Nonverbal learning disability (NLD) can present a diagnostic and treatment conundrum to the child psychiatrist, with children presenting with a number of symptoms and deficits that are common with other conditions.
While the definition of what exactly NLD is varies depending on the researcher or the clinician using it, it most commonly combines deficits in novel problem solving (eg, executive function), visual-spatial learning and memory, tactile/motor skills, mathematics, a marked disparity in verbal compared to performance IQ (sometimes called a V-P split), and deficits in social and interpersonal relatedness and perception. Children with NLD are often described as kids who “miss the forest for the trees”—they have an excessive focus on details, but often miss the big picture or gestalt.
Defining and Diagnosing NLD
Depending on where and in what context you practice, you may have seen a lot of children who have been given this diagnosis on neuropsychological testing. One of the challenges of understanding NLD is the lack of consensus on what exactly constitutes the syndrome (think pre-DSM psychiatry).
Because of this, there are no clear numbers on prevalence, and much of the research done is marked by significant flaws (Fine JG et al, Child Neuropsychology 2013;19(2):190–223). Nevertheless, it is a diagnosis that is used more frequently, and which is often useful clinically.
Nonverbal learning disability was first described by Helmer Myklebust in 1975, but is most closely associated with Byron Rourke, who has been the most visible and productive researcher in the field of NLD (see for example Rourke BP, Nonverbal Learning Disabilities: The Syndrome and the Model. The Guilford Press; New York, NY:1989). The term was originally coined to differentiate NLD from the more common language-based learning disabilities such as dyslexia.
NLD is also sometimes called a right hemisphere learning disability, as it is thought to arise predominantly from deficits in this area. Rourke himself has more recently focused on the idea that disturbances in white matter may be connected and causal (Rourke BP, The Syndrome of Nonverbal Learning Disabilities. The Guilford Press; New York, NY:1995).
Sorting Through the Controversies
Since researchers have been unable to agree on a definition of NLD, it should not be surprising that many different and contradictory opinions exist on what the most important elements of the disorder are and how it relates to other conditions.
Common controversies include:
Its relationship to Asperger’s syndrome
Its persistence over time
The importance of the V-P split
The rates of comorbidity with depression and anxiety
Whether challenges in mathematics are a core feature
The most significant debates revolve around whether social skills deficits are a core part of the disorder, or only present in a subset of individuals.
The overlap between Asperger’s syndrome and NLD is also controversial, with estimates as high as 80% of all kids with AS having NLD with lower amounts of kids with NLD having Asperger’s. Others argue that they are actually quite distinct syndromes (Palombo J, Nonverbal Learning Disabilities: A Clinical Perspective. WW Norton & Company:2006).
Working With Children with NLD
Yet, despite all the limitations, the diagnosis is useful to a great many clinicians both in schools and in mental health offices for explaining the struggles and behaviors of some quirky and challenging kids. In my experience, I have found it most useful to think about the diagnosis as one in which kids have a tendency to focus on details, and to have difficulty with abstract thought or gestalt.
This means that they often learn to decode words well, and thus have few problems with early reading, but struggle with abstract reading comprehension in the later grades. They often do well with fact-based arithmetic, but struggle with more conceptual math. And while they have very large vocabularies and interact well with adults, they often miss nonverbal cues and the overall social context and therefore struggle socially with peers.
Kids with NLD often live with the sense that they are constantly letting people down; their experience of life is one of constantly doing less well than people expect them to. As a shorthand, I often explain to parents and teachers that their verbal skills are much more strongly developed than their ability to actually perform (ie, the V-P split).
Without parents, teachers, and the child himself understanding why, they are prone to problems with self-esteem, loneliness, and motivation. (For a detailed and excellent guide to working with children and their families see Palombo op.cit).
What the Psychiatrist Can Do for NLD
Individual and family therapy, parent guidance, social skills groups, outreach to teachers, and medications can be useful. Medications can treat the accompanying depression and anxiety that develop from both the interpersonal and intrapsychic struggles. In some cases, and on a mostly temporary basis, medications such as clonidine (Kapvay), guanfacine (Intuniv), or even in more severe cases atypical antipsychotics, can also be used to help with difficulties with emotional regulation that often develop because of the secondary effects of living with undiagnosed or poorly understood NLD.
The goal of therapy is to help the parents and the child understand the nature of the struggles. Parents often don’t understand why their kids appear so smart and yet struggle academically.
Kids themselves often wonder why other kids seem to like them at first, but they struggle to keep friends. All too often, they come to the conclusion that other kids are mean or untrustworthy because they so often get angry at them seemingly out-of-the-blue. If the child develops enough trust in the therapist that he or she will share details of social experiences, the therapist can often help decode what happened and help the child see the other’s perspective.
Often these same social difficulties play out in their relationships within the family, as well. Because they don’t read nonverbal cues well, they don’t display nonverbal cues well either, leading parents to misunderstand what their child is thinking or feeling. This is compounded by the fact that the child himself may have difficulty expressing or explaining his mood-state. This often leads to a pattern of feeling not well heard or understood, leading to subtle deficits in attachment. The process of therapy can help the parent and child be more direct about their emotions, and less angry and disappointed with each other.
The difficulty of appreciating the big picture also often makes it difficult for a child to make sense of his experience, instead seeing a fragmented and frustrating series of negative events. Talking about these experiences in therapy, and helping children understand how the experiences fit together and actually make sense, helps them improve their abilities to construct narrative, in general, and feel less pessimistic and despondent about their prospects in life, in particular.
Helping teachers recognize the concreteness of these kids’ verbal interactions and their frequent difficulty reading non-verbal signals can help teachers know better how to approach discipline in the classroom setting (for example, always giving clear verbal directions, not signals like a finger to the mouth or a “look” to signal the need to stop talking). Teachers also often get many useful suggestions from the neuropsychological testing reports documenting NLD for how to help kids academically.