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Barbara Rissman speaks on her personal experience with Nonverbal Learning Disabilities (NLD) and her new book "Medical and Educational Perspectives on Nonverbal Learning Disability in Children and Young Adults"

…But She Speaks So Well!

By IGI Global on Jul 18, 2016
Medical and Educational Perspectives on Nonverbal Learning Disability in Children and Young AdultsContributed by Barbara Rissman (Queensland University of Technology, Australia)

In the United States and Canada, a nonverbal learning disability (NLD) reportedly affects 1% of the general population (Rourke, van der Vlugt, & Rourke, 2002). “Nonverbal” denotes a disability that originates from deficits in the nonverbal processing domains. When a child is deficient in nonverbal processing and cannot learn from experience, “he indeed has a serious learning disability” (Myklebust, 1978, p. 85). Since all learning involves verbal and nonverbal processes, “NLD is considered a learning disability in the fullest sense” (Tsatsanis & Rourke, 2008, p. 181). Even if a person’s verbal abilities are limited, he or she can still function independently as long as nonverbal abilities are well-developed. NLD impairments are lifelong and most individuals come to the attention of psychologists or neuropsychologists in the mid- to late childhood years or during adolescence (Casey, 2012; Rourke, 1989).

For a child with NLD, impaired tactile-visual-spatial perception and psychomotor skills are primary deficits that restrict exploratory behaviour and limit experience with cause-and-affect relationships. Tactile, visual and spatial perception refer to mental recognition of information from the sense of touch, sight, and space - all important for exploration and gainful experience. Through normal development, children learn to feel and pick up objects, squeeze, throw, drop and taste. Visual perception and eye muscle control determine the accuracy of a visual image while visual-spatial perception helps us to judge distance between our self and an object in the environment. Psychomotor skills involve mental and muscle activity. Gross motor activities use large muscle groups to coordinate body movements to walk, run, jump, skip, hop, ride a bike, throw and catch a ball, cross the road, and maintain balance. Fine motor tasks require precise coordinated movements to dress, do buttons, zips and shoelaces, use a knife, cut, paste, glue, control a pencil, use a rubber, knit or sew. Any combination of such deficits will disrupt childhood learning and experience (Rissman, 2007, 2011, 2016).

Teachers often guide academically-challenged students towards vocational subjects. Home economics for example is a multifaceted and challenging subject for students with NLD. Preparing a meal, chopping, using an iron, cutting material, using a sewing machine, or hammering a nail all involve manual dexterity, motor coordination, manipulation, and tactile-visual-spatial perception, together with ability to judge and problem solve along the way. Although middle and high school teachers consider vocational subjects more suited to less academic students, many requisite skills are problematic for a student with NLD.

Lack of environmental experience and human interaction prevents a child with NLD from accurately forming basic concepts, as would be expected. As summarised by Davis and Broitman (2011), physical clumsiness, tactile insensitivity, spatial and organizational deficits, difficulty handling new tasks and situations, and trouble integrating all aspects of a social situation provide more sufficient grounds for “despair and depression than other forms of learning disabilities” (p. 31).

My daughter was born with an occipital encephalocele, otherwise known as spina bifida or a neural tube defect. At age 15, a neuropsychological assessment diagnosed significant deficits in the nonverbal areas of functioning, and intellectual impairment. Clumsiness and co-ordination problems were attributed to the primary problem at birth. She was able to complete tasks in the early school years with support. Reading and speech were fluent from a young age and rote learning skills were excellent. Repetition was our ticket to success and she thrived on sameness and predictability. Changes to routines, class outings, school camps, and new situations caused extreme anxiety, even illness. Many extra-curricular activities complemented therapies and formal school. From Year 6, as learning involved more complexity, adaptability and problem solving skills, age-appropriate expectations could not be realised. In retrospect, success with rote learning tasks created an impression of competence and fluent speech caused misperception. A severe Nonverbal Learning Disability (NLD) was diagnosed as an adult.

So- what is NLD?

It is not a disability in the traditional sense but a neurological disability that manifests with age. Individuals with NLD face many difficulties not experienced by those with a language learning disability. Poor motor coordination and ability to plan, organize, make decisions, solve problems, and understand social interaction distinguish students with NLD from those with a language learning disability. Individuals with a language learning disability usually show age-appropriate development in these areas but have trouble with speech and reading which are areas of strength for students with NLD (Antshel & Khan, 2008; Hardanek & Rourke, 1994).

NLD may therefore be considered a disability with a very misleading profile.

The physical appearance of a student with NLD is no different to that of any other student. Striking characteristics are a child’s chatty personality, mature vocabulary, and ease of rote learning, all of which charm teachers and professionals but create a paradox when functional capacities fall short. Despite fluent speech, good oral presentations, and top marks for spelling, a student with NLD has cognitive and functional limitations that impair ability to develop age-appropriate coordination, accurately perceive messages from the senses, and develop social competence. Dysfunctional behaviours often lead to the student being called “lazy”, “uncooperative”, or “babied” instead of being addressed as neurological dysfunctions (Rissman, 2007; Tanguay, 2002). As more independence and responsibility are expected at home and school, friendships become harder to sustain, and everyday life for can be full of fear if the NLD is not identified. Loneliness may be a constant companion and trouble with daily routine tasks may threaten personal and economic independence.

If teachers and career advisors do not understand the seriousness of deficits in the nonverbal areas of functioning, how can they offer reliable guidance and plan meaningful training programs for students with NLD? Vocational subjects can be problematic for students with NLD which begs the question “What happens post-school when students seek work in a competitive workforce?” Students with NLD appear bright, but they have trouble coping with simple everyday tasks, and they do not quite fit in with peers. The post-school period is when functional and social problems magnify as teacher aide support evaporates and the young person wants to pursue work initiatives introduced through school. The individual has likely been involved with career development programs and engaged in vocational training programs.

These young adults are at risk of falling through the cracks. If difficulties are not identified and addressed so career guidance can be couched within a realistic framework, depression can set in as the young person grows older and compares his or her real prospects with those of age-peers. As peers forge ahead vocationally and socially, families struggle to make life productive for their young adult with NLD. The young person may be trusting and impeccably honest, which makes them an easy target for predators as well as physical, emotional, and financial exploitation in adulthood.

The most serious crises seem to occur at the point when [students] leave school and attempt to enter the competitive work force. It is at this juncture that they begin to experience the most devastating effects of their deficits. (Rourke, 1989, p. 145)

Significant predictions that can be made about students with the NLD profile include:
  • Poor basic self-help skills
  • Over-dependence between mother and child
  • Excessive speech with little meaningful content
  • Incoordination and clumsiness
  • Poor early handwriting
  • Inability to handle complex maths (word problems, volume, area, measurement, algebra)
  • Difficult to manage time, initiate and complete tasks without individual support
  • Poor comprehension (written and verbal)
  • Difficult to understand social interaction, develop and maintain friendships
  • Few or no friends of the same age
  • Anxiety, depression (Davis & Broitman, 2011; Rissman, 2007, 2011, 2016; Rourke et al., 2002; Whitney, 2002)
Rourke (1989) points out that classification of students into a disability subtype such as NLD does not mean those students are identical. Although individuals may share characteristics of a particular subtype, they will also display “substantial individual differences” (p. 186). Clear understanding of the neuropsychological profiles of NLD and similarly presenting disorders will assist a diagnostician to make a differential diagnosis.

Theorized Cause

NLD is believed to be caused by damage, disorder, or destruction of neuronal white matter in the brain’s right hemisphere. It may be seen in persons suffering from a range of neurological diseases such as:

  • Hydrocephalus (shunted)
  • Williams syndrome
  • Colossal agenesis
  • Velocardiofacial syndrome
  • Turner syndrome
  • De Lange syndrome
  • As well as other types of brain injury (Broitman & Davis, 2013; Delgado et al., 2011; Gross-Tsur, Shalev, Manor, & Amir, 1995; Harnadek & Rourke, 1994; Molenaar-Klumper, 2002; Rourke et al., 2002; Rourke 1989, 1995)
Although widely recognized and diagnosed in America and Canada, NLD is not formally identified in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) or the International Classification of Functioning (ICF). The ICF measures an individual’s functioning and disability from medical and social perspectives. It goes beyond disease classification and mortality to describe how people live with their condition, its influence on body functions, effects on daily tasks and actions, and impact on the individual’s ability to participate in everyday life with due consideration to environmental and personal factors.

Forty years of research into the theoretical and neuropsychological underpinnings of NLD, publication of several hundred peer-reviewed journal articles, dozens of books and book chapters, and creation of several websites devoted to NLD, provide compelling evidence to support inclusion of NLD in the International Classification of Functioning (ICF) (Casey, 2012; Ris & Nortz, 2008; Rissman, 2016). Formalization of an NLD diagnosis would provide a framework and language for describing NLD characteristics, interrelationships, and behavioural consequences. Official recognition in the ICF would guide clinical practice and future research. It would support development of policies and services that better meet the needs of people affected by NLD in Australia and the world at large (AIHW, 2003; Casey, 2012).

A key objective here is to inform teachers, doctors, allied health, and government disability service providers that a young person who reads and speaks well can still have a complex neurological disability.

As part of the Advances in Early Childhood and K-12 Education Book Series, Medical and Educational Perspectives on Nonverbal Learning Disability in Children and Young Adults offers a comprehensive discussion on the niche topic of nonverbal learning disabilities as well as the difficulties faced by those affected by them. This title is currently available to order on the IGI Global Bookstore as well as through the InfoSci® Databases, which offer full-text book chapters and journal articles from over 3,100 books and 158 scholarly journals. To adopt this book for use in your courses, please submit an examination request form here. To request a copy of this book for review, please contact Promotions Coordinator Ann Lupold at alupold@igiglobal.com.
About the Author
Barbara Rissman, Ph.D., brings personal experience to Medical and Educational Perspectives on Nonverbal Learning Disability in Children and Young Adults. Her daughter was born with an encephalocele, a neural tube defect estimated to occur in two to three out of every 10,000 live births. The extreme demands of caring for and educating a child with spina bifida, hydrocephalus, and undiagnosed learning difficulties led Barbara to pursue a private teaching practice so she could be available for her daughter’s many surgeries and therapies. After teaching piano, organ, and theory of music for 22 years to students of all ages and ability levels, Barbara transitioned to the field of tertiary education. Following under- and post graduate degrees, she undertook doctoral research, inspired by her daughter’s 12-year journey through school. Dr. Rissman’s 2007 study explored the learning experiences of students with spina bifida, hydrocephalus and an NLD profile in mainstream Australian schools. She currently works at Australia’s Queensland University of Technology as a sessional academic, equity project officer, and previously served as a unit coordinator and tutor. Her immediate goal is to raise awareness of NLD among educational, medical, and allied health practitioners to prevent serious emotional, developmental, and educational consequences if the NLD is not identified early and managed.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Antshel, K. M., & Khan, F. M. (2008). Is there an increased familial prevalence of psychopathology in children with nonverbal learning disorders? Journal of Learning Disabilities, 41(3), 208–217. doi: 10.1177/0022219408317546

Australian Institute of Health and Welfare (AIHW). (2003). ICF Australian User Guide Version 1.0. Retrieved May 24, 2014, from http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442455729

Broitman, J., & David, J. M. (2013). Treating NLD in children: Professional collaborations for positive outcomes. New York, NY: Springer. doi: 10.1007/978-1-4614-6179-1

Casey, J. E. (2012). A model to guide the conceptualization, assessment, and diagnosis of nonverbal learning disorder. Canadian Journal of School Psychology, 27(1), 35-57. doi: 10.1177/0829573512436966

Centers for Disease Control and Prevention. (2012). International classification of functioning, disability and health (ICF). Retrieved June, 2016, from http://www.cdc.gov/nchs/icd/icf.htm

Davis, J. M., & Broitman, J. (2011). Nonverbal learning disabilities: Bridging the gap between science and practice. New York, NY: Springer. doi: 10.1007/978-1-4419-8213-1

Delgado, S. V., Wassenaar, E., & Strawn, J. R. (2011). Does your patient have a psychiatric illness or nonverbal learning disorder? Current Psychiatry, 10(5), 17-24, 34-35. Retrieved from http://www.currentpsychiatry.com/

Gross-Tsur, V., Shalev, R., Manor, O., & Amir, N. (1995). Developmental right-hemisphere syndrome: Clinical spectrum of the nonverbal learning disability. Journal of Learning Disabilities, 28(2), 80-86. doi: 10.1177/002221949502800202PMID:7884301

Harnadek, M. C. & Rourke, B. P. (1994). Principle identifying featrues of the syndrome of nonverbal learning disabilities in children. Journal of Learning Disabilities, 27(3), 144-160. Retrieved from 10.1177/002221949402700303

Molenaar-Klumper, M. (2002). Non-verbal learning disabilities: Characteristics, diagnosis and treatment within an educational setting. London: Jessica Kingsley.

Myklebust, H. R. (1978). Nonverbal learning disabilities: Assessment and intervention. In H. R. Myklebust (Ed.), Progress in learning disabilities, 3 (pp. 85–121). New York, NY: Grune & Stratton.

Ris, M. D., & Nortz, M. (2008). Nonverbal learning disorder. In J. E. Morgan & J. H. Ricker (Eds.), Textbook of clinical neuropsychology (pp.346-359). New York, NY: Taylor & Francis.

Rissman, B. M. (2007). They didn’t ask the question: An inquiry into the learning experiences of students with spina bifida and hydrocephalus (Doctoral dissertation). Retrieved from http://eprints.qut.edu.au/16528 on 3 June, 2016

Rissman, B. M. (2011). Nonverbal learning disability explained: The link to shunted hydrocephalus; British Journal of Learing Disabilities, 39(3), 209-215. doi: 10.1111/j.1468-3156.2010.00652.x

Rissman, B. M. (2016). Medical and Educational perspectives on nonverbal learning disability in children and young adults (pp. 1-404). Hershey, PA: IGI Global. doi: 10.4018/978-1-4666-9539-9

Rourke, B. P. (1989). Nonverbal learning disabilities: The syndrome and the model. New York: Guilford.

Rourke, B. P. (1995). Syndrome of nonverbal learning disabilities. New York, NY: Guilford Press.

Rourke, B. P., van der Vlugt, H., & Rourke, S. B. (2002). Practice of child-clinical neuropsychology: An introduction. Steenwijk, Netherlands: Swets & Zeitlinger.

Tanguay, P. (2002). Nonverbal learning disabilities at school. London, United Kingdom: Jessica Kingsley.

Tsatsanis, D., & Rourke, B. P. (2008). Syndrome of nonverbal learning disabilities in adults. In L. E. Wolf, H. E. Schreiber, & Wasserstein (Eds.), Adult learning disorders: Contemporary issues (p. 181). New York, NY: Psychology Press.

Whitney, R. (2002). Bridging the gap: Raising a child with nonverbal learning disorder. New York, NY: Berkeley Publishing Group.
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