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