project READ Reading Comprehension Strand </li></ul></ul><ul><ul><li>Highlighting techniques </li></ul></ul><ul><ul><li>Consumable text books </li></ul></ul><ul><ul><li>Extra time to compensate for difficulties in complex comprehension </li></ul></ul><ul><ul><li>Accept literal translations of language </li></ul></ul><ul><ul><li>Teach to look for main idea; key concepts; notes </li></ul></ul>
  39. 39. Instructional Methods <ul><li>Math : SDI’s for complex reasoning & calculation </li></ul><ul><ul><li>Saxon math series </li></ul></ul><ul><ul><li>Teach using step-wise procedures </li></ul></ul><ul><ul><li>Rote verbal memory for steps </li></ul></ul><ul><ul><li>Extend time </li></ul></ul><ul><ul><li>Shorten assignments </li></ul></ul><ul><ul><li>Spot tutoring </li></ul></ul><ul><ul><li>Calculator </li></ul></ul>
  40. 40. Instructional Methods <ul><li>Writing : SDI’s for written expression </li></ul><ul><ul><li>Teach touch typing at an early age </li></ul></ul><ul><ul><li>Teach rules: capitalization, punctuation, spelling, grammar (step-wise procedures) </li></ul></ul><ul><ul><li>Teach key word note taking methods </li></ul></ul><ul><ul><li>Teach step-wise procedures for expository writing </li></ul></ul><ul><ul><li>Teach word processing after keyboard is mastered </li></ul></ul><ul><ul><li>Extend time/shorten written assignments </li></ul></ul><ul><ul><li>Oral tests instead of essay tests </li></ul></ul>
  41. 41. Instructional Methods <ul><li>Social Skills Training : Direct & Explicit Teaching </li></ul><ul><ul><li>Skillstreaming curriculum (Arnold Goldstein & Ellen McGinnis) </li></ul></ul><ul><ul><li>Role playing </li></ul></ul><ul><ul><li>Videotaping </li></ul></ul><ul><ul><li>Counteract withdrawal </li></ul></ul><ul><ul><li>Involvement in physical activity </li></ul></ul>
  42. 42. Instructional Methods <ul><li>Executive functions & higher level reasoning </li></ul><ul><ul><li>Cannot shift gears; needs help with transitions </li></ul></ul><ul><ul><li>Perseverative behavior </li></ul></ul><ul><ul><li>Require direct eye contact </li></ul></ul><ul><ul><li>Preferential seating away from distractions </li></ul></ul><ul><ul><li>Avoid visually stimulating environments </li></ul></ul><ul><ul><li>Keep all possessions in one central place </li></ul></ul><ul><ul><li>Assist with organization </li></ul></ul>
  43. 43. Observed problems: Language <ul><li>No problem learning vocabulary word meanings </li></ul><ul><li>Problem with pragmatics </li></ul><ul><ul><li>Cannot understand or express emotional intonation </li></ul></ul><ul><ul><li>Hyperverbal in social context; drone on relentlessly over boring topics </li></ul></ul><ul><ul><li>Content of speech is simple & repetitive </li></ul></ul><ul><ul><li>Restricted range of interests (TV & computers) </li></ul></ul>
  44. 44. Instructional Methods <ul><li>Language Therapy </li></ul><ul><ul><li>Pragmatics </li></ul></ul><ul><ul><li>Non-verbal language: Gestures, body language </li></ul></ul><ul><ul><li>Tone of voice </li></ul></ul><ul><ul><li>Jokes </li></ul></ul><ul><ul><li>Idioms, slang, play on words </li></ul></ul><ul><ul><li>Social language: Requires direct & explicit instruction </li></ul></ul>
  45. 45. Instructional Methods <ul><li>General Teaching Considerations: </li></ul><ul><ul><li>Part-to-whole, stepwise approach </li></ul></ul><ul><ul><li>Redundant, sequential teaching </li></ul></ul><ul><ul><li>Encourage participation in physical exercise </li></ul></ul><ul><ul><li>Explain everything verbally: This type of student cannot read “body language” </li></ul></ul><ul><ul><li>Give practice for repetitive, motor skills </li></ul></ul><ul><ul><li>Tell student what to listen for when giving directions </li></ul></ul><ul><ul><li>Counter passivity & withdrawal (blends into woodwork) </li></ul></ul>
  46. 46. Recommended Reading: Neurology <ul><li>Rourke, B.P. (ED) (1995). Syndrome of Non-Verbal Learning Disabilities: Neurodevelopmental Manifestations . Guilford Press. </li></ul><ul><li>Roman, M.A. (1998). The Syndrome of Nonverbal Learning Disabilities: Clinical Description & Applied Aspects. Current Issues in Education , 1 (1). </li></ul><ul><li>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. </li></ul>
  47. 47. Recommended Reading: Teachers <ul><li>Thompson, S. (1997). The Source for Non-Verbal Learning Disorders . LinguiSystems. </li></ul><ul><li>Foss, J.M. (1991). Nonverbal learning disabilities and remedial interventions. Annals of Dyslexia, 41, 128-140. </li></ul>
  48. 48. Recommended Reading: Counselors & Therapists <ul><li>McGinnis, E. & Goldstein, A.P. (1997). Skillstreaming the Elementary School Child: New Strategies & Perspectives for Teaching Prosocial Skills . Research Press. </li></ul><ul><li>McGinnis, E. & Goldstein, A.P. (1997). Skillstreaming the Adolescent: New Strategies & Perspectives for Teaching Prosocial Skills . Research Press. </li></ul>
  49. 49. On-line Resources <ul><li>NLD Line http://www.nldline.com/ </li></ul><ul><li>OASIS http://www.udel.edu/bkirby/asperger/ </li></ul><ul><li>NLD on the Web http://www.nldontheweb.org/ </li></ul><ul><li>Social learning disabilities project at Yale University http://info.med.yale.edu/chldstdy/research.htm </li></ul><ul><li>ASPEN of America http://www.asperger.org/ </li></ul><ul><li>ASPEN http://www.aspennj.org/ </li></ul>