Nonverbal Learning Disorders

By: Sue Thompson, M.A., C.E.

An introduction

There is no question that most scholastic accomplishments are measured and defined through language-based communication. Yet, it has been found that more than 65% of all communication is actually conveyed nonverbally. We are all familiar with "non-verbal communication," but few professionals have been specifically trained to look for deficits in this area. Although intelligence measures are designed to evaluate both the verbal and nonverbal aspects of intelligence, educators tend to ignore evidence of nonverbal deficiencies in students. Or worse, they brand students with nonverbal learning disabilities as "problem" children.

We are all aware of the important role language plays in human learning. The competence of an individual, in our present-day society, is most often judged by their verbal proficiencies. A person who speaks eloquently and has a well-developed vocabulary tends to be accorded more credibility than an individual who makes constant grammatical errors and demonstrates a limited vocabulary. A student who has innate difficulties reading, spelling, and/or expressing herself stands out in most classroom situations. And likewise, a student who is a top reader, achieves excellent spelling scores, and expresses herself articulately usually does not prompt her teacher to consider a learning disorder. But, this is often exactly the presentation a child with nonverbal learning disabilities (NLD) syndrome manifests in the early elementary grades.

Nonverbal learning disorders (also called "right-hemisphere learning disorders") often go unrecognized and unaided by teachers and other professionals for a large part of a child's schooling. Overall, there has been an inadequate awareness of the underlying causes for the difficulties these students encounter in school. There are currently few resources available for the child with NLD syndrome through schools or private agencies. It is still difficult to find a professional who understands nonverbal learning disabilities. These children are often labeled "behavior problems" or "emotionally disturbed" because of their frequent inappropriate and unexpected conduct, but NLD is known to have a neurological rather than a deliberate and/or an emotional origin.

The NLD syndrome reveals itself in impaired abilities to organize the visual-spatial field, adapt to new or novel situations, and/or accurately read nonverbal signals and cues. It appears to be the reverse syndrome of dyslexia. Although academic progress is made, such a student will have difficulty "producing" in situations where speed and adaptability are required. Whereas language-based learning disorders have been shown to be genetic in origin, heredity has not, as yet, been linked to NLD. It is known that nonverbal learning disabilities involve the performance processes (generally thought of neurologically as originating in the right cerebral hemisphere of the brain, which specializes in nonverbal processing).

Brain scans of individuals with NLD often confirm mild abnormalities of the right cerebral hemisphere. Developmental histories have revealed that a number of the children suffering from nonverbal learning disorders who have come to clinical attention have at some time early in their development: (1) sustained a moderate to severe head injury, (2) received repeated radiation treatments on or near their heads over a prolonged period of time, (3) congenital absence of the corpus callosum, (4) been treated for hydrocephalus, or (5) actually had brain tissue removed from their right hemisphere.

All of these neurological insults involve significant destruction of white matter (long myelinated fibers in the brain) connections in the right hemisphere, which are important for intermodal integration. Hence, current evidence and theories suggest that early damage (disease, disorder, or dysfunction) of the right cerebral hemisphere and/or diffuse white matter disease, which leaves the left hemisphere (unimodal) system to function on its own, is the contributing cause of the NLD syndrome (definitely not dysfunctional home lives). Clinically, this learning disorder classification resembles an adult patient with a severe head injury to the right cerebral hemisphere, both symptomatically and behaviorally.

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 is thought that only 1 to 10% of those individuals would be found to have NLD (or between 1.0 to 0.1% of the general population). Unlike language-based learning disabilities, the NLD syndrome affects females as often as males (approximately 1:1 sex ratio) and incidence of left-handedness is uncommon.

Even though NLD is, by definition, a "low incidence disability," there are indications that, as school assessment/intervention procedures improve, a higher proportion of children will be identified with the NLD syndrome. The low rate of occurrence (as low as 1 out of 1,000), is no excuse for the lack of identification and services victims of this devastating impairment currently receive. The symptoms are distinct and display themselves early in a child's development.

The discovery of the NLD syndrome began in the early 1970s, with research involving groups of children with learning disabilities identified by discrepancies between their verbal and performance IQs. It is unfortunate that 25 years later, even professionals in the field of education are largely uninformed about and/or unfamiliar with nonverbal learning disorders as these disabilities can be much more devastating to a child than language-based learning disorders in the long run.

Since diminished access to and/or disordered functioning of the right-hemisphere systems impedes all understanding and adaptive learning, it is fair to say (as Helmer R. Myklebust did in 1975) that nonverbal learning disabilities "are more debilitating than verbal disabilities." The specific central processing abilities and deficits that characterize this syndrome are now well defined. Still, nonverbal learning disorders remain predominantly misunderstood and largely go unrecognized.

A child's earliest mode of communication should be nonverbal. Both parents and teachers will often suspect that "something is amiss" early on, but they can't quite "put a finger on it." Three categories of dysfunction present themselves: (1) motoric (lack of coordination, severe balance problems and/or difficulties with fine graphomotor skills), (2) visual-spatial-organizational (lack of image, poor visual recall, faulty spatial perceptions, and/or difficulties with spatial relations), and (3) social (lack of ability to comprehend nonverbal communication, difficulties adjusting to transitions and novel situations, and/or significant deficits in social judgment and social interaction).

Early consultation with a school psychologist or family physician typically only serves to dismiss or minimize a teacher's or parent's worries about this child. More often than not, parents are assured that everything is fine; perhaps their child is "just a perfectionist" or "immature" or "bored with the way things are normally done" or "a bit clumsy." Rarely are a parent's or teacher's concerns given any credence until the child reaches a point in school where he is no longer able to function given the limitations of his disability and/or, in some cases, the child suffers a "nervous breakdown" (or worse).

The child with nonverbal learning disorders commonly appears awkward and is, in fact, inadequately coordinated in both fine and gross motor skills. She may have had extreme difficulty learning to ride a bike or to kick a soccer ball. Fine motor skills, such as cutting with scissors or tying shoe laces, seem to be impossible for this child to master. She "talks her way through" even simple motor activities. A young child with NLD is less likely to explore her environment motorically because she cannot rely upon her kinesthetic processing and spatial perceptions. This child learns little from experience or repetition and is unable to generalize information.

In the early years, such a child may appear "confused" much of the time (he is confused) despite a high intelligence and high scores on receptive and expressive language measures. Closer observation will reveal a social ineptness brought about by misinterpretations of body language and/or tone of voice. This child is unable to "look and learn." He does not perceive subtle cues in his environment such as: when something has gone far enough; the idea of personal "space"; the facial expressions of others; or when another person is registering pleasure (or displeasure) in a nonverbal mode.

These are all social "skills" that are normally grasped intuitively through observation, not directly taught. If a child is constantly admonished with the words, "I shouldn't have to tell you this!," this should alert everyone that something is awry because you do have to tell them (everything). The child's verbal processing may be proficient, but it can be impossible for her to receive and comprehend nonverbal information. Such a child will cope by relying upon language as her principal means of social relating, information gathering, and relief from anxiety. As a result, she is constantly being told, "You talk too much!"

The child with NLD often develops an exceptional memory for rote material; a coping skill he has had to hone in order to survive. Since the nonverbal processing area of his brain is not giving him the needed automatic feedback, he relies solely upon his memory of past experiences, each of which he has labeled verbally, to guide him in future situations. This, of course, is less effective and less reliable than being able to sense and interpret another person's social cues (because of the vast array of differences in human nature).

Cumbersome monologues are another trait of a child with nonverbal learning disabilities. Normal conversational "give and take" seems to elude her. Teachers complain of a child who "talks incessantly" and parents resolve, "She just doesn't seem to know when to be quiet!" Owing to visual-spatial disturbances, it is difficult for this child to change from one activity to another and/or to move from one place to another. A child with NLD uses all of her concentration and attention to merely get through a room. Imagine the frustration produced when attempting to function in a complicated and/or new social situation. Owing to her inability to "handle" such informational processing demands, she will instinctively avoid any kind of novelty.

The importance of identifying and servicing children with nonverbal learning disorders is especially acute. Overestimates of the child's abilities and unrealistic demands made by parents and teachers can lead to ongoing emotional problems. A favorable prognosis seems to depend upon early identification and accommodation. The child with NLD is particularly inclined toward seriously debilitating forms of internalizing psychopathology, such as depression, withdrawal, anxiety, and in some cases, suicide.

Dr. Byron P. Rourke of the University of Windsor and his associates have found that nonverbal learning disabilities "predispose those afflicted to adolescent and adult depression and suicide risk." The child with NLD is regularly punished and picked on for circumstances he cannot help, without ever really understanding why, and he is in turn often left with little hope that his situation will ever improve. After amassing years of embarrassing and misconceived unintentional social blunders, it is not too difficult to comprehend how a person with nonverbal learning disorders could come to the conclusion that his environment is not structured to accommodate him.

Identifying nonverbal learning disorders

Whereas language-based disabilities are usually readily apparent to parents and educators, nonverbal learning disorders routinely go unrecognized. Many of the early symptoms of nonverbal learning disabilities instill pride, rather than alarm, in parents and teachers who ordinarily applaud language-based accomplishments. This child is extremely verbose and may "speak like an adult" at two or three years of age. During early childhood, he is usually considered "gifted" by his parents and teachers. Sometimes the child with NLD has a history of hyperlexia (rote reading at a very young age). This child is generally an eager, enthusiastic learner who quickly memorizes rote material, only serving to reinforce the notion of his precocity.

Extraordinary early speech and vocabulary development are not often suspected to be a coping strategy being employed by a child who has a very deficient right-hemisphere system and limited access to her nonverbal processing abilities. The child with NLD is also likely to acquire an unusual aptitude for producing "phonetically accurate" reproductions of words (spelling), but few adults will consider this to be a reflection of her over-dependence upon auditory perceptions (as opposed to visual or tactile). Likewise, remarkable rote memory skills, attention to detail, and a natural facility for decoding, encoding, and early reading development do not generally cause red flags to go up. Yet, these are some of the important early indicators that a child is having difficulty relating to and functioning in her world nonverbally, and a warning that she has developed an excessive reliance upon her verbal strengths.

Dr. Rourke and his associates have found that the dysfunctions associated with NLD are "less apparent at the age of 7 to 8 years . . . than at 10 to 14 years," and that they become "progressively more apparent (and more debilitating) as adulthood approaches." Although this child has a history of poor coordination and was probably slow to acquire motor skills, typically initial academic concerns will generate from the fact that he is not completing and/or turning in written assignments during his late elementary school years. This child produces limited written output and the process is always slow and laborious for him.

When the skills for organizing and developing written work don't advance at the expected rate for this student, finally the red flags go up. However, by this time, the child may have already "shut down" or become locked into an oppositional struggle, as a coping mechanism to deal with the academic pressures and performance demands which have been placed upon him by unsuspecting parents and teachers and which he is unable to meet.

The three broad aspects of development in which NLD presents deviations and abnormalities are (1) motoric, (2) visual-spatial-organizational, and (3) social. If a child has right hemispheric dysfunction, deficits in these areas should be quite evident to an observer during the child's early years, despite his valiant efforts to compensate for them. The more novel the psychomotor, visual-spatial, and/or social situation, the more evident his impairments will be. Following are some of the early adjustment problems to be aware of in each category.

Motoric:

This child generally has a history of poor psycho-motor coordination. Motor clumsiness is often the first concern his parents observe. There may be a recognizable difference between the dominant and non-dominant sides of the body with more noticeable problems on the left side of the body. He will avoid crossing his body midline. Later, in school, he may exhibit problems with dysgraphia and impaired tactile-discrimination abilities, including finger agnosia.

His lack of motor control can manifest in social rejection, as this child is constantly "getting in the way," bumping into other people and objects, and is generally unaware of the position in space his body encompasses. In addition to social ostracism, his motor disabilities (along with spatial misconceptions) put him at an increased risk for personal injury.

As a toddler, she will be hesitate to explore her environment motorically, instead she explores the world verbally by asking questions and receiving verbal answers to her questions about the environment. Extreme vacillations with balance are often first evident when the child is learning to walk. She may appear "drunk" in her early attempts at walking. An unusual amount of falling will cause this child to be reluctant and to cling to objects and/or a parent's hand to gain stabilization long after this would normally be expected. She may also have a fear of heights and avoid climbing up on the jungle gym. It is believed that because of these deficiencies, this child receives little benefit from the sensorimotor period of development, which consequently hinders her development of higher-order concept formation and problem-solving abilities.

Often, when the toddler with nonverbal learning disorders is set down after being held, it takes several seconds for him to cognitively secure his equilibrium. As this function of the central nervous system is not integrated for him through the right hemisphere, his body will not automatically resume a position of balance. The child must "remember" a previous experience of equilibrium and restructure that memory cognitively to achieve a position of bodily balance. His everyday experience is similar to the unbalanced sensation a well-integrated adult encounters when stepping off of a boat onto "solid" land after a time at sea.

These faulty balance perceptions will make learning to ride a bike laborious beyond belief. A child with NLD takes years, not days or weeks to conquer riding a two-wheel bicycle unaided. At the dinner table or (upon entering a school situation) at a desk, this child needs to muster an extraordinary amount of determination to remain seated in her chair. And, as soon as she diverts her attention to the task at hand (i.e. eating or school work), the cognitively maintained balance is gone, and over she topples. This child naturally prefers to eat and do school assignments on the floor, where she senses more security and support.

Simple athletic skills cannot be mastered in early childhood. When this child lifts his foot to kick a soccer ball, while concentrating on the ball rather than his balance, he will subsequently lose (forget) his balance and tumble over. When jumping up to shoot a basket, he cannot land solidly on his feet. When attempting to do "jumping-jacks," it is impossible to coordinate the two sides of his body. The ridicule suffered by this child is catastrophic, even at the hands of possibly well-meaning "coaches" and P.E. teachers.

Fine motor skills are also impacted. The NLD toddler resists eating with a spoon or fork owing to the lack of dexterity in his fingers. Learning to tie her shoe laces can take years and she will have to "talk herself through" the process well into adolescence and beyond. Using scissors can be a difficult to hopeless task, as is holding a pencil correctly. This child will adapt a "static tripod" pencil grip and press very deeply in an attempt to control her writing, often producing dark, heavy lines.

It has been said that such a child always "draws" and never actually learns to "write" (it's not too difficult to imagine the consequences this causes in school). The child with NLD's handwriting may be quite neat, but the process remains slow and arduous for him. His daily experience with fine motor skills has been likened to an adult who, after a stroke or being prescribed a muscle relaxant, have extreme difficulty controlling their handwriting.

Visual-spatial-organizational:

Problems with spatial perceptions; spatial relations; recognition, organization, and synthesis of visual-spatial information; discrimination and recognition of visual detail and visual relation-ships, visual-spatial orientation (including right-left orientation problems); visual memories, coordination of visual input with the motoric processes (visual-motor integration); visual form constancy; gestalt impressions; and concept formation are rooted in basic deficits in visual perception and visual imagery. This child does not form visual images and therefore cannot revisualize something he has seen previously. He focuses on the details of what he sees and often fails to grasp the "total picture."

Visual-spatial confusion underlies many of the unusual behaviors which are evident in a young child with nonverbal learning disorders. This child will endeavor to "bind" to an adult, through continuous dialog, in order to stabilize her position in a room. She needs to "verbally" (albeit subconsciously) label everything that happens around her, in order to memorize and try to comprehend the everyday circumstances which others instantly and effortlessly recognize and assimilate. Experiences are stored in her memory by their verbal labels, not by visual images or by proprioceptive recall. She will have a relatively poor memory for novel and/or complex material and/or material which is not easily verbally coded.

The child with NLD must employ intense forethought to label everything he comes into contact with in his environment. Owing to faulty perceptions, these labels may be incorrect, but the child perseveres because this is his only accessible means of processing the information. He does not form the visual images which help the rest of us to recognize and comprehend something we've seen or a place we've been before. This causes extreme difficulty for him in trying to find his way in new places.

Spatial reference is often neglected entirely (i.e., the child may recall many distinct details of a house she has just visited, but she will not be able to describe its location in reference to other houses on the same block and/or to her own home; she cannot conceptualize the details she has memorized in an integrated fashion to form a holistic view). This child, naturally, is not drawn to building or construction toys. Once in school, she will have difficulty figuring out where and how to place written responses on a sheet of paper and/or how to get back to her classroom from the nurses' office. Specific problems in arithmetic can result from deficits in visual-spatial reasoning and visual perception. She will commonly have problems aligning columns of numbers, observing directionality, and in organizing her work.

The child with nonverbal learning disorders constantly "talks himself through" situations as a means of verbally compensating for his motoric and visual-spatial deficiencies. Although he may be unaware of the spatial position his house occupies in the neighborhood, he will find his way back from a friend's house by counting homes which come in between, labeling environmental markers, and/or recounting a sequence of details which he has taken pains to label and commit to verbal memory.

Such a child is able to achieve a limited degree of comfort in her environment through well-developed rote memory skills. This coping technique, however, breaks down whenever the child encounters novel or highly complex situations. She is conditioned to prefer predictable situations in which she has had some previous success. Tossing in a new variable to an already fairly constant situation (such as a substitute teacher taking over the control of a classroom where the child has previously gained a certain degree of stability with his regular teacher) can totally disrupt this child's coping strategies and generate an increased level of anxiety for her.

Along with the aforementioned graphomotor and pencil grip problems, the child with nonverbal learning disorders may have difficulty remembering the shapes of letters (visual memory) and using the correct sequence of strokes to form letters (visual-sequential memory). He will have difficulty with the concept of visual form constancy; the ability to perceive that an object possesses unchanging properties, such as specific shape, position, and size, in various representations of its image. All writing tasks will be slow and arduous. Copying accurately from the board or a book are impractical and agonizing for this child.

Social:

Deficits in social awareness and social judgment, though the child is struggling to fit in and her actions are certainly not deliberate, will often be misinterpreted as "annoying" or "attention getting" behavior by adults and peers alike. It is clear that these students are motivated to conform and adapt socially, but sadly, they perceive and interpret social situations inaccurately. The blunders committed are usually not flagrant in nature, but rather incessant and tenacious; hence the label "annoying." Social competence disabilities are an integral component of the NLD syndrome and this aspect of the impairment may lead to an overdependence upon adults (especially parents).

The social indiscretions frequently committed by the child with NLD are representational of his inability to discern and/or process perceptual cues in communication. The aforementioned visual-spatial-organizational deficits cause him to be ineffective at recognizing faces, interpreting gestures, deciphering postural clues, and "reading" facial expressions. Conventions governing physical proximity and distance are also not perceived. Changes in tone and/or pitch of voice and/or emphasis of delivery are not noticed or distinguished. Likewise, this child will not appropriately alter his expression and elocution in speech. This can be evidenced in what may appear to be terse or curt response styles.

The importance of nonverbal signals and cues was noted previously. It has been shown that more than 65% of the intent of an average conversation is conveyed nonverbally. However, the child with nonverbal learning disorders will try to resolve all quandaries by employing her strong verbal skills. She has to piece together the meaning of a conversation or directive from this approximately 35% (verbal) that she actually receives and processes. She totally "misses" the large amount (majority) of relevant content which is being conveyed nonverbally and, as a result, much of her conversational responses don't "fit" with the tone and mood of the occasion. This child is likely to become withdrawn in novel social situations and/or to appear "out of place."

The impairments of NLD also lead to a preponderance of very literal translations which, in turn, precede continuous misjudgments and misinterpretations. The child with NLD is naively trusting of others (to a fault) and does not embrace the concept of dishonesty (even in terms of white lies) or withholding (even inflammatory) information. He also will not recognize when he is being lied to or deceived by others. Deceit, cunning, and/or manipulation are beyond this child's scope of assimilation. He assumes that everyone is friendly who displays that front verbally and that the intentions of others are only that which they expose verbally. This inability to "read" the intentions of others often results in a lot of unfortunate "scapegoating" of this child. He needs to be taught to question the motives of others - he won't learn from experience.

A child with nonverbal learning disorders is very "concrete" in her translations, expression, and outlook of the world. Her social relationships tend to be routinized and stereotyped. Everything is seen in terms of black or white - true or false. "Hidden meanings" have to be pointed out to her - they will not be intuitively detected or conceived. She may be regarded as a "smart aleck" because of her constant misinterpretations. This child is frequently reprimanded with the words, "You knew what I meant!" when, of course, she didn't have a clue. She had no way to access what was "meant," but not actually said.

Perceptual cues serve in the same capacity as traffic signals; they govern the flow, give-and-take, and fluctuations in our conversations. The child who cannot "read" these nonverbal cues is frequently determined to be ill-mannered, discourteous, curt, immature, lacking in respect for others, self-centered, and/or even defiant. This child is none of the above. Like the color blind driver who cannot respond appropriately to traffic lights, this is a child who is utilizing all of the resources available to him in order to try and make sense of a world which is providing him with faulty cues and unreliable information.

It is currently difficult to locate a professional who understands nonverbal learning disorders, but such professionals are out there. If a child exhibits the developmental deficiencies described above, she can be helped to lead an easier, less troublesome life. An effective remedial approach incorporates constantly and explicitly "spelling out" to this child what other children would be able to pick-up or infer intuitively with a strong verbal component because this is the only way the child will process and assimilate accurate observations of her environment. Appropriate accommodations will have to be made by the family and the school staff working with this child to lessen the likelihood of shattering consequences resulting from the disability. Professionals in the field of Special Education must hone their diagnostic skills in order to identify and provide services for NLD students at an earlier age.

Servicing nonverbal learning disorders

Nonverbal learning disorders are often overlooked educationally because the student is, as a means of compensating, very verbal. He has a highly developed memory for rote verbal information so early reading and spelling skills usually constitute a strong domain. If you observe all, or most, of the early adjustment problems detailed earlier in this article, an intelligence screening may support your suspicions. An IQ measure, such as the WISC-III, which reveals a performance IQ (PIQ) scale score depressed (by 10 - 15 points or more) relative to the student's verbal IQ (VIQ) score, denotes a deficient right-hemisphere system.

It is not relevant to the diagnostic process whether one or both of these scores is above the norm; the crucial determinate is the relative discrepancy between the VIQ and PIQ. It is not unusual for a child with nonverbal learning disabilities to have a VIQ in the very superior range. When subtest scores are grouped, the verbal conceptualization cluster will generally be the strongest for the child with NLD while the spatial cluster will be the weakest.

Depending upon the severity of the disorder, and also upon the child's intelligence and the coping techniques which she has already put into place, the discrepancy can be 20 points or more. This is severe and warrants immediate attention no matter what the child's full-scale IQ (FSIQ). You are not merely discovering that the child has a dominance of the left cerebral hemisphere, but rather that she is having difficulty accessing the processes specialized in the right cerebral hemisphere. A 10-point discrepancy is generally considered significant.

Once a child has been diagnosed, parents should not accept the rationale of some well-meaning professionals who may tell them that NLD will play a minor role in their child's ability to perform well in school. Physicians and psychologists may assume that a child with superior expressive language skills can easily compensate for a deficit in nonverbal skills. This assumption is true only in relation to the child's capacity to "parrot" back school work in the early grades and does not address the child's inability to "flow through life."

As the child moves into the higher grades, where less and less will be "spelled out" for him, he will reach a point where functioning in school is impossible without specific compensations, accommodations, modifications, and strategies (CAMS). The incredible rote memory which served this child very well in the lower grades, before he was asked to interpret and evaluate information, fails him when academic demands shift to more complex applications.

At this point he may cease to try or "burn-out" attempting to succeed under the impossible demands now being placed upon him. Recognizing this eventuality and employing interventions early in the child's schooling is certainly preferable to waiting until junior or senior high to accommodate his disability when he finally "bottoms out." Early implementation of CAMS will maximize his success in school. Unless appropriate CAMS are initiated during the elementary years, prognosis for success in school is poor for this child.

A child with NLD is especially inclined towards developing depression and/or anxiety disorders if the nonverbal learning disorders are not recognized early and accommodated in a compassionate, responsible, and supportive fashion. If the child is continually being told by the adults around her, "You could do better, if you really tried," or, "You're just not applying yourself" (both false observations in this case) her level of frustration will naturally intensify and her self-image will plummet. It is not unusual for the child with nonverbal learning disorders to become increasingly isolated and withdrawn as failures in school multiply and intensify.

At this point, the child may be treated for the secondary complaints which now overshadow the underlying primary disorder of NLD. Misdiagnosis, or an incomplete diagnosis (many learning disorders have a comorbid-morbid relation), will only serve to compound the problems a child is experiencing. It is not uncommon for a child with nonverbal learning disorders to be misdiagnosed with conditions such as Attention Deficit Disorder (ADD) or emotional disturbance.

Even when a child has been correctly diagnosed with NLD, it may still be difficult for him to receive the program modifications and accommodations he needs in school. After all, he is probably performing at or above grade level on most academic achievement tasks which are routinely measured at school, especially during the early elementary years. Although the deficits in motor, visual-spatial, and social skills may be obvious to any interested and observant persons, these impairments will not necessarily evoke the concern and/or compassion of any but the most caring of teachers.

If the "formula" for language-based (specific) disabilities is called upon, parents may be told that their child does not "qualify" for the Special Education services because there is not a "severe discrepancy" between the child's intelligence and her achievement in the academic areas. In fact, the child's level of accomplishment in academics may even appear to go beyond her potential if the measurement techniques are largely verbal (oral/written). "Overlearning" is common in individuals with the NLD syndrome.

Nonverbal learning disorders constitute a dysfunction in the basic cerebral processes and, as such, denote a disability which warrants specialized support and program modifications for the student. "Traumatic brain injury" was added to IDEA by the Education of the Handicapped Act Amendments of 1990. Since this child's condition seriously interferes with his ability to perform in school, an Individualized Education Program (IEP) can and should be developed and implemented for this child. Or, since this child's NLD impairments "substantially limit one or more major life activities," a 504 plan can be drawn up to help define appropriate accommodations for him.

This child will often have already been mislabeled by unenlightened adults at her school. Today, thankfully, intelligent parents are not so quick to accept educators' misguided declarations that their child is "lazy," "purposefully disruptive," "a troublemaker," "disturbed," "defiant," and/or merely "being annoying" as if these presentations were a diagnosis rather than an indicator of symptoms to be considered within the context of a syndrome. It is always wise to locate the underlying cause of behavioral observations (i.e., a disorder of the central nervous system) so that appropriate, helpful, and nonpunitive measures can be implemented, knowing that the child's behavior is not deliberate and that mistakes and misdeeds are the result of her disability and are unintentional on her part.

Parents should be especially leery of self-righteous educators who use the superficial psycho-babble "he chose" implying that this child has made a conscious choice to put himself in a position of disadvantage. If a child has been determined to have NLD, it is important for everyone to understand that this impairment is neurological in nature and there is no choice involved for that child. No child chooses to fail. To dismiss or label the adjustment problems (which are symptoms) as "attention getting" behavior, is as harmful as it is unprofessional.

The child with NLD can usually be accommodated in a "fully-included" mainstreamed educational setting if her unique academic and social needs are understood by her parents and her school staff. A comprehensive and detailed Individualized Education Program (IEP) put together by a team of informed experts will aid in a successful outcome. The more extensive the IEP, the less likely the child will encounter unforeseen roadblocks and/or fall through the cracks. She may also benefit from some Special Education support services such as speech and language therapy for deficiencies in linguistic pragmatics and occupational therapy for gross and fine motor skill concerns.

All too often though, the coping behaviors of the child with NLD are misinterpreted by uninformed adults as "emotional" and/or "motivational" problems. However, when this child's verbal strengths are capitalized upon and her teachers are flexible and receptive to her needs, she can be quite successful in school. It is so easy for adults to punish and to try to put the responsibility back on the child, but a true professional will recognize that if a child is not fulfilling expectations, it is due to faulty planning on the part of the educational team, and is in no way a reflection on the child.

The child's parents have probably already gained an intuitive or learned appreciation of what works best for their particular child with NLD. Often this child prospers at home because of his parents' insightful adaptive strategies, while continuing to struggle at school. It is wise for educators to benefit from the knowledge that these parents can offer regarding their child. School staff and parents should work closely together in planning to accommodate this child's unique needs.

Although often suggested, "insight-oriented," dynamic psycho-therapy has proven to be counterproductive as a model of intervention for an individual with NLD and is not advised. Individuals with NLD are often assumed to be very perceptive because they display well-developed verbal skills. Since their symptomology can appear to be emotionally-based, insight-oriented psychotherapy is frequently attempted. Dr. Byron P. Rourke has found that "formal educational intervention" is the treatment modality most likely to "increase the NLD youngster's probability of success." Treatment within a class or center for the emotionally disturbed is also not recommended, as therapeutic approaches to emotional problems are quite different from those which have proven effective for the NLD syndrome.

The child with NLD requires individualized approaches to educational intervention in order to succeed in school because her right-hemisphere systems are dysfunctional or inaccessible to her. The left cerebral hemisphere processes information based upon fixed systems of rules and is not equipped to deal flexibly with problem-solving strategies. Effective remedial methods include direct verbal training in planning, organizing, studying, written expression, social cognition, and interpersonal communication.

Unlike Individualized Education Programs in which the primary goal is to master a continuum of curricular skills, the educational program for the child with NLD consists of providing additional coping skills, practical support, and CAMS. Interventions for this child are not curative in nature, but rather designed to offer compensatory skills and to lessen the daily stress he encounters. Some of the specific compensations, accommodations, modifications, and strategies which should be employed to help this child follow:

Compensations:

1. This child will have difficulty with internal and external organization and coordination. Tardiness is something he may struggle with (despite great pains to be punctual) and this should not be treated as a misbehavior. Help this child by allowing him extra time to get places and by giving him verbal cues to navigate through space. Continually assess his understanding of spatial and directional concepts. 2. Never underestimate the gravity of this disability. Dr. Rourke states, "One of the most frequent criticisms of remedial intervention programs with this particular type of child is that the remedial authorities are unaware of the extent and significance of the child's deficits" and he emphasizes that "the principal impediment to engaging in this rather slow and painstaking approach to teaching the child with NLD is the caregiver's (faulty) impression that the child is much more adept and adaptable than is actually the case." Dr. Rourke also warns that: "Observers tend to overvalue the intelligence of NLD adolescents (and) this is the principal reason for an unwillingness to adopt an approach to formal educational intervention that would increase the NLD youngster's probability of success." The naiveté of parents and educators regarding the significance of the NLD syndrome inevitably leads to inappropriate expectations being placed upon this child. Expectations for this child should always be applied with flexibility, taking into consideration the fact that she has different needs and abilities than her peer group. (Note: This individual's progress is almost always further impeded by anosognosia-the "virtual inability to reflect on the nature and seriousness of [her own] problems"). 3. Do not force independence on this child if you sense she is not yet ready for something (trust your instincts and be careful not to compare her with other children of the same age). It is detrimental to isolate her, but don't make the mistake of thinking she can be left to her own resources when faced with new and/or complex situations. Give her verbal compensatory strategies to deal more effectively with novel situations. The world can be very scary for someone who is misreading 65% of all communication and she will naturally be reluctant to try new things. The social skill development of this child has been delayed by misconceptions which may have caused serious issues of insecurity to evolve. The myth of the "overprotective mother" needs to be dismissed; parents and professionals must both assume a "protective" and helpful role with the child with NLD. Dr. Rourke states, "Although sensitive caregivers are often accused of 'overprotection', it is clear that they may be the only ones who have an appreciation for the child's vulnerability and lack of appropriate skill development." Care and discretion need to be taken to shield the child from teasing, persecution, and other sources of anxiety. Independence should be introduced gradually, in controlled, non-threatening situations. The more completely those around her understand this child and her particular strengths and weaknesses, the better prepared they will be to promote attitudes of personal independence. Never leave this child to her own devices in new activities or situations which lack sufficient structure. 4. Avoid power struggles, punishment, and threatening. This child does not understand rigid displays of authority and anger. Threats, such as "if you (do this), then (something unfortunate) will happen to you," only serve to destroy this child's sense of hope. The goals and expectations assigned to him must be attainable and worthwhile. Remember that taking away "privileges" will not cure a child of a neurological disability (but may very well establish him on the path to depression). This is an inappropriate intervention model on the part of the adults involved and it is detrimental and damaging to this child's development and well-being. The "confusion" and social awkwardness he displays are real and unintentional; they should not be viewed as conduct to be penalized. 5. All adults owe it to this child to always assume the best - to always take a positive rather than a negative approach. As we have seen, life is very demanding and difficult for the child with NLD. Most of her unusual behavioral responses serve a purpose and usually represent the child's own attempt at compensation. It is wise to try to uncover the reason for the behavior and to help the child devise an appropriate (more acceptable) replacement behavior (usually through a detailed verbal explanation). Parents and professionals need to make the effort to have the child explain his dilemma and to try to determine what purpose the behavior might be serving. Then serve the child's need rather than punishing her resulting behavior. Remember, as with all children, at least 90% of your interactions with this child must be positive in nature!

Accommodations:

1. School assignments which require merely copying text need to be modified or omitted, owing to the visual-spatial nature of such an exercise. Active verbalization and/or subvocalization are the best memory approaches for this child. 2. Test answer sheet layouts and the arrangement of visual-spatial math assignments need to be simplified (no credit should be lost for a correct answer placed in the wrong column or space). Whenever possible, use of graph paper is recommended to keep columns aligned in written math assignments or consumable math texts should be provided for this student. 3. Paper and pencil tasks need to be kept to a minimum because of finger dexterity and visual-spatial problems. Occupational therapy is a consideration for the younger child. Verbally mediated practices to improve handwriting may result in improvements in control and fluency, but the process will remain laborious. Use of a computer word processor is highly recommended for all written school assignments, as the spatial and fine motor skills needed for typing are not as complicated as those involved in handwriting. 4. The global confusions which underlie nonverbal learning disorders also result in limiting the student's ability to produce the quantity of written work normally expected of her grade-level peers. This child requires continuous assistance with organizing information and communicating in writing. Adjustments must be made in teacher expectations for volume of written products. Additional time will be needed for all written assignments. 5. Tasks requiring folding, cutting with scissors, and/or arranging material in a visual-spatial manner (maps, graphs, mobiles, etc.) will require considerable assistance, provided in an accommodating manner or they should be eliminated entirely. 6. Any timed assignments will need to be modified or eliminated. Processing of all information is performed at a much slower rate when you are compensating for any type of cerebral dysfunction. Time constraints often prove to be counterproductive, as this student is easily overwhelmed by the unrealistic expectations of his teachers. 7. Adults need to check often for understanding and present information in plain and clear verbal terms (i.e., "spell out" everything). A "parts-to-whole" verbal teaching approach should be utilized. This child will need to ask a lot of questions, as this is her primary means of gathering information. 8. All expectations need to be direct and explicit. Don't require this child to "read between the lines" to glean your intentions. Avoid sarcasm, figurative speech, idioms, slang, etc., unless you plan to explain your usage. Write out exact expectations for any situation where the child may seriously misperceive complex directions and/or proper social cues. Feedback given to the student should always be constructive and encouraging or there will be no benefits derived. 9. This student's schedule needs to be as predictable as possible. He should be prepared in advance for changes in routine, such as assemblies, field trips, minimum days, vacation days, finals, etc. 10. This child needs to be assigned to one case manager at school who will oversee her progress and can assure that all of the school staff are implementing the necessary accommodations and modifications. Inservice training and orientation for all school staff that promotes tolerance and acceptance is a vital part of the overall plan for success, as everyone must be familiar with, and supportive of, the child's academic and social needs.

Modifications:

1. This child needs to be in a learning environment that provides daily, non-threatening contact with nondisabled peers (i.e., not a "special" or "alternative" program) in order to further his social development. 2. This child will benefit from cooperative learning situations (when grouped with "good role models"). Active verbalization is an important element in how this child learns. She usually has extensive verbal information to share with the others and can be exposed to the "give and take" of a miniature social environment in a non-threatening, controlled milieu. Obviously, the child with nonverbal learning disorders would not be expected to be the "scribe" in a cooperative grouping - her contribution should be in the verbal arena. The least effective learning model for this child is isolation. She must be allowed to verbalize and to have verbal feedback in order to learn. 3. Transitions will always be difficult for this child so he will need time during the school day to collect his thoughts before "switching gears." This may mean: extra time before and after breaks to disengage and readjust to the changes in pace; less changing of rooms and more time spent with one teacher; a study hall that is built into the student's schedule at middle and high school levels; and/or a carefully selected non-NLD peer "buddy" to help guide him through the day. 4. Placement must be in an environment which has a well-established routine because this child will not decipher non-verbal cues. She cannot adjust well to constant changes in routine (this child lacks the ability to "wing it" in times of doubt) and has learned to fear all new and/or unknown situations and experiences. She needs to know what will happen next and to be able to count on consistent responses from the staff who work with her. 5. Special presentation procedures need to be adapted for those subjects requiring visual-spatial-organizational and/or nonverbal problem-solving skills. Or, as Rourke suggests, "avoid such material altogether."

Strategies:

1. Do tell this child everything and encourage her to give you verbal feedback. The most effective instructional procedures are those that associate verbal labels with concrete situations and experiences. "I shouldn't have to tell you" does not apply - assume you do have to tell her. She cannot "look and learn." 2. Verbally teach (don't expect the child to observe) cognitive strategies for the skills of conversational pragmatics (the "give and take" and comfortable beginnings and endings of a conversation, how and when to change the subject, formal versus informal conversational idiosyncrasies, tone and expression of voice, etc.) and nonverbal body language (facial expressions, correct social distance, when the limit or cut-off point has been reached, etc.). This child will not perceive that he is trying someone's patience until that person verbally explodes! Give him some additional verbal cues before the boiling point because he does not "sense" tension or displeasure. 3. Observe and expand the coping techniques that the child has already acquired on his/her own. Focus on developing flexible concepts and time order. 4. Group the child with "good role models" so that she can label and learn appropriate behavior. Remember she won't differentiate between appropriate versus inappropriate behavior unless the distinctions are verbally pointed out to her. Isolation is the "kiss of death" for this child. 5. Adult role models should "talk their way" through situations in the presence of this child in order to give him a verbal view of someone else's "internal speech" process. In essence, you will be making your internal speech external so that the child can pick up the skills needed to coordinate his own problem-solving approaches. Help the child devise a sequence of steps for self-questioning and self-monitoring, verbalizing each step. 6. Isolation, deprivation, and punishment are not effective methods to change the behavior of a child who is already trying his best to conform (but misinterpreting all kinds of nonverbal cues). If inappropriate behaviors are causing problems at school, a functional analysis and behavioral intervention plan detailing a course of action which is designed to be useful and non-punitive in nature may need to be a part of this child's IEP or 504 plan.

About the author

Sue Thompson holds a master's degree in Special Education from St. Mary's College of California. She has taught for 25 years in California public schools in both regular and special education classrooms and now provides services to individuals as an Educational Consultant and Therapist. In addition, Sue has written a book on nonverbal learning disabilities, titled The Source for Nonverbal Learning Disorders.