Nonverbal Learning Disabilities (NLD), 2nd Edition
Short Description of Definition
Nonverbal learning disability (NLD) is a neurobehavioral disorder that impacts a person’s intelligence due to dysfunctions of the brain. NLD is a developmental disorder which constrains a child’s linguistic performance in the nonverbal domain. While an individual with NLD shows deficits in understanding nonlinguistic signs, he/she can be highly functional in verbal communications. Other neuropsychological disorders related to NLD can impact a child’s abilities to perform in academic, social/emotional, and vocational areas (Palombo 2006). A critical challenge for an individual with NLD is social interaction due to the lack of visual processing abilities such as recognizing facial expressions and lack of spatial perception. NLD is not apparent at a very young age, such as preschool age, although the inability to understand nonverbal signs significantly manifests at the age when children begin to understand social interaction through engagement in verbal conversation (Thompson 1996). NLD does not necessarily constrain academic skills, but impairs mainly social interactions with characteristics similar to what was previously identified as Asperger’s syndrome, now part of Autism Spectrum Disorder (ASD), and pragmatic language impairment (PLI).
Nonverbal learning disorder was first identified by Doris Johnson and Helmer Myklebust in 1967 as a subtype of learning disability. Based on research by Rourke et al. (1989), this class of learning disability is organized into two categories: phonological processing disorder and nonverbal learning disorder (p. 169). Typically, people with learning disabilities fail to perform at age level and exhibit difficulty in rote-verbal learning and in phonological processing. Unlike children with general learning disabilities, children with NLD demonstrate significantly higher verbal IQ than performance IQ. For example, children with NLD show primary impairments in visual processing, tactile perception, complex psychomotor skills, fine motor skills, and manipulation of materials (Rourke 1989). Accordingly, they need significant support in adapting to changes, in generalizing what they have learned, and in following instructions with multiple steps.
There is no consensus on the cluster of learning disabilities that comprises NLD. Accurate procedures to diagnose children with NLD are not yet available as there have been multiple changes in classification. The American psychiatric association (APA) uses the diagnostic and statistical manual of mental disorder (DSM) to produce an accurate diagnosis within various mental disability categories (APA 2000). NLD was not included in the DSM-IV or in the current revision of the DSM-5 (APA 2013). Moreover, many symptoms of NLD are similar to those of ASD and PLI. The differences among these three disorders have not been clearly defined. It has been proposed that NLD may be a disorder on the “borderlands of autism” (Bishop 1989, p. 107). Children with ASD, who perform well in cognitive and linguistic areas, have features in common with both NLD and PLI. PLI is also considered to be a social communication disorder, meaning that children with PLI have difficulty using language appropriately in social situations. Overall, NLD, ASD, and PLI have overlapping, but not identical, symptoms. For example, an individual diagnosed with NLD will show some of the features of PLI, but the reverse may not be true (Bishop and Norbury 2002). The overlap of symptoms among these three learning disorders involves patterns of behavior in a social context. There is yet no evidence of restricted or repetitive patterns of behavior that clearly distinguishes the disorders.
Bilateral deficits in tactile perception, usually more marked on left side of the body. Simple tactile perception may reach normal levels as the child ages, but interpreting complex tactile stimulation remains impaired.
Bilateral deficits in psychomotor coordination, usually more marked on the left side of the body. Simple, repetitive motor skills may reach normal levels with age, but complex motor skills remain impaired or worsen relative to age norms.
Extremely impaired visual-spatial-organizational abilities. Simple visual discrimination can reach normal levels with age, particularly when stimuli are simple. Compared to age norms, complex visual-spatial-organizational abilities worsen with advancing years.
Substantial difficulty in dealing with novel or complex information or situations. A strong tendency to rely on rote, memorized reactions, approaches, and responses (often inappropriate for the situation), and failure to learn or adjust responses according to informational feedback. Also, frequent use of verbal responses in spite of the requirements of the novel situation. These tendencies remain or worsen with age.
Notable impairments in nonverbal problem solving, concept formation, and hypothesis testing.
Distorted sense of time. Estimating elapsed time over an interval and estimating time of day are both notable impairments.
Well-developed rote verbal abilities (e.g., single-word reading and spelling), frequently superior to age norms, in the context of notable poor reading comprehension abilities (particularly so in older children).
High verbosity that is rote and repetitive, with content disorders of language and deficits in functional/pragmatic aspects of language.
Substantial deficits in mechanical arithmetic and reading comprehension relative to strengths in single-word reading and spelling.
Extreme deficits in social perception, judgment, and interaction, often leading to eventual social isolation/withdrawal. Easily overwhelmed in novel situations, with a marked tendency toward extreme anxiety, even panic in such situations. High likelihood of developing internalized forms of psychopathology (e.g., depression) in later childhood and adolescence.
Nonverbal learning disorder (NLD) is diagnosed less frequently than other language-based learning disorders (e.g., reading and written expression disorder). While approximately 10% of the population has been diagnosed with having a learning disability, only 0.1– 1.0% of the population has been found to have NLD. NLD has been diagnosed equally in female and male populations (Thompson 1996). Moreover, based on social behavioral problems, children with NLD also show some features of attention deficit hyperactivity disorder (ADHD) and are easily misdiagnosed as having ADHD (Antshel and Khan 2008). Educators often define NLD as a language-based learning disability based on academic and cognitive assessments. Thus, the data regarding NLD are unclear and, as a result, NLD is often misdiagnosed as other types of learning disorder.
Analysis from Case Study
Chris, a child diagnosed with NLD, was able to read before she started school. On a widely used intelligence test, she achieved a verbal IQ score of 120 and a performance IQ score of 102 indicating that she has high functioning verbal ability that is not matched by her nonverbal ability. When she was in preschool she had difficulties in comprehending, transitioning, socializing with other peers, and making self-decisions. She was unable to choose how she wanted to play during free-choice time because reading was the only activity Chris enjoyed in school. When someone stopped her from reading, she became belligerent and refused to comply. This behavior caused the other students to become wary of being close to Chris during free-choice time. When Chris became a 1st grader, she was exceptional in reading and spelling. She was a fast learner with high auditory attention ability. She also liked to create imaginative stories. However, she was not interested in writing down her stories because handwriting was a challenge. Moreover, Chris struggled with math and tended to avoid the teacher’s attention during math class. Aside from math, her scores on other achievement tests were higher than average.
Chris also showed some difficulties in music and art classes. The music class included lots of rhythmical activities. Chris mostly excused herself from those activities to use the bathroom or read books. Drawing, coloring, and creating were the main activities in the art classes. Chris rushed to finish these activities in order to read books. When her art creation was returned to her with feedback to revise, she got angry and threw away her art. Due to her lack of physical coordination and endurance, gym classes were also not enjoyable for Chris. She refused to go to the playground for activities.
This case study contains multiple prognostic factors for NLD. NLD impacted the child’s academic and social activities. Chris had difficulties with handwriting, math reasoning, and fine motor skills. These difficulties are related through deficits in visual processing, motor function, and the child’s social/emotional profile. Children with NLD generally show lack of both gross and fine motor skills. In this case study, the gym classes preponderantly required gross motor skills (e.g., big movements) and involvement of larger muscles. The handwriting and art projects required mostly fine motor skills (e.g., dexterity) and use of small muscles. Regardless of size of movements, children with NLD demonstrate inadequate kinesthetic processing due to weakness of spatial perception. Moreover, non-reaction towards non-verbal signs is significant evidence of NLD. The case study also contains a significant cue to Chris’s diagnosis with NLD by emphasizing how well she responded to auditory directions.
The natural history of NLD shows that symptoms of NLD may be confused with those of ADHD and what used to be termed Asperger’s syndrome (a part of ASD). However, main indicators of NLD include critical deficits in visual-spatial processing, nonverbal recognition, and kinesthetic discrepancy. Challenges in these areas greatly impact how children with NLD improve in academic and social/behavioral performances (Palombo 2006).
Clinical Expression and Pathophysiology
Intact repetitive motor skills
Bilateral tactile-perceptual and psychomotor deficits (primarily left side)
Responsive to learning through repetition and the auditory modality
Impaired visual discrimination
Well-developed auditory perceptual skills
Impaired visual-spatial organization (e.g., drawing patterns from memory)
Well-developed rote verbal and verbal memory skills
Difficulty with novel and complex situations
Ability to sustain attention to simple, repetitive verbal information
Deficits in nonverbal problem-solving concept formation, hypothesis testing, and use of feedback
Strong receptive language skills including rote verbal memory and verbal associations
Difficulty with cause-effect and recognizing incongruities
Advanced phonemic awareness, including blending and segmentation
Verbose with poor pragmatics (i.e., miss social cues), including inefficient prosody and over reliance on language for relating socially and decreasing anxiety
Average single-word reading and spelling skills
Deficits in math (i.e., functions, decimals, percents, ratios, estimation, geometry, and any visual-spatial math function)
Impairments in social perception, judgment, and interaction skills, including tendency to withdraw
Increased risk for suicide
In addition to the challenges outlined in the chart above, deficits in higher-level reasoning and problem-solving skills impact on social-emotional learning of an individual with NLD (Rourke 1989). In other words, children with NLD often lack executive functions related to cognitive abilities. These functions engage with complex goal-directed behavior and adaptation in environmental changes. Because these executive functions require self-monitoring and self-awareness to produce appropriate behavior, children with NLD commonly show difficulties with cause-and-effect reasoning, problem solving in various social contexts, and time perception. These are the critical foundations and skills needed for social interactions (Palombo 2006). Issues related to executive function also impact breakdown in social interaction. Children with NLD are less motivated to be social with their peers because of difficulty processing new information and adapting to unfamiliar interpersonal interactions (Volden 2004). Psychopathologies are more evident in children with NLD more than neurotypical children. For example, there is greater risk for depression, withdrawal, and suicide in NLD (Fuerst and Rourke 1995). Awkwardness with other social peers is a distinctive feature of NLD.
Mothers of children with NLD have high levels of maternal stress and high levels of dysfunctional interaction with their children. Indeed, the more severe the disability that children have, the greater the stress and emotional breakdown that the parents have (Antshel and Jospeh 2006). The lack of relationship between a mother and a young child with NLD will create a challenge to maintain the relationship in later years. Thompson (1997) described the developmental progression of Nonverbal learning disorder and included additional signs and symptoms presented in early preschool age (3–5 years old). These additional symptoms included strong ability in verbatim memory skills, extreme verbosity, development of early reading skills (e.g., strong letter/number recognitions, spelling skills), and use of literal translations. However, symptoms of impaired gross motor development remained, including balance and body coordination (e.g., problems riding a bike and spatial confusion).
As they grow into elementary school age (ages 6–10), individuals with NLD will demonstrate deficits in copying text, continue to make literal translations, and continue misjudging and misinterpreting social information. At ages 11–14, individuals with NLD will continue having difficulties in understanding emotional expectations and this will lead to miscommunication with teachers and other social peers at school. Furthermore, difficulties with visual-spatial organizational skills become obstacles to children with NDL and their productivity on tasks. The same behavior deficits involving literal translation, misinterpretation, and misunderstanding cause children with NLD to have difficulties understanding abstract concepts as well as communicating with other social peers. Because of these continued, under-appreciated behavior deficits, children with NLD start to experience some level of depression. Although in high school years (ages 15–18) they appear, at best, to be immature in socializing, they will show improvements in some social domains. Peer tolerance tends to increase so that children with NLD may establish intimate friendships. Relationships between sexes will gradually develop. Eventually, their NLD symptoms will disrupt the ability to become independent adults. Their continuing challenges with literal understanding, lack of ability to solve abstract concepts, and visual-spatial impairments will increase their low self-esteem, depression, withdrawal, and anxiety.
Neuroscience studies have shown that NLD involves abnormalities in the right cerebral hemisphere of the brain which is important for nonverbal processing skills. Rourke and colleagues have spent three decades designing a neuropsychological model to explain the strengths and challenges of individuals with NLD. Their work, White Matter Model, was published in 1987. White matter refers to long myelinated fibers in the brain. Their work shifted the focus on the origin of NLD from a primary dysfunction of the right cerebral hemisphere to consideration of an underdevelopment of white matter in the brain (Rourke 1987, 1989, 1995; Rourke et al. 2002). This novel idea stemmed from observations that cerebral white matter malfunctions in various conditions manifesting impairments in perceptual and cognitive functions similar to NLD, such as agenesis of the corpus callosum, in which the large bundle of white matter connecting two cerebral hemispheres has failed to develop. In addition, children who experienced severe head injuries or who have received repeated radiation treatment on their brains may have damage to white matter and, therefore, may have higher risk to develop the symptoms of NLD.
Evaluation and Differential Diagnosis
The fact that NLD does not produce outstanding symptoms on its own, and has considerable similarities to other disorders, necessitates careful consideration of the evaluation and diagnostic procedures for NLD. The clinical diagnosis of NLD evaluates neuropsychological strength and weakness by implementing Rourke’s classification criteria and the preliminary communication profile (Rourke and Tsatsanis 1996). Differential diagnosis should involve a comprehensive neuropsychological evaluation incorporating examination of academic, social-emotional, and cognitive skills. An interdisciplinary team approach should be used to assess functional impairments and disabilities. These professional disciplines may include occupational therapy, speech-language pathology, medicine, psychology, and education. It is critical that various professionals and experts work together to establish concrete understanding of the individual’s challenges over time and across multiple developmental domains. From a history of the child, physicians can share profiles of the child’s impairments with other professionals to prevent missing possible red flags (e.g., poor psychomotor development, clumsiness, and challenges with early handwriting tasks). It is clearly important that the child be evaluated later in their development such as in middle school or high school. A discrepancy in performance IQ and verbal IQ at any stage of development is a critical piece of evidence.
Based on evidence obtained by multiple professionals, schools can support individuals with NLD using relevant services (Thompson 1996). Assessment of communication skills must proceed along with examinations in semantic (meaning of words) and pragmatic (functional language use) skills, as these are the areas of common concern for children with NLD. Challenges in literacy or language are often observed in the relative strengths with phonological processing (speech sound processing) and syntax (grammar). Children with NLD may seem to have a rich vocabulary because of favorable scores on receptive/expressive language measures (e.g., Peabody Picture Vocabulary Test-4th edition (PPVT-4), Expressive One-Word Vocabulary Test-2nd edition (EVT-2)). However, these test measurements are limited by their examination of the use of socially accepted words, use of multiple words across various contexts, or use of those words that occur with less frequency. The tests do not measure the extent to which individuals with NLD miss meaningful contents in their conversations because they do not fully understand the words they are using. Thus, it is essential to evaluate the higher-level semantic skills of children with NLD including understanding of multiple meanings and figurative language. Standardized measures available to administer tests of these linguistic skills include the Test of Problem Solving-3rd edition (TOPS-3), The Word Test-3, and the Test of Language Competence-2nd edition (TLC-2). Professionals should be encouraged to collect valuable information on the appropriate social use of language (e.g., conversational turn taking, maintaining and building on topics, and recognizing and repairing communication breakdowns). Assessments may also be implemented by using Children’s Communication Checklist-2 (CCC-2), Pragmatic Protocol, Assessment of Language Impaired Children’s Conversations, Topic Checklist, and Narrative Analysis (i.e., analyzing a child’s narrative for story grammar and other components).
Because the symptoms of NLD are varied, the most efficient treatment for children with NLD involves establishing individualized goals and specialized instruction. Educators can then coordinate the interventions to produce the best long-term outcomes. These interventions should include functional practices children with NDL can use on a daily basis. The ultimate goal of all interventions is to improve active processing of new information by helping individuals with NLD to explain concepts, instructions, and stories in their own words rather than relying on repeating known information verbatim from memory (Rourke 1995). Sets of compensations, accommodations, modifications, and individualized learning strategies (CAMs) should be implemented for the appropriate needs of the individuals with NLD (Thompson 1997). For example, a child with NLD may be provided with extra time to navigate himself to a place when given verbal cues. This intervention will require the child to practice utilizing his understanding of spatial and directional concepts. Task analysis is a procedure based on Applied Behavior Analysis (ABA) that is another intervention strategy for children with NLD. Task analysis is a strategy that divides a targeted behavior into a series of step-by-step instructions (Smith 1999). Rather than teaching the multiple steps of the task all at once, an educator can introduce small sets of tasks so that children with NLD have ample time to adapt and process the new information. Depending on the types of tasks, an instructor starts the instruction sequence beginning with the first step (called Forward Chaining) or the children with NLD can start from the last step of the instruction sequence (called Backward Chaining).
Berg (2000) introduced the use of gestalt imagery as an intervention for children with NLD. Children with NLD often get frustrated when creating a gestalt to support their comprehension levels. Since individuals with NLD show deficits in abstract-concept processing, they are not able to organize the parts of a concept from the whole. Implementation of gestalt instruction will help children with NLD to connect incoming language (both oral and written) to prior knowledge. Therefore, these gestalt interventions facilitate smooth socialization of children with NLD by helping them to interpret what they see, hear, and feel from the surrounding environments. To utilize the gestalt imagery, one needs to learn how to describe a picture, an image, a simple sentence, and then add interpretation and critical thinking to this imaging process (Bell 1986).
Expectations for this child should always be applied with flexibility, taking into consideration the fact that she has different needs and abilities than her peer group.
Independence should be introduced gradually in controlled, nonthreatening situations. The more completely those around her understand this child and her particular strengths and weaknesses, the better prepared they will be to promote attitudes of personal independence. Never leave this child to her own devices in new activities or situations which lack sufficient structure.
School assignments which require merely copying text need to be modified or omitted, owing to the visual-spatial nature of such an exercise. Active verbalization and/or subvocalization are the best memory approaches for this child.
Adults need to check often for understanding and present information in plain and clear verbal terms (i.e., “spell out” everything). A “parts-to-whole” verbal teaching approach should be utilized. A child with NLD will need to ask a lot of questions, as this is her primary means of gathering information.
All expectations need to be direct and explicit. Do not require this child to “read between the lines” to glean your intentions. Avoid sarcasm, figurative speech, idioms, slang, etc., unless you plan to explain your usage.
This student’s schedule needs to be as predictable as possible. He should be prepared in advance for changes in routine, such as assemblies, field trips, vacation days, finals, etc.
Placement must be in an environment, which has a well-established routine because this child will not decipher nonverbal cues. She cannot adjust well to constant changes in routine (this child lacks the ability to “wing it” in times of doubt) and has learned to fear all new and/or unknown situations and experiences.
This child will benefit from cooperative learning situations (when grouped with “good role models”). Active verbalization is an important element in how this child learns.
Tell the child everything and encourage her to give you verbal feedback. The most effective instructional procedures are those that associate verbal labels with concrete situations and experiences.
Isolation, deprivation, and punishment are not effective methods to change the behavior of a child who is already trying his best to conform (but misinterpreting all kinds of nonverbal cues). If inappropriate behaviors are causing problems at school, a functional analysis and behavioral intervention plan detailing a course of action needs to be completed.
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