To recap my previous article entitled Nonverbal Learning Disorders: The term Nonverbal Learning Disorders (or NLD) refers to a neurological syndrome believed to result from damage to the white matter connections in the right-hemisphere of the brain, which are important for intermodal integration. Three major categories of dysfunction present themselves: (1) motoric (lack of coordination, severe balance problems, and difficulties with fine graphomotor skills); (2) visual-spatial-organizational (lack of image, poor visual recall, faulty spatial perceptions, and difficulties with spatial relations); and (3) social (lack of ability to comprehend nonverbal communications, difficulties adjusting to transitions and novel situations, and deficits in social judgement and social interaction). Individuals with NLD generally have exceptional verbal skills, do well in school subjects requiring decoding (the word recognition aspect of reading) and encoding (spelling) written language, have excellent auditory attention and memory, and learn primarily through verbal mediation. This syndrome appears to be the exact opposite of dyslexia.

NLD often resembles Attention Deficit Disorder (ADD) because the student with NLD has poor attention to visual and tactile input. However, a closer observation of this child will reveal that the deficiencies he experiences in these areas are not actually attentional deficits (medication to improve attention does not usually improve this child's dysfunctional visual and tactile processing), but rather they are brought about by limited access to the areas of the brain which are linked to these modalities.

Since I wrote my previous Gram article on Nonverbal Learning Disorders, a lot has changed and a lot has stayed the same. There is definitely more recognition of NLD by educators, parents, and those in the medical profession today. Children are being identified at a much younger age, and many are receiving the CAMS (Compensations, Accommodations, Modifications, and Strategies) they need in school, at home, and on the job. School districts are now providing inservice training for their staff members to educate them about NLD and colleges are offering curriculum on NLD for educators and educational therapists.

I personally have had requests from all over the United States, and also Canada, to provide workshops and staff development related to NLD. At this year's LDA-CA state conference in Costa Mesa, my presentation on Nonverbal Learning Disorders drew over 100 participants, made up of a combination of parents and professionals. And, several of the other sessions I attended this year also included at least a mention of NLD, such as: Arnie Purisch on "Neurological Perspectives on Learning Disorders and ADD;" Daniel Amen on "Images into the Mind;" Lynne Stietzel on "Putting Together the Pieces;" and Jennifer Zvi on "Making the Leap: From High School into Post-Secondary Education" (all excellent presentations - worth purchasing the audio tapes). This was not the case, even one year ago. In the past, it was hard to find any speakers referencing NLD at any learning disability conference. These strides give me hope for the future. As public awareness improves, so will the prognosis for the children and adults suffering from this devastating neurological syndrome.

Last April, SHARE Support (a non-profit organization which provides education and support for families living with and professionals working with individuals experiencing neurobiological challenges) sponsored its first all-day symposium on Nonverbal Learning Disorders in Walnut Creek, CA. The response was overwhelming. Participants had to be turned away because the rooms were filled to capacity. Attendees hailed from Massachusetts, Florida, Utah, and all parts of California. Some of the presenters from this symposium are now working together to compile a survey which could yield information to be used as a screening instrument for Nonverbal Learning Disorders. Herbert Schreier, M.D., of Children's Hospital Oakland, is supervising this team.

So, awareness of NLD is progressing. However, these advancements are not happening quickly enough for many of those individuals currently diagnosed with Nonverbal Learning Disorders. Because most achievement measures are still based upon a student's ability to identify and use words correctly (verbal abilities), language-based learning disorders still receive the bulk of recognition in our schools. I believe it is still fair to say most students with NLD are still not receiving adequate services in our schools, and therefore, are not receiving a free and appropriate public education, as PL 94-142 requires. There are still numerous school districts refusing to accommodate students with NLD. There are still educators who resist making the needed modifications which would ensure the success of these students in regular classrooms. And, there are still many employers who do not want to provide the necessary on-the-job provisions for individuals with NLD.

Teen and adult suicide is still prevalent among individuals suffering from undiagnosed and/or unserviced NLD. We've come a long way, but we still have a long way to go.

In my previous article, I noted that Nonverbal Learning Disorders appear much less frequently than Language-based Learning Disorders. Whereas it is approximated that about 10% of the general population could be found to have identifiable learning disabilities, it was thought that only 1 to 10% of those individuals would be found to have NLD. This information was based upon clinical records and it is now thought by many to be a glaring underestimation of actual rates of occurrence. What is safe to say is that NLD is grossly under-recognized and these individuals are frequently misdiagnosed. The unprecedented response to both my Gram article and my NLD manual alone would appear to indicate an under-representation of the extent of the problem. Everyone I meet seems to know at least one person with NLD. Maybe I'm moving in the wrong circles, but my own experiences would indicate this low measure of calculated incidence will probably rise as proper identification becomes more standard.

Early research delineated NLD to be a "right-hemisphere" disorder. Dr. Byron Rourke's research points to a white matter dysfunction as the cause for NLD. White matter is found predominately in the right-hemisphere of the brain, explaining the initial assumption that NLD was right-hemisphere related. Dr. Rourke has observed NLD symptomology in individuals with known closed head injury, hydrocephalus, and other neurological insults. However, he also presents a strong case for a "developmental" manifestation of the NLD syndrome, as well. These are children who have been afflicted since their earliest developmental stages (presumably the syndrome existed at birth, although a genetic link has not been confirmed). Dr. Rourke believes that the symptomology is slightly different when the onset of the syndrome occurs in an older child, an adolescent, or an adult (due to neurological insult) who has enjoyed a normal early developmental progression until that point in their life.

And, finally, to clear up a few other misconceptions, although the majority of children with NLD experience early speech development and spontaneous early reading, not all children with NLD talk and read early. Some have significant oral motor problems which produce difficulty imitating and sequencing tongue, lip and jaw movements. However, receptive language is intact for these children, and generally once they are able to coordinate their oral motor skills, their vocabulary will rapidly exceed that of their peers. Likewise, not all children with NLD will read early. Initially reading is a novel task.

Units of print need to be linked with previously learned units of linguistic communication. This requires visual-spatial feature-analysis skills. For some children with NLD, their impaired visual-spatial abilities do not allow this link to occur within the normal time frame, despite their high verbal intelligence. Once the sound-symbol match is made, however, word-decoding skills advance rapidly, again exceeding age-level peers by leaps and bounds.

Dr. Byron Rourke notes that children with NLD who read late are often misdiagnosed with dyslexia in the early grades. They are then placed in Resource Specialist and Reading Specialist Programs for remedial help. And they become the "poster children" for whatever particular method is being used for remediation, because they exhibit such remarkable gains in single-word reading (decoding). Dr. Rourke points out that those children with NLD who display apparent reading difficulties in their early years, will all eventually read at a superior level, regardless of what program is utilized to help them.

Cognitive testing will reveal a significant discrepancy between verbal and performance scores, with verbal scores often in the very superior range. Clinical observations will reveal a child who is exceptionally verbal, often overelaborating on tasks requiring a verbal response. This child will also rely upon verbal strategies to talk himself through performance-based problems. He will frequently ask the examiner how he is doing, trying to illicit verbal feedback related to his performance.

Verbal coaxing and encouragement will often facilitate task completion. On tasks which require the integration of visual information based on a contextual meaning, such as Object Assembly and Block Design, the child with NLD will hone in on the visual details of the manipulatives and fail to fit the pieces together based upon the picture as a whole or gestalt. This child's inability to visualize will most likely result in a reduced processing speed. His motor planning is impaired, which produces difficulty understanding, organizing, and completing tasks. The child with NLD will proceed in a step-by-step manner, often failing to view a task in holistic terms. He can be expected to have difficulty with all tasks which rely upon simultaneous processing, rather than sequential processing.

Good prognosis for the child with NLD depends upon early identification and appropriate early intervention. Special education is a series of individually designed services and supports; it is not a place to which a student is assigned. A child is not either "in" or "out" of special education; his intervention plan should be in effect in every class he attends, during every passing period, during recesses and breaks, on every field trip and at every assembly. Since each student is unique, the student's IEP provides the individual framework for appropriate CAMS, which should be implemented throughout the school day. Successful implementation of an inclusionary placement requires careful planning.

Regular education and special education personnel must plan together for the educational and social integration needs of a student with NLD. Open communication between parents and school staff is also imperative. Ideally, the inclusion program for the upcoming school year should be developed and set up during the spring prior to the coming school year.

The planning and implementation phase can be decisive, yet frequently little time is devoted to this stage of the process. CAMS (Compensations, Accommodations, Modifications, and Strategies) should be clearly defined and put into place from day one of the school year. All educators must be ready and willing to implement changes in the way they've always done things, in order for an intervention plan to prove successful for the child with NLD.

Proper implementation does not just happen because a good plan is in place; it also takes a high level of professional commitment from the school staff. Inservice training must be provided for all faculty members involved with this student. The child with NLD requires daily modifications of assignments and consistent accommodations for his areas of neurological dysfunction. Careful planning is crucial to forming a successful program and communication is the key to keeping it running smoothly.

To develop effective teaching strategies, it is important to differentiate NLD from other learning disorders. Specific intervention techniques will be different from those employed for other subtypes of learning disabilities and/or those employed for behavioral or emotional disorders. Although the child with NLD learns differently from his peers, he learns rote material quickly and easily. He seems to have endless storage space in his memory and he constantly "absorbs" details and information. Capitalize on these strengths. His strong verbal skills should be used as a primary means for acquiring additional skills. The future successes of this child are dependent upon his acquisition of compensatory strategies, usually verbal, to circumvent his areas of incompetency.

Teacher lesson plans must take into account the fact that a student with NLD will have difficulty processing information presented primarily through the visual modality. Teachers need to think about how they can take some of the visual stimulation out of their worksheets. Visually delivered materials should always be supplemented with verbal input. Also, written responses should not be the exclusive method of evaluating this child's learning. Leave enough response space on worksheets to allow for poor graphomotor control. Always determine the goal of the task. Don't needlessly torture a child who has difficulty with handwriting when an oral response could be substituted in place of a written response. The CAMS recommended for the individual with NLD are all relatively inexpensive to develop and implement (please refer to Part 3 of Nonverbal Learning Disorders from Winter Gram 1996, for some specific CAMS).

My intense gratitude is extended to all of the dedicated researchers, especially Dr. Byron P. Rourke and his colleagues at the University of Windsor, whose work in the field of learning disabilities has been instrumental in isolating the NLD syndrome and in formulating the NLD model.

Copyright:  Sue Thompson, 1997 

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