Nonverbal Learning Disabilities in Children

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1 Nonverbal Learning Disabilities in Children

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3 John M. Davis Jessica Broitman Nonverbal Learning Disabilities in Children Bridging the Gap Between Science and Practice

4 John M. Davis California State University, East Bay Carlos Bee Boulevard Hayward, CA , USA Jessica Broitman San Francisco Psychotherapy Research Group Clinic and Training Center 9 Funston Street San Francisco, CA 94129, USA drjess@comcast.net ISBN e-isbn DOI / Springer New York Dordrecht Heidelberg London Library of Congress Control Number: Springer Science+Business Media, LLC 2011 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper Springer is part of Springer Science+Business Media (

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7 Foreword The field of child psychology is continually evolving. Nonverbal learning disability (NVLD) is not currently recognized by the Diagnostic and Statistical Manual, yet research about NVLD is burgeoning. The number of publications concerning NVLD has risen from 15 in the years between 1981 and 1990 to 85 in the years (Semrud-Clikeman, Fine, & Bledsoe, 2008). The clinical interest in NVLD has also increased with 14 articles submitted for publication concerning diagnosis NVLD in just the last 7 years. As interest has increased, our knowledge of the underlying etiology and diagnostic features of NVLD has expanded. Unfortunately, efficacious treatments for children with NVLD have not progressed at the same rate, and most interventions that are published are based on anecdotal or clinical experience. It is important to collect such information in one volume so we can more fully evaluate the efficacy of such treatments and to begin to establish empirical bases for such treatment. This volume examines diagnostic criteria for NVLD and current knowledge about assessment and treatments for NVLD. As such, this book allows the practitioner to become aware of possible treatments and allows researchers to begin empirically validating these treatments. In addition, this book suggests new ways to conceptualize NVLD as a disorder with subtypes. There are many thorny issues that are unresolved regarding the diagnosis of NVLD. As suggested in this volume, one important unresolved issue is knowledge of the differences between NVLD, high functioning autism, and Asperger s syndrome. Our current work at Michigan State University has identified differences between NVLD and Asperger s syndrome mainly in the areas of behavior but also in the academic area of math. In a recently completed large study conducted at our center, we found that children with NVLD significantly differed on measures of mathematical calculation as well as on visual-spatial organization when compared to children with Asperger s syndrome. While children with Asperger s syndrome did have difficulty with visual-spatial skills, the difficulty was not of the same magnitude as it was for children with NVLD. In addition, a comprehensive diagnostic interview (Autism Diagnostic Interview-Revised) with the main caretakers of these children revealed that children with NVLD scored within the normal range on all of the scales except social communication. In contrast, those with Asperger s syndrome had significant difficulty with stereotyped behaviors as well as with social reciprocity (Semrud-Clikeman, Fine, Bledsoe, Vroman, & Crow, 2010). The differentiation of vii

8 viii Foreword Asperger s syndrome (and likely high functioning autism) appears to rest on the presence of stereotyped or ritualistic behaviors. We found that another characteristic difference between children with NVLD and children with Asperger s syndrome is the tendency of children with NVLD to be diagnosed solely on the basis of a verbal performance-iq-split or a mathematics delay (Semrud-Clikeman, Walkowiak, Wilkinson, & Christopher, 2010) yet a sizable minority of children with Asperger s also share these characteristics. Thus, it appears that making a diagnosis of NVLD based solely on these two characteristics (visual-spatial and VIQ > PIQ split) may result in a false diagnosis and children with Asperger s syndrome being misdiagnosed with NVLD (Semrud-Clikeman et al., 2010). Consequently, careful diagnosis, as described in this volume, is crucial for the appropriate classification and treatment of children with NVLD or with Asperger s syndrome. Our recent large study of children with NVLD, Asperger s syndrome, and neurotypical children used functional magnetic resonance imaging (fmri), and preliminary findings indicate that children with NVLD and Asperger s syndrome may appear neuropsychologically similar with comparable deficits in social perception, visual-spatial reasoning, and cognitive flexibility. However, our fmri findings indicate that children with NVLD activate many more areas of their brain while solving a social problem compared to neurotypical children or children with Asperger s syndrome and these areas tend to be in the posterior region of the brain. In contrast children with Asperger s syndrome and those with no diagnosis show less activation in these regions with the typically developing children showing more right hemispheric activation than either the children with NVLD or with Asperger s syndrome. Such findings suggest that there may be differential brain networks that solve problems for each type of diagnosis. Further study is warranted to more fully understand the brain behavior connections in NVLD as well as in Asperger s syndrome. I believe that many school personnel as well as parents will find this volume helpful in working with their children to help ensure the child s eventual adjustment to adulthood. We surely need more research in this area particularly in the area of treatment and intervention. Some preliminary work has been completed that found creative drama to be efficacious for children with NVLD (Corbett & Glidden, 2000; Guli, Wilkinson, & Semrud-Clikeman, 2008) but more work is necessary. This book, which is the result of many years of clinical experience, provides an excellent overview of the current state of knowledge about NVLD for parents, educators, and professionals caring for children with this disorder. Recent estimates have indicated that between 7 and 10% of the population have difficulties with social interaction and may be considered socially incompetent (Semrud-Clikeman, 2007). In an epidemiological study, approximately one-fifth of the population was found to show loneliness, anxiety, and shyness (Luanaigh & Lawlor, 2008). Although there has been a great deal of attention in recent years paid to verbal learning disabilities as well as to Attention Deficit Hyperactivity Disorder, problems with social functioning have not been as readily accepted particularly for special services in K-12 or in college. Moreover, poor social adaptation has been

9 Foreword ix associated with subsequent cardiovascular difficulties as well as to psychiatric problems (Hawkley & Cacioppo, 2003). There is also a great deal of current interest in the field of autism, and while reading and attention are important aspects of functioning, so is social adaptation. However, children with NVLD are often missed, not diagnosed, or not served and yet these children have similar needs to those who have a diagnosis of autism. I am hopeful that as the research and clinical writing concerning NVLD continues to expand, children and adults with this diagnosis will finally be provided the needed services and NVLD will be recognized as a legitimate disorder. One clinical example of the effect of understanding the brain behavior relationships in NVLD occurred spontaneously during an evaluation of a young man. He had just completed the fmri task and I was walking him through the activation and structures that were on his MRI scan. I mentioned that he showed less activation in the right hemisphere the hemisphere believed to be responsible for social understanding compared to his brother who we had just also had an fmri. His brother was developing typically. The young man remarked to me, So my brain is abnormal, and I replied, No it is just organized different. There is nothing abnormal on your scan. Two days later his mother contacted me and said, Thank you so much for talking to my son. He came home and told his father I know now that I am not abnormal my brain is just organized differently Dr. Peg said so and I have pictures to prove it! These types of interventions likely occur frequently but are undocumented. My experience as a pediatric neuropsychologist suggests that providing a therapeutic assessment involves not just explaining the results of the testing but also helping the client understand how the results may impact his/her life and which interventions might improve their adjustment. One of the goals of this current volume is to provide a blueprint for understanding NVLD as well as possible interventions that can be useful. Books such as this one are needed to understand these disorders from a clinical standpoint as well as to put together the extant research. It is hoped that the diagnosis of NVLD will at some point be recognized by the Diagnostic and Statistical Manual as well as by the school systems as a disorder that can be very handicapping to the child and adolescent. As is so eloquently expressed in the afterword in this volume, understanding of this disorder by the person affected can be very therapeutic not only in the person s development but also in his/her eventual adult adaptation. Michigan, USA Margaret Semrud-Clikeman

10 x Foreword References Corbett, B. A., & Glidden, H. (2000). Processing affective stimuli in children with attention-deficit hyperactivity disorder. Child Neuropsychology, 6, Guli, L. A., Wilkinson, A., & Semrud-Clikeman, M. (2008). Social competence intervention program. Champaign, IL: Research Press. Hawkley, L. C., & Cacioppo, J. T. (2003) Loneliness and pathways to disease. Brain, Behavior, and Immunity, 17(Supplement 1), S98 S105. Luanaigh, C. O., & Lawlor, B. A. (2008). Loneliness and the health of older people. International Journal of Geriatric Psychiatry, 23, Semrud-Clikeman, M. (2007). Social competence in children. New York: Springer. Semrud-Clikeman, M., Fine, J. G., & Bledsoe, J. (2008). Meta-analysis of empirical literature on NVLD. Paper presented at the International Neuropsychological Society. Semrud-Clikeman, M., Fine, J. G., Bledsoe, J., Vroman, L., & Crow, S. (2010). Asperger s disorder versus nonverbal learning disabilities: A diagnostic conundrum. Paper presented at the National Academy of Neuropsychology. Semrud-Clikeman, M., Walkowiak, J., Wilkinson, A., & Christopher, G. (2010). Neuropsychological findings in nonverbal learning disabilities. Developmental Neuropsychology, 35(5),

11 Acknowledgments We would like to thank Dr. Gibor Basri and Dr. Jodene Fine for their careful reading, editing, and overall support during the process of writing our book. Their thoughtful insights proved invaluable. xi

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13 Contents 1 Introduction and Overview History of the Concept of NVLD... 3 Defining NVLD... 5 A Developmental Orientation... 7 Early Developmental Signs of NVLD... 7 Early Schooling... 8 Later Elementary and Middle School Signs High School Signs Summary NVLD and Subtypes Two-Subtype Model of NVLD Neurological, Social and Academic Concerns for the Two-Subtype Model Three-Subtype Model of NVLD Neurological, Social, and Academic Concerns for the Three-Subtype Model Four-Subtype Model of NVLD Neurological, Social, and Academic Concerns Our Subtype Model Summary The Etiology of NVLD Genetics Neurobiology Environment White Matter Model Summary xiii

14 xiv Contents 5 Prevalence and Associated Conditions Prevalence Other DSM-IV-TR Comorbidities Psychiatric Disorders Academic Difficulties Other Disorders Summary Asperger s Disorder and NVLD Research Clinical Perspectives Summary Eligibility for Special Services, Screening, and Assessment Eligibility: Specific Learning Disability IDEA Eligibility: Seriously Emotionally Disturbed Section Summary Screening and Evaluation Screening for NVLD Psychoeducational Evaluation: A Critical Component Intellectual Assessment Attention and Executive Functioning Learning and Memory Sensory Motor/Graphomotor Language Visual Processing Affect and Behavior Academic Assessment Summary Treatment The Need for Treatment General Intervention Guidelines Palombo: A Clinical Social Worker s Perspective Liza Little: Researcher and Medical Practitioner Matte and Bolaski and Foss: Educators Tsatsanis and Rourke: Seminal Researchers Summary... 72

15 Contents xv 10 Applying Guidelines School Settings Tanguay Molenaar-Klumper Martin Working with the Families Summary Interventions Specific Interventions Motor Coordination Visual-Spatial/Sensory Perception Executive Functioning Social/Emotional Deficits Intellectual Reasoning Academics Reading Comprehension Psychotherapy Summary Final Thoughts Afterword by Brett Mills Appendix References About the Authors Index