NVLD is not recognized by the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV- TR).

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1 COURSE: Non-Verbal Learning Disorder (PDF) Non-Verbal Learning Disorder (NVLD or NLD), also known as Non- Verbal Learning Disability, refers to a neurological syndrome believed to result from damage to the white matter connections in the right hemisphere of the brain (Learning Disabilities Association [LDA], 1997). NVLD is not recognized by the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV- TR). In 1967, Johnson and Mykelburst distinguished a sequelae of symptoms termed Nonverbal Disorders of Learning presented in Learning Disabilities: Educational Principles and Practices. New York: Grune & Stratton. With the advent of research in neurodevelopment in the 1980s, particularly involving the mechanisms of prefrontal functioning, Rourke and colleagues (1989) further differentiated NVLD from other LDs and clinical disorders, proposing that NVLD had a unique set of symptoms deeply rooted in neurological differences. Debate has long existed about the appropriateness of the classification of NVLD as a disorder of learning and many researchers and clinicians consider it to be a developmental disability on the Autistic Spectrum (Tanguay, 2010) closely related, if not identical, to Asperger s Syndrome. Researchers and clinicians generally agree on the major characteristics of NVLD and that and individual with NVLD typically has HIGH verbal ability and WEAKNESSES is non-verbal domains. 3 areas of dysfunction are typically seen in individuals with NVLD, though no assessment tool yet exists specifically for the evaluation of these areas with the purpose of diagnosing NVLD.

2 3 Main Areas of Dysfunction in NVLD: 1. Motoric 2. Visual-Spatial-Organizational 3. Social Motoric Dysfunction may involve one or all of the following: 1. A lack of coordination 2. Severe balance problems 3. Difficulties with fine motor skills Individuals with NVLD may be seen by others as clumsy and struggle with walking, running or gross motor skills, like those involved in athletics. Weaknesses will also be evident in fine motor skills, such as using a pencil, tying shoes, writing and drawing. Visual-Spatial-Organizational Dysfunction may involve one or all of the following: 1. A lack of image closure, abstract visual reasoning and difficulty making sense of what is seen. a. An example of this is the inability or struggle to identify recognizable shapes, faces and environmental cues. Images, like the key below, might be difficult to recognize if incomplete or blurry 2. Poor visual recall 3. Faulty spatial perceptions 4. Difficulties with spatial relations Spatial perception problems can cause significant weakness in certain academic areas, such as math, plotting and planning with

3 visual markers (e.g., using an x & y axis, working with maps), remembering locations and places, and judging speed and distance. Spatial relations skills are considered to be associated with spatial self-awareness or the sense of where one s own body is in space and in relation to other people and objects. Individuals with NVLD typically have deficits in spatial self-awareness, which makes navigating through space difficult. It is not uncommon for an individual with NVLD to misjudge his/her own actions and gestures. One might kick, push, knock into or hit people and objects without understanding that they are doing so. *Training parents and teachers, as well as advocating for children with NVLD, is vital with regard to spatial self-awareness deficits. Misunderstanding of these weaknesses often results in a child being considered oppositional and defiant. A child may be seen as actingout in group settings or be considered intentionally aggressive, though may be unaware and/or unable to regulate his/her body. Please see CEU Master s training on Treatment and Advocacy for Children and Adolescents with NVLD. Social Dysfunction 1. A lack of ability to comprehend nonverbal communications (e.g., gestures, facial expressions, cues and body posturing) 2. Difficulty adjusting to transitions and change 3. Difficulty with new or novel situations 4. Deficits in social judgment and interaction, conversational language exchange, rate and tone of speech in communicating, a lack of understanding of social norms and rules. *Research consistently shows that problems with eye contact are often the first signs of NVLD. Similar to Autistic Spectrum Disorders, repetitive, stereo-typed and restricted interests and behaviors may be evident.

4 Neurofunction & NVLD NVLD is a disorder that involves processing differences. It is, therefore, important to understand the different parts of the brain that are involved. The Left Hemisphere of the brain is responsible for: Processing verbal information The production of speech The Right Hemisphere of the brain is responsible for: Processing visual stimuli Discerning visual-spatial information Recognition and interpretation of emotion Regulating expression 2 brain functions implicated in NVLD involve the NONVERBAL AFFECT LEXICON and EMOTIONAL SEMANTICS. Both are considered components of COLD COGNITION, or the ability to interpret and judge emotional content of behavior regardless of one s own emotional state or direct experience. An example: You come into a room to find a co-worker standing up with hands on hips, breathing hard and scowling. Cold cognition enables you to understand that the person is likely angry, leading you to enter into conversation or interaction with caution. Bowers and colleagues (1996) proposed that the Nonverbal Affect Lexicon is housed in the Right Hemisphere and that the neural processes involved in Emotional Semantics are more widespread in the brain. In essence, the individual with NVLD hits roadblocks as neural fibers carrying information from the emotional processing areas in the right hemisphere attempt to travel to the language areas of left hemisphere.

5 Prevalence of NVLD: *It is important to note that prevalence rates are difficult to reliably report as researchers and clinicians continue to debate the diagnostic appropriateness of NVLD as a subset of learning disorders versus developmental disability. There is also a lack of consistency across studies in the diagnostic methodology utilized. Without a clear and specific set of diagnostic tools and consensus on symptoms, rates of NVLD will remain uncertain. 2-10% of the general population have LDs (DSM IV-TR) 5% of school-age children are identified as LD (DSM IV-TR) 1-10% of the LD population are NVLD (Antshel & Khan, 2008; Rourke, 1996) Learning Disorders (LDs) are included in the DSM-IV-TR section entitled Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. Reading Writing Mathematics Not Otherwise Specified (NOS) disorders that do not meet the criteria for any specific LD While NVLD is not recognized by the DSM at this time, some diagnosticians endorse using the LD NOS category for NVLD. Linda Thompson (1997), an advocate of NVLD as a separate diagnostic category, proposed redefining and reconceptualizing learning disorders in order to more effectively reflect the significant role of nonverbal dysfunction in school age children. Thompson suggested 4 general categories for learning disorders: Reading, Writing, Oral Language and Non-Verbal LD Syndrome. Why a new diagnostic category? Advocates for differentiation of NVLD as a unique and specific LD point out that, like other LDs, NVLD leads to significant disruption in the ways in which a child learns and tolerates the school experience and that they should be

6 offered special accommodations and individualized learning plans under the Individuals with Disabilities Education Act (IDEA). Areas of academic weakness for children with NVLD: reading, math and written expression. Forrest (2002) suggested that social skills deficits may actually be a component of executive functioning, which require neurological assessment and treatment. Executive functioning refers to the ability command and control center of the brain that affords the individual the ability to plan, strategize, organize, attend to and synthesize information while inhibiting or rejecting irrelevant information. Etiology Neurological etiologies have been proposed. These involve dysmyelination of the white matter fibers, predominantly in the right hemisphere. This may occur through: Neurological diseases and conditions, such as Hamartoses (disorder involving non-neoplastic tissue overgrowth),hydrocephalus, Neurofibromatosis type 1, Osteochondromatosis Syndorme, and Klippel- Trenaunay Syndrome Adverse biological events and/or environmental insults to the brain (such as toxins) Trauma and damage to the right hemisphere s white matter and fibers Brain tumors Premature birth (rates of 40%) Other etiological explanations include social/environmental, psychodynamic and multidimensional models Family history may contribute, particularly when genetic link can be drawn to a family member with NVLD or other disorders affecting prefrontal mechanisms, such as ADHD or Schizophrenia (Antshel & Kahn, 2008; Asarnow, et al., 2002). Differential Diagnosis

7 Differentiating NVLD from neurodevelopmental disorders is essential and the clinician should consider existing diagnostic categories: Asperger s Disorder Distinguishing characteristics from Asperger s Disorder may include higher overall functioning and early development of verbal ability. Autism Pervasive Developmental Delay, NOS Central Processing Disorders Commorbidity Conditions secondary to NVLD may include one or more of the following: Stress Social or Specific Phobia Anxiety Panic Disorder Obsessive-Compulsive Disorder Assessment Areas of impairment to qualitatively evaluate: Cognitive/Academic WISC, WIAT, Woodcock-Johnson Physical VMI (for fine motor skills), observation of gross motor ability Neuropsychological Halstead-Reitan, Bender, VMI, Trails A&B Language/Communication Autism rating scales may be helpful, pragmatic language scales Emotional/Behavioral/Social CPQ, Piers-Harris, Child behavior checklists (Connor s, Vanderbilt), Roberts Apperception Test for Children

8 Testing and qualitative evaluation will likely reveal: Verbal IQ higher than Performance IQ, but not in all cases. Poor relative performance on tests of fine motor ability. At an early age, there may be an excellent vocabulary, verbosity and higher than average verbal expression. Word calling (Hyperlexia). Exceptional rote memory skills. Poor performance on Trails tests. Excellent attention to detail, but will likely miss the big picture While reading ability may be strong and develop earlier than peers, reading comprehension may be relatively poor. Deficits in math, especially with word problems and abstract applications. Significant impairment in concept formation and abstract reasoning. Difficulty generalizing information - applying learned information to new situations. Strength in auditory skills relative to visual skills. For additional information on NVLD: Please see CEU Masters training on Treatment and Advocacy for Children and Adolescents with NVLD Trainer: Kacie Fisher, MSW, PsyD