Tutorial

Nonverbal Learning Disability: A Tutorial

for Speech-Language Pathologists
Joanne Volden
University of Alberta, Edmonton, Alberta, Canada

Nonverbal learning disability (NLD) is a

diagnostic category that is unfamiliar to most
speech-language pathologists. This brief tutorial
describes NLDs characteristics, a theoretical
model proposed to explain its source, and areas
of overlap between NLD and similar diagnostic
categories. The communicative profile, made
up of difficulties in pragmatic and semantic
language in the presence of relatively preserved syntactic skill, is also discussed.
Empirical evidence relevant to NLD is also
evaluated. Many questions remain unresolved,

peech-language pathologists report that they are

increasingly faced with children who have been
referred with a diagnosis of nonverbal learning
disability (NLD). These children display fluent grammatical speech but have difficulties with appropriate social
language use and with comprehension. Still, the diagnosis
of NLD is unfamiliar to many speech-language pathologists and is not currently listed in standard references such
as the Diagnostic and Statistical Manual of Mental
DisordersIVText Revision (American Psychiatric
Association, 2000). The purpose of this article is to provide
an overview of the literature on NLD, its characteristics, a
theoretical model proposed to explain it, and its similarities
to and differences from other diagnostic categories. The
communicative profile associated with NLD will be
explored in depth, with a critical analysis of the literature
available in this area and a discussion of implications for
speech-language pathologists in terms of assessment,
intervention, and future research.

Description of the Condition

NLD is described as a subtype of learning disability.
First identified by Myklebust in 1975 (Myklebust, 1995),
the notion of an NLD syndrome was developed by Rourke,
Young, and Leenaars (1989) at the University of Windsor,
Ontario, Canada. Two major subtypes of learning disability
have emerged in their investigations. One type, called basic
phonological processing disorder by Rourke (1989, 1995),
is characterized by extraordinary difficulty in reading,
128

but until systematic research provides definitive

answers, speech-language pathologists are
encouraged to rely on careful description of the
individual childs communicative strengths and
weaknesses to identify appropriate targets and
to focus intervention on improving the childs
ability to communicate effectively in everyday
contexts.
Key Words: nonverbal learning disability, child
language disorder, learning disability

spelling, and language skills but relative strength in

nonverbal problem-solving and visual and tactile perception (Rourke, 2000). Generally, children with this disorder
display performance IQ scores that exceed their verbal IQ
scores (Rourke, 1989). These children are very familiar to
speech-language pathologists and fit well within our
traditional categories of dyslexia or language learning
disability. Their primary difficulty is found in language
and the academic skills that rest on language competence
(Rourke & Tsatsanis, 1996).
The other subtype, referred to as NLD, exhibits a profile
of skills that is largely the opposite, with age-level or
higher skills in rote verbal learning, phonological processing, and amount of verbal output (Rourke, 1989). In
general, children with this disorder display verbal IQ
scores that are significantly higher than their performance
IQ scores (Rourke, 1989). On the other hand, these
children are described as having primary deficits in (a)
visual and tactile perception, (b) complex psychomotor
skills, and (c) dealing with novel material. These fundamental problems are seen as causing secondary difficulties
in physical exploration of the environment and in attention
to visual or tactile stimuli. According to Rourke (1995),
These children remain essentially sedentary, exploring the
world not through vision or locomotion, but rather through
receiving verbal answers to questions posed about the
immediate environment (p. 8). Tertiary deficits in concept
formation, problem-solving, and hypothesis testing are
believed to develop from these problems in exploration
because the restricted information that is gleaned from

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verbal exploration alone, without the benefit of coincident

sensorimotor input, leads to limited conceptual development (Rourke, 1989). In the long run, Rourke (1989, 1995)
proposed that linguistic, academic, and psychosocial/
adaptive skills were deficient as a result.
The communicative profile, which includes disorders in
the content (semantics) and function (pragmatics) dimensions of language, will be discussed in depth later in this
article. In academic terms, Rourke (1993) described children
with NLD as having particular difficulty with mechanical
and computational aspects of arithmetic (e.g., aligning
numbers in columns; attending to mathematical signs such
as + and =; and flexibly shifting from one operation to
another, such as shifting to subtraction after one or more
additions). Additional academic difficulties include problems in reading comprehension and science (Rourke, 2000).
Socioemotional sequelae to the primary, secondary, and
tertiary neuropsychological deficits are also proposed
(Rourke, 1989). For example, dysfunctional social judgment skills might logically arise from more basic problems
in reasoning and concept formation. Problems in interpreting nonverbal information such as facial expressions would
contribute to inappropriate patterns in interaction. Further,
if processing novel information is problematic, the child is
unlikely to be successful in adapting to unfamiliar interpersonal situations, an ability that is central to socially
appropriate behavior. In the long run, Rourke and his
colleagues (Rourke, 1989; Rourke et al., 1989; Rourke &
Fuerst, 1992, 1995) suggested that children with the NLD
profile are more likely than typical children to display
internalizing psychopathologies (e.g., depression,
withdrawal, increased risk of suicide).

Evidence Documenting
Reported Characteristics
Foundations of the Condition
A number of studies have reported on children presenting
with deficits in visual perception and an inability to deal
with novel material (Badian, 1992; Harnadek & Rourke,
1994; Rourke, 1987, 1989, 1993, 2000; Rourke et al., 2002;
Rourke & Conway, 1997; Rourke, Del Dotto, Rourke, &
Casey, 1990; Rourke & Fuerst, 1995). Some of these reports
have applied diagnostic labels such as dyscalculia (Badian,
1983), socialemotional learning disability (Voeller, 1991),
and developmental right-hemisphere syndrome (Gross-Tsur,
Shalev, Manor, & Amir, 1995; Nichelli & Venneri, 1995;
Voeller, 1995), instead of NLD. Most of these reports have
relied on anecdotal evidence gathered from clinical observation or on Rourkes published reports, rather than on original
empirical data.
Empirical support for a subgroup of children with
learning disability who displayed primary deficits in
visual perception and an inability to deal with novel
material was first derived from a series of three studies
conducted by Rourke and his colleagues from 1978
through 1983 (Rourke & Finlayson, 1978; Rourke &
Strang, 1978; Strang & Rourke, 1983). In this early work,
Rourke and his colleagues laid the foundation for their
conceptualization of the NLD syndrome. In the first of

these studies, Rourke and Finlayson (1978) divided

children who had been diagnosed with a learning disability
into groups on the basis of their academic performance.
One group was defined by equal difficulty in reading,
spelling, and arithmetic, demonstrating standardized
reading, spelling, and arithmetic scores at least 2 years
below their expected grade level. A second group was
defined by grade-equivalent arithmetic scores on a standardized test at least 2 years better than grade-equivalent
reading and spelling scores. The third group was composed
of students who exhibited the opposite pattern, that is,
grade-equivalent reading and spelling scores that were at
least 2 years greater than grade-equivalent arithmetic
scores. All three groups were equivalent in terms of age
and full-scale IQ. Rourke and Finlayson administered a
battery of neuropsychological measures to the participants.
Results showed that the group with relatively poorer
arithmetic scores performed worse on measures of visual
perceptual and visuospatial skills (e.g., nonverbal subtests
from the Wechsler Intelligence Scale for Children [WISC;
Wechsler, 1949] and the Target Test (Reitan & Davison,
1974, cited in Rourke & Finlayson, 1978), a test that
requires the child to draw a pattern from memory), but
better on rote verbal and auditoryperceptual measures
(e.g., Peabody Picture Vocabulary Test [PPVT; Dunn,
1965], Speech-Sound Perception Test [Reitan & Davison,
1974, cited in Rourke & Finlayson, 1978], and Auditory
Closure Test (Kass, 1964); see Rourke & Finlayson, 1978,
for a description of test instruments). The other two groups
displayed the opposite profile. Their scores were worse on
rote verbal and auditoryperceptual measures and better on
visualperceptual and visuospatial skills. Rourke and
Finlayson concluded that the group with relatively poorer
arithmetic scores represented a distinct group with unique
neuropsychological assets and deficits. They also proposed
that members of this group were limited in their performance because of compromised functional integrity of
systems within the right cerebral hemisphere, whereas the
other two groups displayed difficulties in skills that are
subserved by the left cerebral hemisphere.
Rourke and Strang (1978) followed up by examining
whether the same three groups of children would perform
as predicted by the deficient right hemisphere hypothesis on tasks that tap motor (e.g., finger tapping, grip
strength), psychomotor (e.g., timed measures for navigating through a maze), and tactilekinesthetic (e.g., finger
tip number writing, coin recognition; see Rourke &
Strang, 1978, for a description of tests) performances on
both sides of the body. The notion here is that differential
impairment over and above that expected as a result of
handedness would suggest impairment in systems that are
subserved by a particular hemisphere. The group defined
by poor performance in arithmetic relative to their rote
verbal performance did indeed score lower than age-level
expectations on some psychomotor and tactile perceptual
tasks and were markedly deficient compared to the other
two groups. Findings of this study were interpreted as
supporting Rourke and Finlaysons (1978) hypothesis
regarding differential hemispheric integrity (Rourke,
1993). Subsequent electrophysiologic studies have found
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reliable hemispheric differences in event-related potentials

between the two subtypes (for a review, see Dool, Stelmack,
& Rourke, 1993; Mattson, Sheer, & Fletcher, 1992;
Njiokiktjien, Rijke, & Jonkman, 2001).
In the third of the initial series of studies, Strang and
Rourke (1983) examined the tertiary-level skills of
concept formation and nonverbal problem-solving abilities.
In this study, similarly constituted groups of 9- to 14-yearold children (one group with specific problems in arithmetic relative to their reading performance and the other
group with reading difficulties relative to arithmetic skill)
were given the Halstead Category Test (Reitan & Davison,
cited in Strang & Rourke, 1983). The Halstead Category
Test is a relatively complex concept-formation test
involving nonverbal abstract reasoning, hypothesis testing,
and the ability to use positive and negative informational
feedback in concept formation. Children are asked to
deduce a principle from a geometric configuration displayed on a screen, and, once they have formed a hypothesis, to indicate the concept by choosing one of four
response options. After a response is chosen, feedback is
provided about whether the hypothesis is correct and, if
not, the child is directed to use that feedback in subsequent
attempts. Performance is evaluated based on the number of
errors the child makes. In Strang and Rourke, the group
with poorer arithmetic scores again made significantly
more errors than what would be expected for their age and
more than the group with poorer reading than arithmetic
scores.
Overall, these three initial studies led Rourke and his
colleagues to the conclusion that reliable subtypes of
learning disability could be differentiated, and that they
were associated with predictable patterns of neuropsychological assets and deficits (Rourke, 1991, 1993). This
association of learning disability subtype with neuropsychological profile has been replicated many times by
members of Rourkes laboratory (see Rourke, 1993, 2000,
for a listing). According to Rourke (2000), several independent investigators have also found the same subtypes
by using large-sample statistical cluster analyses. The
group with poorer arithmetic than reading, and with
associated problems in visuospatial processing, tactile
perception, and processing of novel, meaningful, or
complex material, has been called the group with NLD.

Additional Empirical Evidence

A few other studies have provided independent empirical confirmation of some of the specific deficits of the
NLD profile. For primary deficits in visual perception,
White, Moffitt, and Silva (1992) found that a group with
arithmetic disability differed significantly from reading
disabled, generally disabled, and nondisabled
comparison groups on measures of visuospatial skills and
visualmotor integration. In 1999, Cornoldi, Rigoni,
Tressoldi, and Vio demonstrated deficits in visuospatial
working memory and imagery in children with NLD as
compared to control group children matched for verbal
intelligence and socioeconomic status. As yet, no one has
directly tested the proposition that difficulties in dealing
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with novel material are primary to the NLD syndrome

(Rourke, 2000). Direct empirical evidence of secondarylevel deficits related to dysfunctional environmental
exploration is also lacking.
Some empirical support for deficits in the proposed
tertiary deficit areas of higher order reasoning and executive function may be found in Fisher, DeLuca, and Rourkes
(1997) investigation of children and adolescents with NLD
on the Wisconsin Card Sorting Test (Berg, cited in Strang
& Rourke, 1983) and the Halstead Category Test (Reitan &
Davison, cited in Strang & Rourke, 1983). On both
measures, the participants with NLD were less proficient
than age-, gender-, and full-scale IQ-matched controls with
verbal learning disability.
Overall, the evidence is compelling for the existence of
a group of children who display deficits in visual processing, arithmetic computation, and nonverbal problemsolving in the context of strengths in rote verbal abilities
(Little, 1993). There is, however, less agreement about the
social and emotional characteristics associated with NLD.
A long line of studies in Rourkes laboratory (see Rourke,
2000, for a listing) have documented a strong relationship
between children with NLD and an increased, and growing
over time, risk for severe psychopathology, particularly of
an internalizing nature. The most recent of these, Tsatsanis
and Fuerst (1997), and Pelletier, Ahmad, and Rourke (cited
in Rourke, 2000), confirm that distinct types of psychosocial disorder can be reliably associated with subtypes of
learning disability.
Additional empirical support for fundamental difficulties in nonverbal social perception comes from studies
conducted by Dimitrovsky, Spector, Levy-Schiff, and
Vakil (1998) and Petti, Voelker, Shore, and HaymanAbello (2003). Both of these investigations compared
participants who had been diagnosed with NLD to children
with verbal learning disabilities and non-learning-disabled
controls in their ability to interpret facial expressions. Both
studies found less accurate identifications of emotions in
the group with NLD.
On the other hand, Semrud-Clikeman and Hynd (1991)
and Little (1993) comprehensively reviewed the literature
in the area of social deficits and their relationship to
learning disability. Both reviews indicated that research
results were inconsistent, with some studies finding
significant social difficulties in children with learning
disability and others finding no difference between
children with learning disabilities and typically developing
children on social perception and interaction skills. Several
methodological reasons for such inconsistencies were
suggested, including variations in the measures used,
differing diagnostic criteria (often not consistent from
study to study and sometimes not reported), small numbers
of participants, failure to separate individuals with learning
disability into subtypes, the possibility that subtype profiles
might be different at different ages, and the frequent
absence of an appropriate control group. Any of these
factors could jeopardize the interpretability or generalizability of the findings.
In addition, both reviews (Little, 1993; SemrudClikeman & Hynd, 1991) found that most of the studies

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made little attempt to control for attentional and/or verbal

variables. Very few studies, for example, reported whether
participants also had a diagnosis of attention deficit disorder
(ADD) or whether they had associated language disability.
Either comorbid condition could easily influence performance on measures of social perception. It is also important
to distinguish between correlation and causation. If two
phenomena are related, it does not mean that one necessarily
causes the other. For example, deficits in social perception
are not necessarily the cause of poor peer acceptance and the
resultant lack of social opportunity (Little, 1993). Similarly,
it remains to be determined whether observed relationships
between NLD and socioemotional dysfunction are caused by
a common neuropsychological deficit, environmental
factors, or some complex interaction between the two.
Research is needed that uses large samples of individuals
matched closely by age and employs a variety of measures
of socioemotional functioning. In addition, the inclusion of
control groups with no learning problems would clarify
whether patterns of socioemotional dysfunction found
among children with NLD are unique to this population or
whether they are comparable to the base rates for nondisabled learners (Little, 1993).

The White Matter Model

Rourke was originally inclined to attribute the deficit
profile in NLD to damage or dysfunction in the right versus
the left cerebral hemisphere because observed domains of
relative weakness (e.g., visuospatial processing, tactile
perception) were generally regarded as controlled by the
right hemisphere (Rourke & Finlayson, 1978). Later, Rourke
extended his model so that the focus shifted to underdevelopment of, damage to, or dysfunction of the white matter
(long myelinated fibers) in the brain as the source of the
disorder (Rourke, 1987, 1989, 1995; Rourke et al., 2002).
The shift from focusing on lateralized damage or dysfunction to white matter damage or dysfunction occurred
because Rourke (1987) noticed the NLD neuropsychological
profile in children with a variety of other neurological
conditions such as moderate to severe head injury, hydrocephalus, congenital absence of the corpus callosum, and
post-radiation survival of childhood cancer. The commonality among these conditions was not right hemisphere
damage, but rather destruction or disturbance of white
matter (Rourke, 1987). Because the ratio of white matter to
grey matter is higher in the right hemisphere (Goldberg &
Costa, 1981, cited in Rourke, 1987), the right hemisphere is
often more significantly affected (Rourke, 1987). The
principal working hypothesis of the white matter model is
that the characteristics of NLD will arise in an individual to
the extent that cerebral white matter is damaged, dysfunctional, or underdeveloped (Rourke et al., 2002).

Evidence From Pediatric Neurological

Conditions
What is the evidence to support this theoretical position? To the extent that clinical pediatric neurological
conditions show the characteristic NLD profile and are

connected with white matter damage or dysfunction, the

white matter model is indirectly supported. On the other
hand, circumstances where the NLD profile and white
matter abnormality can be dissociated would argue against
a straightforward causal relationship. Such circumstances
would include instances where the NLD profile is present
but white matter abnormality cannot be found, as well as
cases involving established white matter abnormality in the
presence of a neuropsychological profile that is somehow
inconsistent with NLD.
Rourke and his colleagues (Rourke, 2000; Rourke et al.,
2002) have considered a large body of evidence relating
NLD to a number of forms of pediatric neurological disease,
disorder, and dysfunction. Overall, they found that the
diseases in which the NLD phenotype is particularly evident
are those where it has been demonstrated that perturbations
of white matter are particularly prominent. In some cases,
the evidence is clear in linking white matter disturbance and
the presence of the NLD profile (e.g., early shunted hydrocephalus [Fletcher et al., 1992; Holler, Fennell, Crosson,
Boggs, & Mickle, 1995; Rourke et al., 2002]). In other
cases, however, findings are more equivocal (Rourke et al.,
2002). A few examples of the latter will be presented. Table
1 lists several pediatric neurological conditions that have
been associated with NLD, outlines their associated white
matter impairment, and summarizes data from selected
studies that illustrate mixed research findings regarding the
presence of NLD in these conditions.
Agenesis of the Corpus Callosum. According to Rourke
et al. (2002), virtually all of the NLD assets and deficits are
manifest in cases of agenesis of the corpus callosum. It
should therefore be one of the best test cases of the white
matter model. As shown in Table 1, three case studies were
examined. In all cases, the clinical presentation was very
similar (i.e., the corpus callosum was absent), but significantly different neuropsychological profiles were found.
Overall, it appears that although Rourkes NLD model may
be descriptive of many aspects of white matter impairment,
it may not account for the full range of deficits that are
observed (Panos, Porter, Panos, Gaines, & Erdberg, 2001).
Turner Syndrome. Rourke et al. (2002) regard Turner
syndrome as another pediatric neurological condition
where the clinical features of NLD (weaknesses in visuospatial processing but apparent linguistic strength) are
displayed. Thus, it can be used as a test case scenario for
the white matter model (Hepworth & Rovet, 2000). As
shown in Table 1, there are striking differences in the
proposed nature and extent of white matter involvement in
the conditions of callosal agenesis and Turner syndrome.
Despite these differences, the same profile of neuropsychologic strengths and weaknesses was reported. That
the same profile arises from what appear to be vastly
different origins leads to some speculation about how the
two phenomena are linked. Clearly, the exact mechanism
by which white matter involvement leads to the NLD
profile remains to be established.
Velocardiofacial Syndrome. Velocardiofacial syndrome
(VCFS) is another neurological condition that Rourke et al.
(2002) view as manifesting virtually all of the NLD assets
and deficits, although they agree that the evidence in
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131

TABLE 1. Pediatric neurological conditions associated with nonverbal learning disability (NLD) and the nature and extent of white
matter damage or dysfunction associated with each.
Name
of Condition
Agenesis of the
Corpus Callosum

Nature and Extent of White Matter

Damage or Dysfunction

Selected Studies Reporting on

the Presence of NLD in Each Condition

The corpus callosum, the large white matter bundle

connecting the two cerebral hemispheres, has
failed to develop and is missing (Rourke et al., 2002)

Rourke (1987): Case study of 9-year-old female

with virtually complete agenesis of corpus callosum.
She exhibited all of the clinical features of NLD.
Finlay et al. (2000): Three members of a single family,
all without corpus callosum. Some features of NLD
documented; others not present (e.g., performance IQ
higher than verbal IQ in 2 of 3 cases).
Panos, Porter, Panos, Gaines, & Erdberg (2001): Case
study of 11-year-old male with callosal agenesis.
Significant verbal deficits noted (e.g., verbal learning,
articulation, word finding). Verbal deficits are not
consistent with the NLD profile.

Turner Syndrome

Some disruption in white matter

(Rourke et al., 2002, p. 320)
Core neuroanatomic basis is not firmly established
(Hepworth & Rovet, 2000; Rourke et al., 2002)

Hepworth & Rovet (2000): Case study of 9-year-old

female with Turner syndrome. She displayed
characteristics of NLD but also displayed expressive
verbal skills that were significantly below expectations
given her high receptive language performance. Such
verbal deficits are not consistent with the NLD profile.

Possible sites: reduced white matter in both parietal

lobes plus increased white matter in the
parietaloccipital region (Reiss et al., 1995, cited in
Hepworth & Rovet, 2000)
Velocardiofacial
Syndrome (VCFS)

Condition results from a submicroscopic hemizygous

deletion of a locus of chromosome 22q11.2
(Bearden et al., 2001)

Swillen et al. (1999): Examined neuropsychological and

learning profile of 9 primary-school-age children with
VCFS. Five of the 9 exhibited the NLD profile.

Very little evidence as to the nature of the brain

abnormalities that may exist in the 22q11.2 deletion
syndrome (Bearden et al., 2001, p. 457) but possible
parietal lobe asymmetry (Eliez et al., 2000, cited in
Bearden et al., 2001)

Bearden et al. (2001): Evidence of selective deficit in

visual spatial memory in 29 children with VCFS.
This finding is consistent with the NLD profile.

Metachromatic
Leukodystrophy (MLD)

An autosomal recessive neurodegenerative disorder

leading to progessive, diffuse demyelination (Weber
Byars, McKellop, Gyato, Sullivan, & Franz, 2001)

Weber Byars et al. (2001): Case study of a family, 1

index child with MLD and 8 of her biologic relatives.
Index patient displayed NLD profile. Two of her relatives
demonstrated definite but subtle white matter
abnormalities on MRI, but neither displayed any
evidence of NLD. Another relative displayed some
characteristics of NLD but normal MRI results.

Periventricular
Leukomalacia (PVL)

Areas of necrotic white matter develop in the brain

(Woods, Weinborn, Ball, Tiller-Nevin, & Pickett, 2000)

Woods et al. (2000): Case study of identical twins, 1

with PVL lesions and 1 without. Clinical twin displayed
aspects of NLD; unaffected twin did not. However,
difficulties in computational arithmetic, characteristic of
NLD, are not generally observed in children with PVL.

support of that position is equivocal. Whereas Swillen et

al. (1999) found that 5 of their 9 participants demonstrated
the NLD profile, 4 did not exhibit these symptoms.
Bearden and her colleagues (2001) were successful in
identifying a selective deficit in visuospatial memory in 29
cases of VCFS, a finding that would fit with the presence
of NLD. Contrary to the NLD profile, however, clinically
significant language disorders have also been found in
several studies (Moss et al., 1999; Wang, 1998, cited in
Bearden et al., 2001).
132

Moss et al. (1999) and Wang (1998, cited in Bearden et

al., 2001): Evidence of significant verbal language
difficulties. This type of deficit is not consistent with the
NLD profile.

Metachromatic Leukodystrophy. Metachromatic leukodystrophy (MLD) is a neurodegenerative disorder that leads

to progressive, diffuse demyelination (Weber Byars,
McKellop, Gyato, Sullivan, & Franz, 2001). Weber Byars
and her colleagues presented a case study of a family1
index patient with MLD and 8 of her biologic relatives. The
index patient, at the time of her initial assessment, displayed
a neuropsychological impairment consistent with that of
NLD. After a battery of neuropsychological tests, as well as
enzyme, genetic, and MRI studies was administered to the 8

American Journal of Speech-Language Pathology Vol. 13 128141 May 2004

family members, 2 of them demonstrated definite but subtle

white matter abnormalities on MRI. Neither, however,
displayed any evidence of NLD. A different family
member displayed some characteristics of NLD (e.g.,
significant discrepancy between her verbal and nonverbal
intellectual abilities) but normal MRI results. Weber Byars
and her group concluded that their findings do not support
the white matter model of NLD.
Periventricular Leukomalacia. Periventricular leukomalacia (PVL) is characterized by areas of necrotic white
matter developing in the brain (Woods, Weinborn, Ball,
Tiller-Nevin, & Pickett, 2000). Woods et al. reported a
case study of identical twins, 1 with PVL lesions and 1
without them. The clinical twin displayed NLD whereas
the other twins profile was unremarkable. On the surface
at least, this supports the relationship between dysfunctional white matter and the NLD profile. However, on
deeper examination, there are also some inconsistencies.
For one thing, difficulties in computational arithmetic are
characteristic of NLD but are not usually present in PVL.
One possible explanation is that white matter lesions may
be necessary but not sufficient to produce the whole NLD
profile (Rourke, 1987; Rourke et al., 2002). Alternatively,
there may still be an insufficient research base on either
condition to allow for delineation of respective neurobehavioral and neuropathological characteristics. Woods et
al. concluded that large-scale studies are needed in order to
refine the relationship between NLD and white matter
dysfunction, as well as to determine other possible neuroanatomical, neurophysiological, and disease correlates.
In addition to the relative lack of large-scale studies
testing the white matter model, other methodological
concerns have been raised. Very few studies have examined
neuropsychological findings in relation to data from
independent measures of brain functioning such as structural
and/or physiological imaging procedures. In addition, the
influence on cognitive functioning of psychosocial variables
such as education, amount of school missed, socioeconomic
status, family stressors, and so forth needs to be controlled
before definitive conclusions about the source of learning
disability can be drawn (Regan & Reeb, 1998).
Overall, several studies have found evidence of damage
to or dysfunction of cerebral white matter in a variety of
conditions that demonstrate deficits in perceptual and
cognitive function characteristic of the NLD profile. On
the other hand, questions remain about the nature and
extent of white matter damage or dysfunction that would
give rise to the NLD pattern of deficits. The fact that both
verbal and nonverbal difficulties have been documented
presents an additional challenge to the notion that white
matter damage or dysfunction is specifically related to
nonverbal processing difficulties.

Overlap with Other Diagnostic Conditions

Aspergers Syndrome and
High-Functioning Autism
The NLD profile of neuropsychological assets and
deficits is strikingly similar to the symptoms displayed by
individuals with Aspergers syndrome (AS) (Rourke et al.,

2002). In fact, Rourke posited that the two conditions

should not be dissociated (Rourke et al., 2002). This
continuity between NLD and AS raises an intriguing
question, and that is whether NLD is a phenomenon that
could be considered to be on the autism spectrum. In other
words, if AS is a disorder on the autism spectrum of
disorders, and if the profile of NLD converges with AS,
then NLD could be considered to be part of the autism
spectrum as well. In order to resolve this issue, one must
first consider whether AS is a mild variant of highfunctioning autism (HFA). This topic has been the subject
of considerable debate, with some researchers suggesting
that AS and HFA are indeed distinguishable (Klin,
Volkmar, Sparrow, Cicchetti, & Rourke, 1995; Rourke et
al., 2002), and others suggesting that definite lines separating AS and HFA cannot be found (Mahoney et al., 1998;
National Research Council, 2001). Although the issue has
not been resolved (Klin & Volkmar, 2003; Volkmar &
Klin, 2001), the bulk of the evidence seems to point to the
two conditions as being points on the same continuum. For
example, children with AS are often described as possessing intact early language skills, but Adams et al. (2002)
and Gilchrist et al. (2001) demonstrated equivalent
incidences of early abnormalities of speech such as verbal
rituals, stereotyped utterances, or inappropriate questions
in both groups of children. Szatmari, Bartolucci, and
Bremner (1989), and Schopler (1998), also reported that
children with AS could not be differentiated from those
with HFA on the basis of language competence. Motor
incoordination, sometimes proposed as present in AS but
not in HFA, has been shown to be present in autism
(Ghaziuddin, Tsai, & Ghaziuddin, 1994; Marjiviona &
Prior, 1995). Finally, depressed visuospatial skills in AS
are also proposed as a means of distinguishing between the
two conditions, but several studies have failed to find such
a difference (Miller & Ozonoff, 2000; Ozonoff, Rogers, &
Pennington, 1991; Szatmari, Archer, Fisman, Streiner, &
Wilson, 1995). If AS and HFA are points on a continuum,
and if NLD converges with AS, then NLD is a phenomenon that can be included at least on the borderlands of
autism (Bishop, 1989).

Pragmatic Language Impairment

If one accepts the convergence of NLD and AS, one
must also consider whether NLD might converge with
other disorders that have been discussed as overlapping
with AS and HFA. One of these is pragmatic language
impairment (PLI) (Bishop, 2000), formerly called
semanticpragmatic language disorder, where a childs
structural aspects of language are unimpaired but there
are marked problems in appropriate language use (Bishop
& Rosenbloom, 1987; Rapin & Allen, 1983). This clinical
description is also appropriate for the population diagnosed
with NLD as it is for those diagnosed with AS or HFA.
The relationship between PLI and autism spectrum
disorders has also been a matter of considerable debate.
Several investigators (Gagnon, Mottron, & Joanette,
1997; Brook & Bowler, 1992; Shields, Varley, Broks, &
Simpson, 1996a, 1996b) have concluded that PLI is better
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133

thought of as a form of HFA. On the other hand, Bishop

(1998, 2000; Bishop & Norbury, 2002) suggested that
children might display characteristics of PLI without
exhibiting marked impairments in social reciprocity or
displaying unusually restricted interests. Although it has
not yet been systematically investigated, the same conclusion is likely to be true for the overlap of PLI and NLD
(i.e., children diagnosed with NLD will display characteristics of PLI, but all children with PLI may not automatically
be assumed to have NLD). A definitive statement on this
issue awaits future research.

Developmental Coordination Disorder

and Developmental Attentional Motor
Perceptual Disorder
Gillberg and Billstedt (2000) noted that the lesser
known disorder of developmental coordination disorder
(DCD), as it is called in North America, and developmental attentional motor perceptual (DAMP) disorder, as it is
known in northern Europe, also overlap to a considerable
degree with AS. Descriptions of DCD focus on motor
incoordination in a childs development, but social
sequelae and pragmatic language problems are also
mentioned (Serra, Jackson, van Geert, & Minderaa, 1998).
Although NLD has not been mentioned in the literature in
regard to DCD or DAMP, its overlap with AS begs the
question of whether this too is a manifestation of NLD or
vice versa. As Volkmar and Klin (2001) pointed out, many
investigators work only within their own disciplines and
are therefore sometimes unaware of work in other areas.
As a result, terms for children who display social disabilities have proliferated, and the multiplicity of labels has
added to the confusion about diagnostic categories. Careful
research with clear diagnostic criteria will be needed to
determine whether all of these conditions are essentially
the same, overlap only in some dimensions (e.g., the social
and communicative domains), or are distinctly separate,
with different causes, developmental courses, and responses to treatment.

The Communicative Profile

The communicative profile has largely been neglected
in the research literature on NLD (Rourke & Tsatsanis,
1996). This may be due to several reasons. The first is the
historical background of the disability. Efforts to isolate
the NLD syndrome arose from the attempt to establish
subtypes of learning disability. Originally, labeling this
phenomenon as nonverbal was intended to (a) establish
the foundation of the disability as deficits in nonverbal
processing abilities and (b) distinguish the nonverbal
foundational properties of the disorder from those associated with more traditional conceptions of learning disability where fundamental causes were language related
(Rourke & Tsatsanis, 1996). The unfortunate by-product of
this focus has been a reduced emphasis on systematic
investigation of the communicative profile, with clinicians
and researchers alike ignoring the phenomenon because of
a label that identifies the problem as nonverbal and
134

therefore implies that difficulties lie outside the linguistic

domain.
The second reason for some neglect in the literature is
the behavioral presentation of the disorder. When a child
displays an abundance of verbal output along with precocious vocabulary development and complex grammar,
parents, clinicians, service providers, and many researchers
interpret this to mean that language development is
advanced. Although this approach is considered superficial
by specialists in language development, a deeper examination of subtler communication problems requires systematic investigation by those specialists. To date, this has not
been done in any comprehensive way.
A third reason is that the diagnosis of NLD has only
recently drawn the attention of speech-language pathologists and researchers. As previously discussed, we are
more familiar with semantic and pragmatic impairments of
the type that are reported to be associated with NLD as
subsumed under different diagnostic labels such as AS,
HFA, or PLI. Although systematic research devoted to
semantic and pragmatic competence in these categories
may also be described as in its infancy, it is much further
advanced than work devoted specifically to NLD. In this
review, critical evaluation of the communicative profile
attributed to NLD will be restricted to literature in which
the population with NLD was the specific and identified
target.
Children with NLD present as highly verbal, fluent
speakers, capable of using sophisticated vocabulary and
appropriate sentence structure (Rourke, 1989). Difficulties
arise in the language domains of semantics (content) and
pragmatics (functional use). For example, children with
NLD often have difficulty comprehending inference in
conversation or in text (Worling, Humphries, & Tannock,
1999), they may fail to understand idioms or metaphors
(Rourke & Tsatsanis, 1996), and they are frequently guilty
of violating quite elementary principles of social discourse
(Rourke, 1995).

Phonology, Morphology, and Syntax

Rourke and Tsatsanis (1996) presented the most
complete description of the communicative profile associated with NLD, dividing their discussion into Blooms
(1988) domains of form, content, and use. The domain of
language form includes the dimensions of phonology,
morphology, and syntax. Rourke and Tsatsanis reported
that children with NLD exhibit few difficulties in any of
these areas. In terms of phonology, they demonstrate
advanced skills such as blending sounds together and
segmenting words into component sounds (Rourke, 1989).
Syntactic skills are also reported to be adequate, with
grammatical morphology appropriately applied and a
variety of sentence structures correctly produced (Rourke,
1989).
Data to support Rourke and Tsatsanis (1996) description, however, are limited, and their 1996 article does not
rely on empirical support. An examination of the work in
Rourkes laboratory that established the foundation for the
NLD diagnosis (Rourke, 1987, 1989, 1993, 1995; Rourke

American Journal of Speech-Language Pathology Vol. 13 128141 May 2004

& Finlayson, 1978; Rourke & Fuerst, 1992; Strang &

Rourke, 1983) reveals little evidence that would yield the
detailed description of communication skills provided in
Rourke and Tsatsanis report. Rourke and his colleagues
administered a battery of neuropsychological measures
(described in Rourke & Finlayson, 1978) to many children
over a period of several years. Of the measures reported,
10 are described as assessing verbal skills. They are (a) the
PPVT (Dunn, 1965); (b) verbal IQ (a composite score
derived from all six of the verbal subtestsComprehension, Arithmetic, Information, Similarities, Vocabulary,
and Digit Spanon the WISC [Wechsler, 1949, 1991]);
(cf) individual scores on the Information, Similarities,
Vocabulary, and Digit Span subtests of the WISC; (g) the
Speech-Sound Perception Test (Reitan & Davison, 1974,
cited in Rourke & Finlayson, 1978); (h) the Auditory
Closure Test (Kass, 1964, cited in Rourke & Finlayson,
1978); (i) the Sentence Memory Test (Benton, 1965, in
Rourke & Finlayson, 1978); and (j) the Aphasia Screening
Test (Reitan & Davison, 1974, cited in Rourke &
Finlayson, 1978)
Of the above measures, the Auditory Closure Test and
the Speech-Sound Perception Test provide direct tests of
aspects of phonology. In the Auditory Closure Test, sound
elements are presented via a tape recorder and the child is
required to blend these sounds into words. Correct responding requires verbal memory skills and the ability to
blend sounds together. The Speech-Sound Perception Test
requires the child to listen to a series of speech sounds and
to select the configuration of graphemes that matches the
oral presentation. This test requires the ability to discriminate phonemes and to match them to the appropriate
letters. On these subtests, the children who were classified
as NLD performed at or above age level and well above
the level achieved by children with the more traditionally
acknowledged language learning disability (Rourke &
Finlayson, 1978). Thus, these data provide some support
for Rourke and Tsatsanis (1996) description of phonological processing skills as an area of strength. Notably absent
from Rourke and Tsatsanis account, however, are any
standardized measures of phonological or articulatory
production, or any reports of systematic analysis of
phonological competence as it could be observed in the
speech used throughout the assessment. When Rourke and
Tsatsanis report, then, that phonology is unaffected in the
child with NLD, the reader assumes that phonological
production errors were not observed in conversation, but
limited direct evidence of competence is reported.
With regard to the other dimensions of language form,
none of the measures listed is designed to provide information about morphological or syntactic competence. Rourke
and Tsatsanis (1996) appeared to base their conclusions
about integrity of these structural linguistic dimensions on
clinical observation, failing to note syntactic or morphological errors in the oral language used to complete various
parts of the assessment. Systematic investigation of these
dimensions using one or more standardized, comprehensive language assessments (see Paul, 2001, for an extensive
list) and language sample analysis would begin to document and validate Rourke and Tsatsanis observations.

Semantics
In the domain of language semantics or content, Rourke
and Tsatsanis (1996) described some aspects as strengths
and others as weaknesses. Children with NLD are reported,
for example, to exhibit large vocabularies (Rourke &
Tsatsanis, 1996). On the other hand, Rourke and Tsatsanis
also reported that, although children with NLD tend to be
verbose, there is relatively little in the way of meaningful
content that is conveyed in their discourse (p. 37). These
two observations may be reconciled by considering that,
although children are often able to use a large number of
sophisticated words, they may not understand the complete
meaning of the word or the full range of meanings that a
term connotes. This lack of depth can lead to words being
used inappropriately. One example is a child who was
describing the process of going to a grocery store. As part
of the description, he said after youre finished then you
go to the cashier. Then you go out the door. If its at the
beginning then you can go to the mall (Volden, 2002, p.
141). On questioning, it appeared that the child intended to
describe the grocery store as at the entrance to a shopping
mall, but chose the word beginning instead. Although
syntactic form was intact in this utterance, the selection of
lexical items is unusual, leading one to question the childs
semantic skill.
Difficulties in comprehension become more apparent as
the child grows older and conversational interactions begin
to demand the ability to employ contextual cues. In
addition, the appreciation of humor, irony, idioms, or
metaphors requires an adroit manipulation of literal and
nonliteral meanings and is reported to be difficult for
children with NLD (Rourke & Tsatsanis, 1996). For
example, children who have been diagnosed with NLD
will likely not interpret an utterance like OK, time to wrap
it up now as an indication that an activity is finished, or a
sentence like I just cant swallow that as an expression of
disbelief.
In examining the evidence available on semantic skills
in NLD, several of the neuropsychological measures listed
in Rourke and Finlaysons (1978) original battery would
yield information about semantic competence. The PPVT
(Dunn, 1965) is largely employed as a test of receptive
vocabulary. In response to an examiners production of a
stimulus word (e.g., Show me baby), the child selects
one picture from a choice of four. Appropriate responses
depend on recognition of a single, often the most common,
association between a word and the concept it represents.
Multiple or less frequent meanings of the word are not
assessed.
The verbal subtests (i.e., Information, Similarities,
Vocabulary, and Digit Span) of the WISC (Wechsler,
1949, 1991) tap a variety of skills. The Information subtest
on various versions of the WISC requires that the child
orally respond to a series of questions related to general
knowledge about common events, objects, places, and
people. For example, the child answers questions like
What must you do to make water boil? and Name two
kinds of coins. The Similarities subtest asks the child to
describe how two common objects or concepts are similar
(e.g., How are milk and water alike?). The Vocabulary
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135

subtest asks for definitions (e.g., What is a bicycle?,

What does nonsense mean?). At best, these three
subtests tap basic semantic knowledge by assessing a
childs understanding of words and the concepts they
represent, as well as fundamental properties and relationships. None of these measures would assess the more
sophisticated semantic knowledge that is reported to be
deficient by Rourke and Tsatsanis (1996). Digit Span is the
fourth verbal WISC subtest employed in the battery
described by Rourke and Finlayson (1978). It requires the
child to repeat a series of digits after the examiners oral
presentation (Wechsler, 1991). Correct responding on this
measure rests largely on verbatim verbal memory and does
not require access to semantic knowledge.
On these measures, children who have been classified as
NLD performed significantly better than children in the
other subtype of learning disability, those whose principal
difficulty was in language and the academic skills that rest
on language competence (Rourke & Finlayson, 1978). In
recall of information or word definitions, children with
NLD exhibited average to superior skills when their
performance was compared to test norms. On other
subtests, children in the NLD group exhibited poorer than
normal performance, but they were still superior to
children in the group with language disabilities (Rourke &
Fuerst, 1992). The measures described by Rourke and
Finlayson that pertain to semantic skill yield scores either
within or close-to-within normal limits in the group
described as NLD, but as we have seen, none of these tests
assessed sophisticated semantic skill such as the ability to
understand figurative language. In particular, none would
reveal the depth of the dysfunction described by Rourke
and Tsatsanis (1996), especially if conclusions were to be
drawn from analysis of their scores alone.
Recently, investigators have begun to examine some
aspects of the semantic domain. Fisher and DeLuca (1997)
examined self-initiated verbal memory strategies in
adolescents and adults with NLD. Participants with NLD
relied more on serial clustering (i.e., recalling items in the
order in which they were presented) rather than semantic
clustering (i.e., grouping items into semantic categories
such as food, clothing, etc.) as a strategy to remember lists
of items on the California Verbal Learning Test. Age- and
IQ-matched participants with a verbal learning disability,
on the other hand, did not employ one strategy selectively
over the other. Fisher and DeLuca interpreted their results
as consistent with Rourke and Tsatsanis (1996) observations that children with NLD display stronger rote memory
skills than abilities in active processing and categorization.
Dorfman (2000) administered the Test of Language
CompetenceExpanded Edition (Wiig & Secord, 1989) to
19 children with NLD and the same number of typically
developing children matched on age, gender, and verbal
IQ. She found that children with NLD were significantly
impaired on all of the tested areas (e.g., figurative language, the ability to make inferences, and the ability to
interpret the meanings that are embedded in ambiguous
sentences) as compared to the control group. Worling et al.
(1999) also reported that children with NLD experienced
difficulties in drawing inferences from small vignettes,
136

particularly when the inference depended on interpreting

spatial or emotional relationships. In the Worling et al.
study, the difficulties in inference were found to be
equivalent to those experienced by children with identified
verbal impairments. These studies are the first to document
difficulties in more sophisticated semantic skills in
children with NLD.
These three studies provide some empirical support for
the semantic dysfunction that was reported anecdotally by
Rourke and Tsatsanis (1996). All of these studies cite small
sample sizes as a limitation to widespread generalization of
their results, and all emphasize the need for replication
with larger groups. As Worling et al. (1999) pointed out,
more work is needed in the population with NLD on
examining sophisticated semantic communication skills
such as abstract word meaning, communication where the
information is implied rather than obvious (e.g., emotional
references, inference), and situations where an inconsistency has to be resolved (e.g., jokes, humor). As a first
step, a battery of standardized language measures that
focus on multiple meanings, figurative language, explaining inferences, semantic absurdities, and metalinguistic
skills (e.g., Test of Problem-SolvingRevisedElementary
[Bowers, Barrett, Huisingh, Orman, & LoGiudice, 1994],
The Word Test-R (Elementary) [Huisingh, Barrett,
Zachman, Blagden, & Orman, 1990], and Test of Language CompetenceExpanded Edition [Wiig & Secord,
1989]) should be administered in order to determine
whether the clinically observed deficits are significant
when compared to the performance of typically developing
peers and whether Dorfmans (2000) results can be
replicated. If, as expected, Rourke and Tsatsanis observations and Dorfmans measurements are confirmed,
subsequent investigations could probe further into the
nature and source of these language difficulties.

Pragmatics
Rourke and Tsatsanis (1996) reported that the most
deficient domain of language in children with NLD is that
of language use or pragmatics. Pragmatics refers to the
appropriate social use of language (Paul, 2001) and
includes the ability to use language to accomplish a wide
variety of social purposes (e.g., requesting objects,
requesting information, commenting, greeting [Dore,
1974]) as well as the ability to manage conversations
successfully (e.g., initiating interactions and introducing
topics, taking turns, maintaining and building on topics,
recognizing and repairing conversational breakdowns
[Brinton & Fujiki, 1989; Klein & Moses, 1994]).
Rourke and Tsatsanis (1996) described the discourse of
children with NLD as seriously impaired, not only because
so little content is expressed in their utterances, but also
because children appear to pay so little attention to how
appropriate their language is within a particular situation.
As a result, their conversation is often inappropriate for the
context and is frequently disorganized and incoherent
(Rourke & Tsatsanis, 1996).
As in the other language domains, empirical support is
limited for Rourke and Tsatsaniss (1996) observations

American Journal of Speech-Language Pathology Vol. 13 128141 May 2004

about pragmatic language skills. None of the measures of

verbal ability reported throughout the literature on NLD
would yield conclusive evidence about the state of a
childs pragmatic competence, especially in the sophisticated conversational skills that are reported as deficient.
Obtaining such measures is notoriously difficult because
(a) normative data on pragmatic language skills are limited
and (b) functional language varies according to context and
audience (Adams, 2002). Typical standardized language
assessment methods, where elicited performance in a
single context can be compared to a set of norms, fall short
of the ability to assess context-dependent activity. In
addition, many of the instruments that have been developed (e.g., the Test of Pragmatic SkillsRevised [Shulman,
1986], Test of Pragmatic Language [Phelps-Terasaki &
Phelps-Gunn, 1992], and Pragmatic Protocol [Prutting &
Kirchner, 1987]) quantify pragmatic skill in relation to
skills displayed in the course of typical development rather
than focusing on qualitative abnormalities in communication that characterize the language of those with developmental disorders (Bishop, 1998). In order to evaluate some
of the pragmatic features that are reported to typify the
population with NLD (e.g., verbosity, inappropriate
content), it is important to assess behaviors that are
difficult to elicit in test situations and that may be rare, but
salient, in occurrence. Even fine-grained analysis of
language samples may not yield adequate measures of
infrequently occurring but unusual behaviors (Bishop,
1998).
One alternative is the Childrens Communication
Checklist (CCC), which was developed by Bishop (1998).
A revised version (CCC-2), with norms on British children
between the ages of 4 and 16, has recently become
available (Bishop, 2003). The CCC is a checklist that may
be completed by parents, caregivers, or service providers
(Bishop & Baird, 2001). The respondent is asked to rate
the childs overall behavior on nine dimensions of communication, from which a composite score of pragmatic
language behavior is derived. Bishop (1998) found that this
composite score successfully discriminated between
children with a diagnosis of specific language impairment
and those whose communication problems were pragmatic
in nature. The CCC has the advantage of being relatively
easy and quick to administer as compared to observational
checklists or profiles, and it can tap behaviors that are
difficult to access by sampling. Still, it was not intended as
an instrument that would describe pragmatic skill sufficiently to direct intervention efforts. For this purpose,
detailed observation-based analyses (e.g., Assessment of
Language Impaired Childrens Conversations [Bishop &
Adams, 1989; Bishop, Chan, Adams, Hartley, & Weir,
2000], Topic Checklist [Brinton & Fujiki, 1989], and
narrative analyses) will be necessary.
In summary, anecdotal, clinical case descriptions of
children with NLD reveal a communicative profile that is
characterized by significant pragmatic impairment in the
presence of relatively preserved language form. Although
the elementary semantic skills of the child with NLD
appear to be intact, the child is likely to display deficits in
semantic competence when situations demand deep rather

than superficial comprehension and/or abstract or sophisticated semantic knowledge. Empirical evidence that would
validate the clinical profile has been found to be extremely
limited. Research that would investigate the communicative parameters of NLD is urgently needed. An important
early focus would be determining, at least in terms of
communicative assets and liabilities, whether NLD is
simply another name for conditions that have been described with similar communicative symptoms (e.g., AS,
HFA, PLI, DCD). If these conditions are found to be
essentially the same, research that has addressed language
deficits in these other populations can be readily applied to
children who have been diagnosed with NLD. If substantial and significant differences are found, the nature of
those differences will have important implications for
assessment and intervention with this population.

Implications for Clinical

Assessment and Intervention
If one assumes that Rourke and Tsatsanis (1996)
observations will be confirmed, the speech-language
pathologist would do well to evaluate semantic and
pragmatic skills carefully. Semantic skills to be evaluated
include nonliteral language (e.g., metaphor, irony, absurdities, and humor) (Klin & Volkmar, 2003) and comprehension of abstract, sophisticated concepts. Some standardized
tests (e.g., The Word TestR, Test of Problem-Solving
RevisedElementary, Test of Language Competence
Expanded Edition) that tap these high-level semantic skills
have already been listed in the section dealing with
semantic competence. As always, when standardized
measures reach the limit of their usefulness, informal
clinician-designed probes may have to be used in order to
determine the depth of dysfunction in a particular area.
Klin and Volkmar (2003) also emphasized evaluating
the pragmatic skills of turn-taking, sensitivity to cues
provided by the interlocutor, coherence and contingency in
conversation, metalinguistic skills, and rules of conversation. Nonverbal forms of communication (e.g., understanding and use of gaze and gestures), as well as suprasegmental aspects (e.g., patterns of inflection, stress and
volume modulation), are also important. These and other
pragmatic skills can be measured via the core tool-kit for
pragmatic language assessment as outlined by Adams
(2002). She suggested consulting developmental norms
(where they exist); using a comprehensive checklist of
pragmatic behaviors (such as the one developed by
Prutting & Kirchner, 1987); having parents, caregivers, or
service providers complete the CCC (Bishop, 1998,
2003); and assessing pragmatic language comprehension
(e.g., Test of Language CompetenceExpanded Edition
[Wiig & Secord, 1989], Assessment of Comprehension
and Expression (ACE 6-11) [Adams, Cooke, Crutchley,
Hesketh, & Reeves, 2001]) and detailed specific observation-based analyses for particular areas of interest (e.g.,
Assessment of Language Impaired Childrens Conversations [ALICC; Bishop & Adams, 1989; Bishop et al.,
2000], Topic Checklist [Brinton & Fujiki, 1989], and
narrative analyses).
Volden: Nonverbal Learning Disability

137

Relatively little has been written about strategies for

intervention with the NLD population, and even less is
available that has been empirically tested. Thompson
(1997) wrote a parent and teacher handbook that outlines
strategies gleaned from her clinical experiences. In general,
she suggests that service providers focus on helping the
child compensate for his or her deficits, accommodating
the environment to the childs needs, modifying expectations, and teaching the child verbally based strategies that
will allow him or her to navigate difficult circumstances.
Rourke (1995) also offered a treatment program that is
based on his conceptualization of the NLD phenomenon.
Overall, he supports Thompsons thrust of working
around the deficit, particularly the notion of using explicit
verbal instruction as the instructional medium, but he also
suggests that weak nonverbal processing skills can be
addressed directly by specifically teaching the child the
meaning of nonverbal signals. For example, children
should be directed to interpret facial expressions, their
interpretations should be discussed, appropriate facial
expressions should be role-played, videotapes of that roleplay should be analyzed verbally, and strategies for
subsequent interpretations should be developed.
Rourke (1995) cautioned that interveners must not allow
the child to employ his or her prodigious rote verbal memory
in task completion. In order to ensure that these children do
not simply repeat instructions verbatim, they will need to
restate the direction in their own words. This caution will
also be appropriate in language intervention. As a general
strategy, children should be required to process information actively, restating concepts, instructions, stories, and so
on in their own words rather than simply repeating the
clinicians directions and explanations.
Because NLD has not been addressed specifically in the
language intervention literature, and until more definitive
research is available, clinicians are reminded that clinical
practice has always benefited from relying less on categorical labels and more on detailed and careful descriptions of
developmental status in language domains (Paul, 2001). To
date, there is still no substitute for carefully describing a
childs abilities; comparing those to what we know of the
sequence of typical development; and intervening directly
where a childs performance disadvantages him or her,
relative to his or her peers and/or his or her environment.
Specific goals and possible treatment strategies for the
projected deficits in semantic and pragmatic functioning
are available in several books such as Paul (2001); Fey
(1986); Brinton and Fujiki (1989); and Duchan, Hewitt,
and Sonnenmeier (1994), and in many treatment articles
scattered throughout the generic language intervention
literature.

Summary
In summary, NLD is a diagnostic category that is
increasingly applied but that remains unfamiliar to most
speech-language pathologists. Its neuropsychological
profile has been studied extensively and is marked by
deficits in visual and tactile perception and impaired
psychomotor skills. On superficial analysis, language
138

abilities appear to be spared, as these children display

fluent, grammatical speech. On deeper examination,
though, semantic and pragmatic language skills are found
to be significantly impaired.
Clinical case descriptions and anecdotal reports consistently describe the above profile of communicative
abilities, but empirical research that would validate and
expand on clinical reports is urgently needed. One important question is the extent to which NLD overlaps with
other diagnostic categories such as AS, HFA, and PLI.
Because the communicative profile associated with
NLD is relatively unexplored, and any relevant diagnosisspecific implications are thus unobtainable, clinicians are
advised to intervene with these children in the same way as
they would any child with a significant developmental
delay. That is, by a careful assessment of communicative
strengths and weaknesses, followed by focused intervention on areas of need with increased functionality in the
childs everyday environment as the long-term goal.

References
Adams, C. (2002). Practitioner review: The assessment of
language pragmatics. Journal of Child Psychology and
Psychiatry, 43, 973987.
Adams, C., Cooke, R., Crutchley, A., Hesketh, A., & Reeves,
D. (2001). Assessment of Comprehension and Expression
611. Windsor, U.K.: NFER-Nelson.
Adams, C., Green, J., Gilchrist, A., & Cox, A. (2002). Conversational behaviour of children with Asperger syndrome and
conduct disorder. Journal of Child Psychology and Psychiatry, 43, 679690.
American Psychiatric Association. (2000). Diagnostic and
statistical manual of mental disorders (4th ed., text rev.).
Washington, DC: Author.
Badian, N. (1983). Dyscalculia and nonverbal disorders of
learning. In H. Myklebust (Ed.), Progress in learning disabilities: Vol. 5 (pp. 235264). New York: Grune and Stratton.
Badian, N. (1992). Nonverbal learning disability, school
behaviour, and dyslexia. Annals of Dyslexia, 42, 158178.
Bearden, C., Woodin, M., Wang, P., Moss, E., McDonaldMcGinn, D., Zackai, E., et al. (2001). The neurocognitive
phenotype of the 22q11.2 deletion syndrome: Selective deficit
in visualspatial memory. Journal of Clinical and Experimental Neuropsychology, 23, 447464.
Bishop, D. (1989). Autism, Aspergers syndrome and semantic
pragmatic disorder: Where are the boundaries? British Journal
of Disorders of Communication, 24, 107121.
Bishop, D. (1998). Development of the Childrens Communication Checklist (CCC): A method for assessing qualitative
aspects of communicative impairment in children. Journal of
Child Psychology and Child Psychiatry, 39, 879891.
Bishop, D. (2000). Pragmatic language impairment: A correlate
of SLI, a distinct subgroup, or part of the autistic continuum?
In D. Bishop & L. Leonard (Eds.), Speech and language
impairments in children: Causes, characteristics, intervention
and outcome (pp. 99113). Hove, East Sussex, U.K.:
Psychology Press.
Bishop, D. (2003). Childrens Communication Checklist (CCC-2).
London: The Psychological Corporation.
Bishop, D., & Adams, C. (1989). Conversational characteristic
of children with semanticpragmatic disorder. 2: What
features lead to a judgement of inappropriacy? British Journal
of Disorders of Communication, 24, 241263.

American Journal of Speech-Language Pathology Vol. 13 128141 May 2004

Bishop, D., & Baird, B. (2001). Parent and teacher report of

pragmatic aspects of communication: Use of the Childrens
Communication Checklist in a clinical setting. Developmental
Medicine and Child Neurology, 43, 809818.
Bishop, D., Chan, J., Adams, C., Hartley, J., & Weir, F.
(2000). Conversational responsiveness in specific language
impairment: Evidence of disproportionate pragmatic difficulties in a subset of children. Development and Psychopathology, 12, 177199.
Bishop, D., & Norbury, C. (2002). Exploring the borderlands of
autistic disorder and specific language impairment: A study
using standardised diagnostic instruments. Journal of Child
Psychology and Psychiatry, 43, 917929.
Bishop, D., & Rosenbloom, L. (1987). Classification of
childhood language disorders. In W. Yule & M. Rutter (Eds.),
Language development and disorders, Clinics in Developmental Medicine No. 101/102 (pp. 1641). London: Mac Keith
Press.
Bloom, L. (1988). What is language? In M. Lahey (Ed.),
Language disorders and language development (pp. 119).
New York: MacMillan.
Bowers, L., Barrett, M., Huisingh, R., Orman, J., & LoGiudice,
C. (1994). Test of Problem SolvingRevisedElementary. East
Moline, IL: LinguiSystems.
Brinton, B., & Fujiki, M. (1989). Conversational management
with language-impaired children: Pragmatic assessment and
intervention. Rockville, MD: Aspen.
Brook, S. L., & Bowler, D. M. (1992). Autism by another name:
Semantic and pragmatic impairments in children. Journal of
Autism and Developmental Disorders, 22, 6181.
Cornoldi, C., Rigoni, F., Tressoldi, P., & Vio, C. (1999).
Imagery deficits in nonverbal learning disabilities. Journal of
Learning Disabilities, 32, 4858.
Delis, D. C., Kramer, J. H., Kaplan, E., & Ober, B. A. (1994).
California Verbal Learning Test for Childrenmanual. San
Antonio, TX: The Psychological Corporation.
Dimitrovsky, L., Spector, H., Levy-Schiff, R., & Vakil, E.
(1998). Interpretation of facial expressions of affect in
children with learning disabilities with verbal and nonverbal
deficits. Journal of Learning Disabilities, 31, 286292.
Dool, C., Stelmack, R., & Rourke, B. (1993). Event-related
potentials in children with learning disabilities. Journal of
Clinical Child Psychology, 22, 387398.
Dore, J. (1974). A pragmatic description of early language
development. Journal of Psycholinguistic Research, 4,
343350.
Dorfman, C. (2000). Social language and theory of mind in
children with nonverbal learning disability. Unpublished
doctoral dissertation, University of California, Berkeley.
Duchan, J., Hewitt L., & Sonnenmeier, R. (Eds.). (1994).
Pragmatics: From theory to practice. Englewood Cliffs, NJ:
Prentice-Hall.
Dunn, L. (1965). Expanded manual for the Peabody Picture
Vocabulary Test. Minneapolis, MN: American Guidance
Service.
Fey, M. (1986). Language intervention with young children. San
Diego, CA: College-Hill Press.
Finlay, D., Peto, T., Payling, J., Hunter, M., Fulham, W., &
Wilkinson, I. (2000). A study of three cases of familial
related agenesis of the corpus callosum. Journal of Clinical
and Experimental Neuropsychology, 22, 731742.
Fisher, N., & DeLuca, J. (1997). Verbal learning strategies of
adolescents and adults with the syndrome of nonverbal
learning disabilities. Child Neuropsychology, 3, 192198.
Fisher, N., DeLuca, J., & Rourke, B. (1997). Wisconsin Card
Sorting Test and Halstead Category Test performances of

children and adolescents who exhibit the syndrome of

nonverbal learning disabilities. Child Neuropsychology, 3,
6170.
Fletcher, J. M., Bohan, T., Brandt, M., Brookshire, B.,
Beaver, S., Francis, D., et al. (1992). Cerebral white matter
and cognition in hydrocephalic children. Archives of
Neurology, 49, 818824.
Gagnon, L., Mottron, L., & Joanette, Y. (1997). Questioning
the validity of the semanticpragmatic syndrome diagnosis.
Autism, 1, 3755.
Ghaziuddin, M., Tsai, L., & Ghaziuddin, N. (1994). Is
clumsiness a marker for Asperger syndrome? Journal of
Intellectual Disability Research, 38, 519527.
Gilchrist, A., Green, J., Cox, A., Burton, D., Rutter, M., & Le
Couteur, A. (2001). Development and current functioning in
adolescents with Asperger syndrome: A comparative study.
Journal of Child Psychology and Psychiatry and Allied
Disciplines, 42, 227240.
Gillberg, C., & Billstedt, E. (2000). Autism and Asperger
syndrome: Co-existence with other clinical disorders. Acta
Psychiatrica Scandinavia, 102, 321330.
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, 8086.
Harnadek, M., & Rourke, B. (1994). Principal identifying
features of the syndrome of nonverbal learning disabilities in
children. Journal of Learning Disabilities, 27, 144154.
Hepworth, S., & Rovet, J. (2000). Visual integration difficulties
in a 9-year-old girl with Turner syndrome: Parallel verbal
disabilities? Child Neuropsychology, 6, 262273.
Holler, K., Fennell, E., Crosson, B., Boggs, S., & Mickle, J.
(1995). Neuropsychological and adaptive functioning in
younger versus older children shunted for early hydrocephalus. Child Neuropsychology, 1(1), 6373.
Huisingh, R., Barrett, M., Zachman, L., Blagden, C., &
Orman, J. (1990). The Word Test-R (Elementary). East
Moline, IL: LinguiSystems.
Kass, C. E. (1964). Auditory Closure Test. In J. J. Olson & J. L.
Olson (Eds.), Validity studies on the Illinois Test of Psycholinguistic Abilities. Madison, WI: Photo.
Klein, H., & Moses, N. (1994). Intervention planning for
children with communication disorders. Englewood Cliffs,
NJ: Prentice-Hall.
Klin, A., & Volkmar, F. (2003). Asperger syndrome: Diagnosis
and external validity. Child and Adolescent Psychiatric
Clinics of North America, 12,113.
Klin, A., Volkmar, F., Sparrow, S., Cicchetti, D., & Rourke,
B. (1995). Validity and neuropsychological characterization of
Asperger syndrome: Convergence with nonverbal learning
disabilities syndrome. Journal of Child Psychology and
Psychiatry, 36, 11271140.
Little, S. (1993). Nonverbal learning disabilities and socioemotional functioning: A review of recent literature. Journal
of Learning Disabilities, 26, 653665.
Mahoney, W., Szatmari, P., MacLean, J., Bryson, S.,
Bartolucci, G., Walter, S., et al. (1998). Reliability and
accuracy of differentiating pervasive developmental disorder
subtypes. Journal of the American Academy of Child and
Adolescent Psychiatry, 37, 278285
Marjiviona, J., & Prior, M. (1995). Comparison of Asperger
syndrome and high-functioning autistic children on a test of
motor impairment. Journal of Autism and Developmental
Disorders, 25, 2339.
Mattson, A., Sheer, D., & Fletcher, J. (1992). Electrophysiological evidence of lateralized disturbances in children with
Volden: Nonverbal Learning Disability

139

learning disabilities. Journal of Clinical and Experimental

Neuropsychology, 14, 707716.
Miller, J., & Ozonoff, S. (2000). The external validity of
Asperger disorder: Lack of evidence from the domain of
neuropsychology. Journal of Abnormal Psychology, 109,
227238.
Moss, E., Batshaw, M., Solot, C., Gerdes, M., McDonaldMcGinn, D., Driscoll, D., et al. (1999). Psychoeducational
profile of the 22q11.2 microdeletion: A complex pattern. The
Journal of Pediatrics, 134(2), 193198.
Myklebust, H. (1995). Verbal and nonverbal cognitive processes.
In E. Schopler & G. Mesibov (Eds.), Learning and cognition
in autism (pp. 3356). New York: Plenum.
National Research Council, Committee on Educational
Interventions for Children With Autism, Division of
Behavioral and Social Sciences and Education. (2001).
Educating children with autism. Washington, DC: National
Academy Press.
Nichelli, P., & Venneri, A. (1995). Right hemisphere developmental learning disability: A case study. Neurocase, 1, 173177.
Njiokiktjien, C., de Rijke, W., & Jonkman, E. (2001). Children
with nonverbal learning disabilities (NLD): Coherence values
in the resting state may reflect hypofunctional long distance
connections in the right hemisphere. Human Physiology, 27,
523528.
Ozonoff, S., Rogers, S., & Pennington, B. (1991). Aspergers
syndrome: Evidence of an empirical distinction from highfunctioning autism. Journal of Child Psychology and
Psychiatry, 32, 11081122.
Panos, P., Porter, S., Panos, A., Gaines, R., & Erdberg, P.
(2001). An evaluation of a case of agenesis of the corpus
callosum with Rourkes nonverbal learning disorder model.
Archives of Clinical Neuropsychology, 16, 507521.
Paul, R. (2001). Language disorders from infancy through
adolescence. St. Louis, MO: Mosby.
Petti, V., Voelker, S., Shore, D., & Hayman-Abello, S. (2003).
Perception of nonverbal emotion cues by children with
nonverbal learning disabilities. Journal of Developmental and
Physical Disabilities, 15(1), 2336.
Phelps-Terasaki, D., & Phelps-Gunn, T. (1992). Test of
Pragmatic Language. San Antonio, TX: The Psychological
Corporation.
Prutting, C. A., & Kirchner, D. M. (1987). A clinical appraisal
of the pragmatic aspects of language. Journal of Speech and
Hearing Disorders, 52, 105119.
Rapin, I., & Allen, D. (1983). Developmental language disorders: Nosologic considerations. In U. Kirk (Ed.), Neuropsychology of language, reading and spelling (pp. 155184).
New York: Academic Press.
Regan, J., & Reeb, R. (1998). Neuropsychological functioning
in survivors of childhood leukemia. Child Study Journal,
28(3), 179201.
Rourke, B. (1987). Syndrome of nonverbal learning disabilities:
The final common pathway of white-matter disease/dysfunction? The Clinical Neuropsychologist, 1(3), 209234.
Rourke, B. (1989). Nonverbal learning disabilities: The
syndrome and the model. New York: Guilford.
Rourke, B. (Ed.). (1991). Neuropsychological validation of
learning disability subtypes. New York: Guilford.
Rourke, B. (1993). Arithmetic disabilities, specific and otherwise: A neuropsychological perspective. Journal of Learning
Disabilities, 26, 214226.
Rourke, B. (Ed.). (1995). Syndrome of nonverbal learning
disabilities: Neurodevelopmental manifestations. New York:
Guilford.
Rourke, B. (2000). Neuropsychological and psychosocial

140

subtyping: A review of investigations within the University of

Windsor laboratory. Canadian Psychology, 41(1), 3451.
Rourke, B., Ahmad, S., Collins, D., Hayman-Abello, B.,
Sayman-Abello S., & Warriner, E. (2002). Child clinical/
pediatric neuropsychology: Some recent advances. Annual
Reviews of Psychology, 53, 309339.
Rourke, B., & Conway, J. (1997). Disabilities of arithmetic and
mathematical reasoning: Perspectives from neurology and
neuropsychology. Journal of Learning Disabilities, 30,
3446.
Rourke, B., Del Dotto, J., Rourke, S., & Casey, J. E. (1990).
Nonverbal learning disabilities: The syndrome and a case
study. Journal of School Psychology, 28, 361385.
Rourke, B., & Finlayson, M. A. (1978). Neuropsychological
significance of variations in patterns of academic performance: Verbal and visualspatial abilities. Journal of
Abnormal Child Psychology, 6(1), 121133.
Rourke, B., & Fuerst, D. (1992). Psychosocial dimensions of
learning disability subtypes: Neuropsychological studies in
the Windsor laboratory. School Psychology Review, 21,
361375.
Rourke, B., & Fuerst, D. (1995). Cognitive processing,
academic achievement, and psychosocial functioning: A
neurodevelopmental perspective. In D. Cicchetti & D. Cohen
(Eds.), Developmental Psychopathology, Vol 1: Theory and
methods (pp. 391423). New York: Wiley.
Rourke, B., & Strang, J. (1978). Neuropsychological significance of variations in patterns of academic performance:
Motor, psychomotor, and tactileperceptual abilities. Journal
of Pediatric Psychology, 3, 6266.
Rourke, B., & Tsatsanis, K. (1996). Syndrome of nonverbal
learning disabilities: Psycholinguistic assets and deficits.
Topics in Language Disorders, 16(2), 3044.
Rourke, B., Young, G., & Leenaars, A. (1989). A childhood
learning disability that predisposes those afflicted to adolescent and adult depression and suicide risk. Journal of
Learning Disabilities, 21, 169175.
Schopler, E. (1998). Premature popularization of Asperger
syndrome. In E. Schopler & G. Mesibov (Eds.), Asperger
syndrome or high-functioning autism? (pp. 385399). New
York: Plenum.
Semrud-Clikeman, M., & Hynd, G. (1991). Specific nonverbal
and social-skills deficits in children with learning disabilities.
In J. Obrzut & G. Hind (Eds.), Neuropsychological foundations of learning disabilities (pp. 603629). New York:
Academic Press.
Serra, M., Jackson, A., van Geert, P., & Minderaa, R. (1998).
Brief report: Interpretation of facial expressions, postures and
gestures in children with a pervasive developmental disorder
not otherwise specified. Journal of Autism and Developmental
Disorders, 28(3), 257263.
Shields, J., Varley, R., Broks, P., & Simpson, A. (1996a).
Hemispheric function in developmental language disorders
and high-level autism. Developmental Medicine and Child
Neurology, 38, 473486.
Shields, J., Varley, R., Broks, P., & Simpson, A. (1996b).
Social cognition in developmental language disorders and
high-level autism. Developmental Medicine and Child
Neurology, 38, 487495.
Shulman, B. (1986). Test of Pragmatic Skills (rev. ed). Tucson,
AZ: Communication Skill Builders.
Strang, J., & Rourke, B. (1983). Concept-formation/nonverbalreasoning abilities of children who exhibit specfic academic
problems with arithmetic. Journal of Clinical Child Psychology, 12, 3339.
Swillen, A., Vandeputte, L., Cracco, J., Maes, B., Ghesquiere,

American Journal of Speech-Language Pathology Vol. 13 128141 May 2004

P., Devridndt, K., et al. (1999). Neuropsychological, learning

and psychosocial profile of primary school aged children with
the velo-cardio-facial syndrome (22q11.2 deletion): Evidence
for a nonverbal learning disability? Child Neuropsychology,
5(4), 230241.
Szatmari, P., Archer, L., Fisman, S., Streiner, D., & Wilson,
F. (1995). Aspergers syndrome and autism: Differences in
behavior, cognition and adaptive functioning. Journal of the
American Academy of Child and Adolescent Psychiatry, 32,
16621671.
Szatmari, P., Bartolucci, G., & Bremner, R. (1989). Aspergers
syndrome and autism: Comparison of early history and
outcome. Developmental Medicine and Child Neurology, 31,
709720.
Thompson, S. (1997). The source for nonverbal learning
disorders. East Moline, IL: LinguiSystems.
Tsatsanis, K., & Fuerst, D. (1997). Psychosocial dimensions of
learning disabilities: External validation and relationship with
age and academic functioning. Journal of Learning Disabilities, 30, 490503.
Voeller, K. (1991). Socialemotional learning disabilities.
Psychiatric Annals 21, 735741.
Voeller, K. (1995). Clinical neurologic aspects of the righthemisphere deficit syndrome. Journal of Child Neurology,
10(1), S16S22.
Volden, J. (2002). Features leading to judgements of inappropriacy in the language of speakers with autism: A preliminary study. Journal of Speech-Language Pathology and
Audiology, 26(3), 138146.
Volkmar, F., & Klin, A. (2001). Aspergers disorder and higher
functioning autism: Same or different? International Review
of Research in Mental Retardation, 23, 83110.

Weber Byars, A., McKellop, M., Gyato, K., Sullivan, R., &
Franz, D. (2001). Metachromatic leukodystrophy and
nonverbal learning disability: Neuropsychological and
neuroradiological findings in heterozygous carriers. Child
Neuropsychology, 7(1), 5458.
Wechsler, D. (1949). Wechsler Intelligence Scale for Children.
New York: The Psychological Corporation.
Wechsler, D. (1991). Wechsler Intelligence Scale for Children
III. New York: The Psychological Corporation.
White, J., Moffitt, T., & Silva, P. (1992). Neuropsychological
and socio-emotional correlates of specific-arithmetic disability. Archives of Clinical Neuropsychology, 7, 116.
Wiig, E., & Secord, W. (1989). Test of Language Competence
Expanded Edition. San Antonio, TX: The Psychological
Corporation, Harcourt Brace Jovanovich.
Woods, S., Weinborn, M., Ball, J., Tiller-Nevin, S., & Pickett,
T. (2000). Periventricular leukomalacia (PVL): An identical
twin case study illustration of white matter dysfunction and
nonverbal learning disability (NLD). Child Neuropsychology,
6(4), 274285.
Worling, D., Humphries, T., & Tannock, R. (1999). Spatial and
emotional aspects of language inferencing in nonverbal
learning disabilities. Brain and Language, 70(2), 220239.
Received June 13, 2003
Accepted December 31, 2003
DOI: 10.1044/1058-0360(2004/014)
Contact author: Joanne Volden, Speech Pathology and Audiology, 2-70 Corbett Hall, University of Alberta, Edmonton,
Alberta, Canada T6G 2G4.
E-mail: joanne.volden@ualberta.ca

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