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NONVERBAL LEARNING DISABILITY

& ASPERGERS DISORDER

LINDA C. CATERINO, PH.D., ABPP


ARIZONA STATE UNIVERSITY

Objectives


1. Participants will learn the specific


neuropsychological characteristics of individuals
with Nonverbal Learning Disabilities (NLD).
2. Participants will learn the current status of the
support for the diagnosis of NLD.
3. Participants will learn the specific diagnostic
criteria for Aspergers Syndrome (AS).
4. Participants will learn about differential
diagnosis regarding NLD and AS.

History - Gerstmann Syndrome











Josef Gerstmann- Austrian-American neurologist


Wrote 1st published article on Gerstmann
Syndrome
Symptoms
Finger agnosia
Right-left orientation confusion
Agraphia
Acalculia

Johnson & Myklebust




Proposed a nonverbal type of disability characterized by absence of serious


language problems and adequate or above skills in reading and writing,


Higher verbal than performance IQ

Problems in visual-spatial processing

Spatial orientation, right-left orientation, body image, motor learning

Difficulties in temporal perception

Handwriting

Mathematics

Distractible

Perseveration

Disinhibition

Deficiencies in social perception - unable to comprehend the significance of


many aspects of his environment
(Myklebust, 1967;Johnson &Myklebust, 1975; Boshes & Myklebust, 1964)

Byron Rourke


Neuropsychology of Learning Disabilities: Essentials


of Subtype Analysis (1985)
Syndrome of Learning Disabilities:
Neurodevelopmental Manifestations (1995)
Identified a group of children with a pattern of
neuropsychological strengths and weaknesses

Rourkes Description of NLD








Neuropsychological assets in auditory perception, auditory


attention, and auditory memory, especially for verbal material.
Adequate skills in rote verbal memory & language, amount of
verbal associations and language output.
Poor visual-spatial organizational, psychomotor, tactileperceptual, and concept formation skills, simple motor skills
may be well developed
Academic assets = single-word reading & spelling.
Academic difficulties in (e.g., arithmetic, science)
Difficulties in informal learning (e.g., as transpires during play
and other social situations).
Psychosocial deficits, primarily of the internalized variety, are
usually evident by late childhood and adolescence and into
adulthood.

Cognitive/Neuropsychological











Strengths
VIQ>PIQ by 10-15 pts or
more
Good receptive& expressive
language , High in
Similarities
Verbal Recognition,
Repetition, Associations,
Storage, Output
Auditory Perception
Verbal Attention & Rote
Memory
Focus on Details
Simple motor skills intact
Grip strength normal
Finger tapping average





















Deficiencies
PIQ<VIQ, Block Design, Object Assembly,
Picture Arrangement& Coding
Bilateral Tactile Perception (more on left )
Finger localization, fingertip number
writing
Tactile Form Recognition & Memory
Bilateral Visual Perception
Visual Memory (particularly as figures
become more complex)
Visual discrimination/Visual figure ground
Visual spatial organizational abilities
Perseveration
Attention
Selective attention
Novel Material
Understanding the big picture
Concept Formation
Nonverbal Problem Solving

Specific NLD Proposed Criteria








(1) Less than two errors on simple tactile perception and suppression vs. finger agnosia, finger
dysgraphesthesia, and astereognosis. Simple composite greater than 1 SD below the mean. Simple
tactile-perceptual skills are superior to complex tactile-perceptual skills.
(2) WRAT /WRAT -R standard score for Reading is at least 8 points greater than Arithmetic. Single
word reading is superior to mechanical arithmetic.
(3) Two of WISC/WISC- R Vocabulary, Similarities, and Information are highest of the Verbal scale.
Straightforward and/or rote verbal skills are superior to those involving more complex processing
(e.g., Comprehension).
(4) Two of WISC/WISC -R subtests Block Design, Object Assembly, and Coding subtests are the
lowest of the Performance scale. Complex visual-spatial-organizational skills and speeded eye-hand
coordination are impaired.
(5) Target Test at least 1 SD below the mean. Memory for visual sequences is impaired.
(6) Grip strength within one standard deviation of the mean or above vs. Grooved Pegboard Test
greater than one standard deviation below the mean. Simple motor skills are superior to those
involving complex eye-hand coordination, esp. under speeded conditions. (7) Tactual Performance
Test Right, Left, and Both hand times become progressively worse vis--vis the norms. Complex
tactile-perceptual and problem-solving skills under novel conditions are impaired.
(8) WISC/WISC -R VIQ > PIQ by at least 10 points. Verbal skills are superior to visual-spatialorganizational skills.
The following criteria are currently under investigation:
7 or 8 of criteria = definite NLD
5 o 6 of criteria = probable NLD
3 or 4 of these criteria - Questionable NLD
1 or 2 of these features: Low Probability of NLD

Drummond, C. R., Ahmad, S. A., & Rourke, B. P. (2005). Rules for the classification of younger children with Nonverbal Learning Disabilities and Basic Phonological
Processing Disabilities. Archives of Clinical Neuropsychology, 20, 171-182.

Rourkes Proposed ICD Criteria


Bilateral deficits in tactile perception, usually more marked on the left
side of the body.
Bilateral deficits in psychomotor coordination, usually more marked on
the left side of the body.
Extremely impaired visual-spatial-organizational abilities.
Substantial difficulty in dealing with novel or complex information or
situations. A strong tendency to rely on rote, routinized approaches and
memorized responses (often inappropriate for the situation), and failure
to learn or adjust responses according to potentially corrective
informational feedback.
Impairments in nonverbal problem-solving, concept-formation, and
hypothesis-testing.

Rourkes Proposed ICD Diagnostic


Criteria for NLD
Distorted sense of time. Estimating elapsed time over an interval and
estimating time of day are both notably impaired.
Well-developed rote verbal abilities (e.g., single-word reading and
spelling), frequently superior to age norms, in the context of notably poor
reading comprehension abilities (particularly evident in older children).
High verbosity that is rote and repetitive, with content/meaning disorders
of language and deficits in the functional/pragmatic dimensions of
language.
Substantial deficits in mechanical arithmetic and reading comprehension
relative to strengths in single-word reading and spelling.
Extreme deficits in social perception, social judgment, and social
interaction, often leading to eventual social isolation/withdrawal. Easily
overwhelmed in novel situations, with a marked tendency toward extreme
anxiety, even panic, in such situations. High likelihood of developing
internalized forms of psychopathology (e.g., depression) in late childhood
and adolescence.

Primary Neuropsychological Deficits


Tactile Perception Visual Perception
Complex Psychomotor --- Novel Material

Primary Neuropsychological Assets


Auditory Perception -- Simple Motor
Rote Material

Secondary Neuropsychological Assets


Auditory Attention --Verbal Attention

Secondary Neuropsychological Deficits


Tactile Attention -- Visual Attention
Exploratory Behavior

Auditory Memory --Verbal Memory

Tertiary Neuropsychological Deficits


Tactile Memory -- Visual Memory
Concept Formation -- Problem Solving

Verbal Neuropsychological Assets


Phonology Verbal Recognition
Verbal Repetition Verbal Storage
Verbal Associations Verbal Output

Verbal Neuropsychological Deficits


Oral-Motor Praxis-- Prosody
Phonology-Semantics --Content
Pragmatics -- Function

Tertiary Neuropsychological Assets

Academic Assets
Graphomotor (late)/Word Decoding
Spelling/ Verbatim Memory
Socioemotional Assets

Academic Deficit
Graphomotor (Early)/Reading Comprehension
Mechanical Arithmetic/Mathematics
Science
Socioemotional Adaptive Deficits
Adaptation to Novelty/Activity Level
Social Competence/Emotional Stability

Palombo 4 Types of NLD


1) core deficits in processing complex and nonlinguistic
perceptual tasks who also develop social problems
(perceptual + social)
2) meet subtype 1and also have neuropsychological
deficits in attention & executive functioning (
perceptual + social + EF)
3) meet subtype 1and have social cognition impairments
that manifest in reciprocal social interactions, social
communication and emotional functioning (perceptual
+ social + emotional)
4) meet subtype 2 and have same social cognition
impairments as subtype 3 (perceptual + social + EF +

4 Subtypes of NLD



Davis & Broitman (2011)


All children with NLD have significant visual-spatial
and executive function difficulties
1st Core subtype have visual-spatial executive
functioning, mild social and academic difficulties
2nd Children with visual & executive functioning
difficulties that significantly impact their social
functioning
3rd Children with visual & executive functioning
difficulties and significant academic problems
4th Children with visual-spatial, executive functioning,
social and academic difficulties where all areas are
functionally impaired

Davis & Broitman


4. All areas
impaired
2. VisualSpatial
Executive
Functionin
g that
significantl
y impact
social
functioning

3. Visualspatial
Executive
Functionin
g
Significant
Academic
Problems
1. Visual Spatial
Executive functioning
Mild social &
Academic
Difficulties

Hale & Fiorello (2004)






2 types
Executive novel problem solving - frontal
Posterior visual-spatial holistic problem
solving- right hemisphere

Specific Characteristics Cognitive








WISC-III - VIQ greater than PRI by 10 standard


score points or more
80% have highest standard scores on
Information, Similarities or Vocabulary
90% had lowest scores on Block Design, Object
Assembly, Coding (Drummond, et al., 2005)
Deficits in:
Perceptual and Quantitative Reasoning,
Theory of Mind

Attention





Attentional Problems maybe due to Visual


Perceptual and tactile difficulties (Rourke, 2000)
Auditory verbal attention intact
Problems with Sustained Visual & Divided
Attention
Tend to be diagnosed with ADHD:
Predominately Inattentive type (ADHDPI) but
may not be true ADHD (Semrud-Clikeman,
2007).

Executive Functioning
Hypothesis generation
 Flexible problem solving;
 Self-monitoring;
 Behavior regulation;
 Integration of emotion with context


Speed and Efficiency of


Processing


Assets -- auditory verbal including sustained


auditory attention, reading speed for simple
words, and rapid oral word association
Deficits -- visual attention, tracking, matching,
decision making speed, verbal-visual naming,
color naming and writing speed

Memory & Learning





Assets - auditory verbal learning and memory


Deficits - in visual-visual verbal learning, visual
immediate, visual spatial working memory,
delayed and long term recall of visual
information, Tactile-Kinesthetic Learning and
Memory; Location Memory

Visual Processing Deficits








Visual Perception;
Scanning-Tracking;
Figure-ground disturbance
Visual-spatial
Constructional

Sensory-Motor Deficits






Tactile-Kinesthetic;
Tactile Defensiveness;
Motor Sequencing,
Strength
Gross motor coordination (skipping, bike riding, jump
roping)
Fine Motor coordination (handwriting, coloring,
cutting, tracing, fastening, fine motor speed &
dexterity)
Complex psychomotor tasks,

Language



Asset - but language is pedantic, rote


Poor prosody and high verbal production

NLD Communication Difficulties

Receptive

May
not
understand
social
Nuances
in
conversation

(lack
of
tact)

Problem
s
decodin
g
prosodic
or
vocal
intonation
s

Problems
reading
facial
expressio
ns and
gestures

May
lack
sense
of
humor

Concrete
interpretation

of
metaphors

Expressiv
e

Good
vocabular
y

Lack
of
gestures,
facial
expressions
or
vocal
intonations

Social Deficits





Facial recognition and emotional expression (visual


attention/memory) (Corbett & Constantine, 2006; Fine, SemrudClikeman, Butcher, & Walkowiak, 2008; Rourke, 2000)
Emotional nuancing in communication; poor receptivity to
feeling states and states of others;
Poor prosody and high verbal production does not promote
positive social feed back
Social judgment secondary to problems with reasoning &
concept formation
Adaptation to novelty
Comprehension of humor deficits observed in NLD group with
social perceptual difficulties (not in NLD group with just visualspatial difficulties)(Semrud-Clikeman et al., 2008)

NLD Social Difficulties


Limited peer
interaction, prefer
one-to-one
interaction,, prefer
younger peers
May
withdraw
or
isolate

Problems
forming
friendships

Rigid,
rule-bound
Problems
forming
close
personal
attachments

Socially
awkward &
inappropriate

Difficulty
reading
social cues

Disruptive
play

Problems
with
interpersonal
intimacy

Bossy,
aggressive
& defensive
with peers

Problems
with
adaptability

Emotional
At risk for internalizing problems, e.g., anxiety &
depression (Rourke, 1989; Little, 1993)
 Depression (Cleaver & Whitman, 1998) Children with
sxs of right hemisphere white matter dysfunction had
arithmetic difficulties and showed significant levels of
depression
 Petti et al. (2003) found that children with NLD had a
higher percentage of internalizing diagnoses among
children at psychiatric treatment facilities.
 Higher risk for suicidal behavior as compared to other
LDs (Rourke,1989; Bigler,1989; Fletcher, 1989;
Kowalchuk & King,1989) -based on extremely small


Emotional


Greenham (1999) evidence not clear if emotional problems are cause


or consequence
Most individuals with NLD do not develop psychological problems, and
very few commit suicide (Greenham 1999).
Bloom & Heath (2010) compared 23 12- to 15-year olds with NLD with 23
matching children with general learning disability (GLD) and 23 typicals
Self-report scale, an adolescent depression scale,
Facial affect recognition measure,
Ability to make six different facial expressions
Understanding of facial expressions.
GLD did more poorly on recognition, expression, and understanding of
emotions
NLD group did not differ from the typical group

Co-morbidity- ADHD


Higher rates of ADHD (e.g., Gross-Tur, Shaleve, Manor, &


Amir, 1995; Voeller, 1986)

NLD Emotional Difficulties

Lack of empathy
or compassion

Self critical,
perfectionistic,
lack selfconfidence

Anxious, worried

Increased risk
for depression
& suicide

Problems
modulating
affect

Easily
frustrated, loses
control

Academic











Assets
May initially have trouble
with letter or number
recognition & learning
letter-sound relationships
then become good
readers
May lose place in rdg.
Good spelling skills
Average or above
average in verbal
language skills
Good syntax
Good rote memories
Problems generating
ideas for essays, but








Deficits
Arithmetic (rarely achieve >6th grade level,
even as adults (Rourke, 1995), number
alignment
Word problems (money, msmnt., esp. time
calendar & clock);
Quantitative analysis & size, weight &
distance estimation
Physics , Hypothesis testing
Organization
Spatial representation of abstract nonverbal
concepts (graphs, diagrams)
Written expression early problems with
orthograhic identification of letters spelling,
graphomotor tactile and constructional
deficits that affect legibility & accuracy
Reading comprehension for complex
reading material (e.g., main idea &
inferences),problems understanding
characters/motives
Story Retelling, question response (Worling,
Humphries, & Tannock, 1995)
Handwriting

NLD Assets and Liabilities


Domain

Assets

Liabilities

Sensory-Motor

Auditory-Verbal

Tactile-Kinesthetic; Tactile
Defensiveness; Motor Sequencing,
Coordination, strength

Attention

Sustained Auditory;
Rote Recall, Verbal

Sustained Visual, Divided Attention

Visual-Spatial

None

Visual Perception; Scanning-Tracking;


Constructional

Language

Verbal
Comprehension;
phonological;
Expressive,
receptive, and
repetitive

Prosody, Semantics; Content;

Memory & Learning

Auditory-Verbal;
Visual Immediate, Working; Delayed,
Learning & Memory Recognition, Visual-Verbal Learning;
for Rote Information Tactile-Kinesthetic Learning and
Memory; Location Memory

NLD Assets & Liabilities


Domain

Asset

Liability

Executive

Verbal Problem Solving

Hypothesis generation and


flexible problem solving; selfmonitoring; behavior
regulation; integration of
emotion with Context

Speed &
Efficiency of
Cognitive
Processing

Verbal-Auditory; Word Retrieval;


Rapid Verbal Word Association

Visual Tracking and Matching;


Verbal-Visual Naming; Color
Naming; Writing Speed

General Cognitive Verbal Reasoning

Perceptual and Quantitative


Reasoning, Theory of Mind

Academic
Achievement

Literal Comprehension; Decoding;


Verbal Arithmetic; Spelling

Mechanical Arithmetic;
Science; Writing; Gist
Reading Comprehension

Social-Emotional

General Knowledge; verbal skills

Language Pragmatics;
Nonverbal Cues & Behavior;
Social Judgment

Early Signs of NLD 0-6 years








A. Delays in reaching all developmental milestones, including acquisition of speech, followed by a


late, but rapid development of speech & other verbal abilities (particularly rote skills), usually to
above-average levels. May speak in a monotone.
B. Below normal amount of exploratory behavior. An apparent aversion for any type of exploration of
new stimuli/situations.
C. Impaired development of complex psychomotor skills (e.g., climbing, walking).
D. Avoidance of novelty & preference for highly familiar objects, situations, & information.
E. Preference for receiving information in verbal as opposed to visual format.

F. Strength in rote verbal memory (e.g., reciting the alphabet). Intelligence may be overestimated.

G. Deficits in perception and attention in both the visual and tactile domains.

H. Notably better auditory-verbal memory than visual or tactile memory.

I. Initial problems in oral-motor praxis, and longstanding, mild difficulties in pronouncing complex,


polysyllabic words.

J. Frequently described as inattentive.

Characteristic Evident in Older Children (> 7


Years)
A. Impaired capacity to analyze, organize, and synthesize information, with associated impairments in problem-solving
and concept-formation.
B. Despite high levels of verbosity, very significant impairments in language prosody, content, & pragmatics.
Cocktail-party" speech patterns, with high volume of verbal output but relatively little content (meaning) & very poor
pragmatics.
C. Strengths in single-word reading/recognition , but may have problems with tracking (30% of NLD children need to
be retrained to read fluently) & reading comprehension.
D.

Problems in arithmetic.

E. Fine motor problems, coloring, cutting,& handwriting in early school years, often improving to normal levels but
only with considerable practice.
F. Deficient social perception, social judgment, and social interaction. Poor perception & comprehension /
interpretation of facial expressions of emotion, and marked deficits in providing non-verbal communication signals.
G. May develop stress, anxiety, obsessional preoccupation, depression, self esteem, attentional problems (Palomobo
& Berenberg, 1999)
H. With advancing years, a tendency to become normoactive and then hypoactive. Problems in "attention" in formal
and informal learning environments tend to disappear as the situational stimulus and response demands become
more verbal in nature.

Middle & High School


A.

B.
C.

D.

E.

F.

Social skills deficits even more important,


difficulty getting along with peers & teachers
Math & science even more challenging
More emphasis on executive functioning in
written expression and reading
Increased risk for psychiatric disorders such
as depression (Mokros, Poznanski, &Merrick,
1989)
May do well in learning a foreign language,
drama, language arts
Transition planning becomes essential

Etiology


NLD is the phenotype that may be due to various causes

Hydrocephalus

Agenesis of the Corpus callosum

Turners Syndrome

Fragile X

Aspergers Syndrome




Williams Syndrome similar strengths & weaknesses (Don,Schellenberg, &


Rourke, 1999) = WS lower cognitive
Neurofibromatosis
Velo-cardio-facial syndrome 22p-11q deletion (Lepach, A. C. & Peterman, F.
2011).

leukomalacia

spina bifida

Etiology


Rourke presumed right hemisphere dysfunction


largely secondary to sub-cortical white matter
differences and more association cortex
Findings from existing neurological cases does
suggest involvement of the right hemisphere and
possibly of white matter (Voeller, 1995).
Further study is needed to determine the validity of the
right hemispheric white matter hypothesis in NLD.

Etiology



Filley, 2001
the NLD syndrome remains a theoretical construct,
and there is little documentation of right hemisphere
damage in white (or gray) matter in children with this
disability (p. 262).
the relevance of the NLD syndrome to the behavioral
neurology of white matter must remain conjectural
(p. 204).
careful correlation with neuroradiologic or
neuropathologic data [is necessary] . . . to confirm or
deny that white matter pathology is in fact present (p.
262).

Etiology


Semrud-Clikeman &Fine (2011) found greater number of cysts


on MRIs in children with NLD as compared to children with AS
& controls
(7) of NLD had cysts or lesions, generally in the posterior
region--occipital/cerebellar or parietal regions (visual spatial
perception), equally in the right and left hemispheres and
bilateral in the cerebellum.
Not found as frequently in children with Aspergers syndrome or
with controls.
One child w/Turner syndrome in the sample did not have a
cyst/lesion.
May be a structural abnormality or a genetic disorder that
underlies the expression of nonverbal learning disability.

Aspergers Syndrome

History

Described in 1944 by a Viennese pediatrician, Hans Asperger (1906-1980),


Asperger Syndrome (AS) autistic psychopathy
Asperger identified a special group of children (4 boys aged 6 to 11) with
normal cognitive & linguistic development, but poor social skills
Impairment in nonverbal communication, vague facial expressions, limited
gestures, limited, exaggerated or inappropriate language
Verbal communication idiosyncratic, precise quality
Misunderstanding of humor
Intellectualization of affect
Clumsiness & poor body awareness
Special interests
Conduct problems
Familial patterns
Gender patterns (more males)

Increased anxiety & fear









Lorna Wing, MD
British psychiatrist
 Coined the term Aspergers syndrome &
proposed formal diagnostic criteria
 1979 conducted an epidemiological study in
London
 Triad of Impairments:
 Impairment of social interaction
 Impairment of social communication
 Impairment of social imagination, flexible
thinking and imaginative play


DSM-IV-TR Diagnostic Criteria




299.80 Aspergers Disorder




A. Qualitative impairment in social interaction, as manifested by at


least two of the following:
 1.

marked impairment in the use of multiple nonverbal


behaviors such as eye-to-eye gaze, facial expression, body
posture, and gestures to regulate social interaction
 2. failure to develop peer relationships appropriate to
developmental level
 3. lack of spontaneous seeking to share enjoyment, interests,
or achievements with other people
 4. lack of social or emotional reciprocity

Diagnostic Criteria Continued




B. Restricted repetitive and stereotyped patterns of behavior,


interests, and activities, as manifested by at least one of the
following:
 1.

encompassing preoccupation with one or more


stereotyped and restricted patterns of interest that is
abnormal either in intensity or focus
 2. apparently inflexible adherence to specific,
nonfunctional routines or rituals
 3. stereotyped and repetitive motor mannerisms
 4. persistent preoccupation with parts of objects

Diagnostic Criteria
 C.

The disturbance causes clinically significant


impairment in social, occupational, or other
important areas of functioning.
 D. No clinically significant general delay in
language.
 E. No clinically significant delay in cognitive
development or in the development of age
appropriate self-help skills, adaptive behavior
(other than in social interaction), and curiosity
about the environment in childhood.
 F. Criteria are not met for another specific
Pervasive Developmental Disorder or
Schizophrenia.

AS - Social Impairments
May not like
physical contact

Inability to engage
in appropriate play

Extremely
egocentric; selfcentered

Socially awkward

Failure to develop
developmentally
appropriate peer
relationships

Lack of
spontaneously
seeking enjoyment

Limited desire for


social contact

Difficulty
understanding
other peoples
expressions &
feelings

AS - Motor Impairments
Odd Motor
Mannerisms

Delayed
Acquisition of
Motor Skills

Poor
Manipulative
skills

Impaired
mirror-image
imitation

Poor
Coordination
& Balance

AS - Sensory Impairments
Sensitivity to
Pain and
Temperature

Visual
Sensitivity to
Certain Colors

Sensitivity to
taste and
texture of food

Tactile
Sensitivity

Sound sensitivity- 3 types of noises:


1. sudden, unexpected noise (telephone ringing,
dog barking, clicking of a pen)
2. high pitched, continuous noise (hair dryer,
vacuum cleaner, mix-master)
3. confusing, multiple sounds (shopping
centers, large classrooms)

Synaesthesia
A sensation in one sensory system
and as a result experiences a
sensation in another modality
Colored hearing seeing colors
when hearing a sound

AS Language Impairments
Adult like
speech/little
professors

Poor ability to initiate


and sustain
conversation with peers

May have no language


delay; Well developed
speech but poor
communication

Monologue type speech;


egocentric
conversational style

Lack of tact

Poor prosody,
monotone, strange
intonation, rate (too
fast), volume (too loud),
poor fluency.

Difficulty understanding
metaphors/idioms/jokes

Echolalia

Emotional Co-morbidities

Eating Disorders

Depression

ADHD
Substance Use

ODD

Bipolar
Anxiety
(GAD, PTSD, Social
Phobias, Phobias,
OCD, PTSD

Other Co-morbidities

Seizure
Disorders

Tourettes
& Tics

Developmental
Coordination
Disorder

Learning
Disabilities

Hyperlexia

Other Characteristics
Rigidity in rituals
& routines

Above Average
Rote Memory

Executive
Function Deficits

Intense Interest
in circumscribed
subjects

Nonverbal Learning Disability & Aspergers


Syndrome

NLD & AS


NLD profile is often associated with AS (@80%), but AS is not


always associated with NLD
Individuals with AS present with virtually all characteristics of
NLD (Rourke, 2000)
Most children with AS have a NLD profile, but not all children
with NLD have AS
Both NLD & AS have problems with social communication, and
reciprocity, nonverbal communication, pragmatic language,
and visual-spatial skills (Gunter, Ghaziuddin, & Ellis, 2002;
Voeller, 1995).
Stronger verbal compared to performance skills on cognitive
testing were found for children with AS or NLD (Gillberg &
Billstedt, 2000; Klin et al., 1995).

NLD & AS


Pennington (1991) Rourke took 2 different groups &


conflated them
 1 group problems with spatial cognition
 1 group problem with social emotional
 only first group should be called NLD
 Second group should be on autistic spectrum
 Pennington (2009)reviewed NLD again
 in sum, we do not have sufficient evidence to
accept it as a valid learning disorder apart from
either autism spectrum disorder (ASD),
mathematics disorder (MD) or developmental
coordination disorder (DCD) all of which are
covered in the DSM-IV-TR (ASD in the category
of PDDs) (p. 248).

NLD vs. AS
Palumbo (2001)- hypothesized that AS & NLD
could be 2 different subtypes of the same
syndrome
 Children with Aspergers Syndrome have more
profound social difficulties than children with
developmental NLD (Thompson 1997).
 NLD & AS could be on a continuum of severity
ranging from NLD to Aspergers and finally
autism (Roman, 1998)


NLD & AS (Klin, Sparrow,


Cicchetti, & Rourke, 1995).







NLD & AD profiles share many characteristics


Strong verbal skills
Poor visual spatial ability
Problems with executive functioning.
NLD is evident in many with AS, but not in HFA
The NLD profile is an adequate model of
neuropsychological assets and deficits encountered in
individuals with AS (p. 1133)
AS is one of several pathways including
hydrocephalus, acquired brain injury and Williams
Syndrome to the manifestation of NLD

NLD vs. AS
Children with Aspergers Syndrome typically
have restricted interests, where they
become obsessed with unusual interests
(Stein, Klin, & Miller 2004,
 The presence of stereotyped and restricted
patterns of interest and the need to adhere
to routines present in children with AS but
not NLD (Semrud-Clikeman, 2007).


NLD vs. AS







Semrud-Clikeman, Walkowiak, Wilkinson, & Minne, 2010


Compared 24 NLD, 52 AS, 27 ADHD 9- to 15-year-old children
Found no significant differences in social perception between
the NLD & AS groups (both lower than controls)
Differences between AS & NLD groups on calculations
Differences on the Autism Diagnostic InterviewRevised,
particularly in the area of stereotyped and restricted behaviors.
No significant difference for AS & NLD on Rey-Ostereith
Complex Figure test. Both lower than norms

NLD, AS & ADHD




Semrud-Clikeman, Walkowiak, Wilkinson, &


Christopher, 2010
Compared NLD, AS, & ADHD-C & ADHD PI

NLD & AS No significant


differences









Semi-structured interview (SIDAC)


Behavioral Measures BASC-2 Hyperactivity&
Attention
Social Skills (SSRS)
Math calculations
Mathematics reasoning
Reading recognition
Fluid Reasoning (WJCOG-III) (Concept formation
& Analysis & Synthesis)
Motor Skills (Grooved Pegboard)

NLD & AS








Visual-Spatial NLD group significantly lower on


VMI than AS (Rey-Osterreith)

Judgment of Line Orientation test (JLO) NLD


lower than AS
AS screener AS group scored higher
WASI
PIQ NLD lower than AS
VIQ - no significant difference among groups
NLD group showing the largest split between VIQ
& PIQ

NLD, AS, & ADHD








74% of NLDs had a V > P split of more than 15 SS


points & 40% had a split of 25 SS points or higher
(15-55)
63% of AS group had BIQ &PIQs within 15pts.
But 37% of AS showed VIQ >PIQ in the AS group.
While children with NLD are more likely to show a
VIQ > PIQ split; there is a sizable minority of children
who do not.
Finding is not sufficient to provide a distinction
between NLD & AS
also found in Pelletier, Ahmad, & Rourke, 2001).

NLD vs. AS
NLD

Aspergers

diagnosed from
neuropsychological perspective
Psychological test scores
learning disability, discussion of
how children learn

diagnosed from psychiatric


perspective
observations
developmental disorder

Prevalence
NLD









.1 1%
10% (Ozols & Rourke,
1991
25% (Bender & Golden,
1990
29% (Van der Vluat, 1989)
Higher or equal rates in
females
1:1
Recognized in 4th & 5th
grades

AS
1-10 in 10,000
 Higher rates in
Males
 Recognized
around 3-4 yrs.
of age


Neuropsychological
NLD









VIQ > PIQ


Weak visuospatial
skills,
Visual motor
integration
Right left confusion
Visual memory
deficits
Attentional problems
Hyperactivity as
child)
May have Theory of
Mind deficits

AS


VIQ>PIQ (X = 23.8 pts.)


Ghaziuddin & MountainKimchi (2004) found that
only 82% of their AS group
had VIQ > PIQ

Weak visuospatial skills

Visual motor integration

Visual-spatial perception

Nonverbal concept
formation

Visual memory deficits

Attentional problems

More likely to have Theory


of Mind deficits

Visual Motor









NLD
Psychomotor coordination
problems
Clumsy, poor at sports
Delayed Gross Motor
Milestones
Fine Motor difficulties,
drawing, handwriting
(Frankenberger, 2005)
Avoidance of graphomotor
tasks
Difficulties dressing, problems
with fasteners
Poor organizational skills
May not learn from diagrams,
need verbal explanations (Fast,
2004)







AS
Psychomotor
coordination problems
Clumsy
Fine and Gross Motor
delays (Tantam, 1988; Gillberg,
1990)

Stereotypic motor
mannerisms (Mamen, 2007)
Do not have visual
issues & may be visual
learners (Fast, 2004)

Language


AS

Generally appropriate language


skills

Generally appropriate language skills

More verbose than NLD

Verbal >performance

Verbal >Performance

Pragmatic language deficits

Pragmatic language deficits

May have early language delays

Poor prosody

Monologues

Verbose, large vocabulary




NLD

Poor prosody

Verbose, verbal with little content




Lack of appreciation of
incongruities and humor

Poor nonverbal communication


Difficulty understanding and
using facial expressions,
gestures

Pedantic conversation, concrete


speech

Literal interpretation

Poor nonverbal communication

Difficulty understanding and using


facial expressions, gestures, vocal
intonation
Repetitive speech patterns

Academics
NLD
Significantl
y

delayed
arithmetic
skills
(Rourke, 1989;
1995; Rourke &
Conway,
1997))

AS

Average
or above
word
reading

Delays
in
reading
compre
hensio
n

Difficulties
in
written
expression

Inconsiste
nt reports
of
arithmetic
performan
ce (some
show good
math skills
(Kuipers, 1962)

Reading
relatively
intact,
may be
voracious
readers

Social




NLD

Social delays
Problems developing
friendships
At risk for peer
rejection
Poor social
perception, judgment
& interaction
Problems in empathy
Automatized
stereotyped ways of
(Little, 2001)







AS
Social delays
Problems developing
friendships
At risk for peer rejection
(Little, 2001)




Poor social perception,


judgment and interaction
Problems in empathy
Lack of spontaneous
sharing of enjoyment
Failure to develop
friendships
Social problems more severe

Social -- NLD Vs.AS


Children with NLD
are easier to make a
social connection
with (Palumbo,
1991)

Withdrawal in NLD
is reactive
Primary in
Aspergers

NLD children crave


social contact more
than do children
with Aspergers

Children with NLD


may ineptly reach
out to other people

Emotional
NLD


AS

Emotional problems
(internalizing anxiety &
depression)
( Petti, Voelker, Shore &

Hayman-Abello, 2003

MMPI - NLD group had


no scores above 70 on
clinical scales,
High risk for suicide
(Waldo et al., 1999)




(Klin, 2004)

( Ellis, Ellis, Fraser,

& Deb, 1994; Gujikawa, Kobayashi, Koga, & Murata, 1987

( Bigler,
1989; Fletcher, 1989; Rourke, Young, & Lennars, 1989)

Have normal emotions,


but cant express them
or recognizing them in
others
(Fast, 2004)

Anxiety (esp. in
adolescence)
Potential of mood
disorders is high

MMPI -2 study with


adults elevations on L
and Depression, social
introversion, social
discomfort
(Ozonoff, Garcia, Clark &

Lainhart,2005

Have flatter affects

(Fast, 2004)

Repetitive Behaviors
NLD

Inability to
Adapt to
Change

AS

Inability to adapt to
change/novelty

Ritualistic

Preoccupation with
stereotyped and
established routines

Focus on special interest


Amass factual information

AS & NLD
Klin, Volkmar,
Sparrow, Cicchetti,
& Rourke, 1995

Cederlund &
Gillberg (2004)

Semrud-Clikeman

21 students with AS (x= 16.11 yrs.) & 19 persons


with HFA (X = 15.36 yrs.) were compared
18 of 21 with AS presented with NLD profile

found that only 51% of AS subjects met criteria for


NLD

NLD group did more poorly on PIQ than AS group


using the WASI

Model
AS
Preoccupations
Special Interests
Facts
Ritualistic

NLD
Social
Communication
Nonverbal
Communication
Psychomotor
Emotional
Visual Motor
Executive
Functioning
Theory of Mind
Attention
Novelty
Problems

Neuropsychological
Difficulties
Math
Reading
Comprehension
Written Expression &
Organizational
Problems

Assessment




Cognitive Assessment
Thinking &reasoning skills must be at least average
Although IQ does not have to be average (e.g., average WJIII
Thinking ability or Cognitive Efficiency)
There must be an impairment in at least one psychological
process related to learning

Neuropsychological
Assessment







Impairment in at least one psychological


process related to learning
Visual/motor/spatial/tactile memory and
attention
Visual motor or fine motor processing
Speed
Pragmatic language
Executive functioning (e.g., planning,
monitoring, selective focusing, organization

Possible Assessment Measures





WISC-IV
Woodcock-Johnson Cognitive Battery III (WJCog III) (Woodcock, McGrew, & Mather,2001a)
esp. Analysis & Synthesis & Concept
Formation)
KABC-2(Chow & Skuy, 1999) found that NLD
children showed significantly higher
successive than simultaneous processing
WASI

Possible Assessment Measures




NEPSY (e.g., Design copying, Arrows)

Delis-Kaplan Visual Motor Integration


(Beery)
 Wisconsin Card Sort (Jing, Wang, Yang, &
Chen, 2004)
 Category Test (Strang & Rourke, 1983)
 The Childrens Category Test (Boll, 1993)
Ris et al. (2007) - good predictor of the NLD
group (Ris et al., 2007)


Possible Assessment
Instruments
Rey-Osterreith Complex Figure (Osterreith,
1944)
 Grooved Pegboard (Klove, 1963).
 Finger Tapping Test (Reitan & Wolfson, 1985).
 Purdue Pegboard
 Judgment of Line Orientation (JLO) (Benton,
Sivan, Hamsher, Varney, & Spreen, 2004)(Semrud-Clikeman, yes, not Benton, Varney, &
Hamsher, 1978)


VMI (Beery et al., 2006).

Possible Assessment
Instruments


Childrens Auditory Verbal Learning Test 2


(CAVLT-2)
Childrens Memory Scale

Possible Assessment
Instruments


AS Screener (AS screener based on DSM-IV-TR Asperger syndrome criteria)

ADI-R

Asperger Syndrome Diagnostic Scale (ASDS)

Autism Spectrum Rating Scales (ASRS)

The Structured Interview for Diagnostic Assessment of Children (SIDAC) (PuigAntich & Chambers, 1978). (K-SADS)
Behavior Assessment System for Children2 (BASC2) (Reynolds & Kamphaus,
2004).

Social Skills Rating Scale (SSRS) (Gresham & Elliott, 1990)/SSIS

Child and Adolescent Social Perception (1995) (Semrud-Clikeman & Glass,2008)

CBCL

Conners Parent/Teacher Rating Scales

Behavior Rating Inventory of Executive Function (BRIEF)

Childrens Depression Inventory

NLD scale http://www.nldline.com/

Possible Assessment
Instruments







WJ-Ach III (Woodcock et al., 2001b) Math calculations &


Math reasoning (Forrest, 2004) didnt find that poor
mathematical reasoning predicted NLD
WIAT-III
Key Math
Gray Oral Reading-4

Is NLD a Valid Diagnosis?




Spreen (2011) NLD remains a hypothesis, but


it should not be used in clinical practice unless
it is supported by solid research findings.

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