The Misunderstood Child: The Child With a …

1 The Misunderstood Child :The Child with a Nonverbal LearningDisorderby Liza Little, PsyD, RNLearning disorders are common among elementaryschool children. As many as 10% of school-agedchildren have problems with educational achievementor behavior in school (Weinberg, Harper, & Brumback,1995). As many as 15%-30% of children may sufferschool failures because of learning disorders that resultfrom subtle problems with neurological development ormild brain dysfunctions (Levine, 1995).Despite the prevalence of learning disorders inchildren, few nursing professionals are familiar withnonverbal learning disorders (NLD) and theirmanifestations. This may be because 80% of allchildren with learning disabilities have verbal learningdisabilities that affect their ability to read, speak, orlisten (Johnson, 1995) but not their nonverballearning. Or it may be that nurses see learning as thedomain of educational specialists and health consequences abound for children withlearning disorders, particularly the Child with , a search of the nursing literature over thelast five years produced no articles on NLD.

2 Thepurpose of this paper is to introduce nurses to thecharacteristics of NLD and their psychosocial trajectoryin children. The implications for nurses working withchildren with NLD will also be Learning Disorders versus NonverbalLearning DisordersLearning disabilities "are circumscribed deficiencies in acognitive area in an otherwise intellectually normalchild or adolescent" (Johnson, 1995, ). Learningdisabilities generally can be divided into three types:verbal learning disabilities; nonverbal learningdisabilities; and learning disabilities that affectexecutive functions, such as attention-deficithyperactivity disorder (ADHD). Children with NLD havedifficulties with nonverbal communication. Sinceapproximately 65% of meaning is communicated bynonverbal cues, such as tone of voice, facialexpression, posture and body language, there is asignificant deficit for the Child who cannot decipher orinterpret nonverbal behavior (Nowicki & Duke, 1992;Thompson, 1997).

3 Learning disabilities research on the long-termoutcomes of children with verbal and nonverballearning disorders suggests that the Child with NLDmay have increasing difficulties as he/she ages andfaces worse over time than the Child with a verballearning disability (Fuerst & Rourke, 1993; Harnadek &Rourke, 1994; Rourke, 1995). This is due in part tothe nature of the nonverbal disorder. Children withNLD have problems integrating new information, whichmakes it difficult for them to cope with new also have difficulties applying learning from onesituation to another (Rourke, 1995; Voeller, 1995).The Child 's learning difficulties, coupled with theinability to decipher social cues and deal withincreasing levels of social complexity, make life moredifficult as the Child gets of Nonverbal Learning DisordersNonverbal learning disorders, or right-hemispheredysfunction affect one of every ten children with alearning disability (Rourke, 1995; Torgeson, 1993).

4 Characteristics of children with NLD can be divided intofive areas and remembered by the acronym SAVME(Table 1). The characteristics include problems in theareas of social competencies, academic performance,visual spatial abilities, motor coordination, andemotional functioning. Part of the difficulty indiagnosis is that a Child may not show deficits in everydomain. In addition, children may vary in terms of theseverity of the particular 1 Social CompetenciesExtreme difficulty in coping with novel and complexsituations and an over-reliance on rote, commonplacebehaviors are observed (Harnadek & Rourke, 1994).The Child with NLD may find it very difficult to try newSAVME: Common Characteristics ofNonverbal Learning DisordersSocialLack of ability to comprehendnonverbal communicationSignificant deficiencies in socialjudgment and social interactionAcademicProblems in math, readingcomprehension, handwritingProblems with organization,problem-solving, higherreasoningStrengths include strong verbaland auditory attention andmemoryVisual-SpatialLack of image, poor visualrecallFaulty spatial perception andspatial relationsMotorLack of coordinationSevere balance problemsDifficulties with fine motorskillsEmotionalFrequent tantrums, difficultiessoothing, easily overwhelmedFears of new places andchanges in routinesProne to depression andanxiety as they get olderthings, such as playing a game they haven't playedbefore.

5 These children find new experiences anxiety-provoking, so that staying at a friend's house, summercamp, vacationing in new places, or being left withbabysitters may be with NLD may speak well and be verbose, butit is of a rote nature with poor linguistic children and young adults often interrupt andhave difficulty entering into a conversationappropriately. Their speech has little rhythm orvariation in tone and inflection; long, windymonologues are not uncommon (Gregg & Jackson,1989) and what they talk about may seem conversation may be difficult, as they interruptand change the subject to unrelated and irrelevantissues. Friends of these children may find them boringbecause they talk all the time, the substance often isirrelevant, and the conversation may be with NLD demonstrate significant deficits insocial perception, social judgment, and socialinteraction skills, and marked deficiencies in theappreciation of incongruities and age-appropriatehumor.

6 Nonverbal cues serve multiple affective andcognitive functions that affect communication (Hoy,Gregg, King, & Moreland, 1993). Since children withNLD have difficulty noting and understanding facialexpressions, tone of voice, and body language, theyfrequently have difficulty with relationships. The poorinterpretation of social cues makes children and adultswith NLD vulnerable to ridicule, rejection, andvictimization (Denckla, 1991; Foss, 1991; Fuerst andRourke, 1993; Grace & Malloy, 1992; Harnadek andRourke, 1994; Little, 1998; Rourke, 1995; Thompson,1997, Weintraub & Mesulam, 1983). These childrenoften are negatively labeled by their with NLD make many social faux pas. Theymay laugh at someone who is crying or angry, or saysomething inappropriate to another peer or adult andbe absolutely unaware of its appropriateness. Amiddle-school Child with NLD might tell her mixed-gender peer group that the reason her friend isn't inthe room at that moment is "she is changing hertampon.

7 " He/she may tell a friend bluntly, "I am boredof you." or "You are fat."Academic performanceMarked lack of aptitude and proficiency in mechanicalarithmetic, reading comprehension, spelling, difficultieswith concept formation, problem-solving, andtransferring learning from one situation to a newsituation, are evidence with NLD. Academicachievement in mechanical arithmetic beyond a fifth-grade level is uncommon (Rourke, 1995). Commonelementary school math competencies, such as tellingtime and handling money, are difficult. Wordrecognition and sight reading are strong but overallreading comprehensive is not. The children may tellyou the story but not be able to describe the mainpoint, the main conflict, or the major is arduous and spelling errors are limitedalmost exclusively to a phonetic variety. As the childmoves into middle school, science becomes verydifficult because of the demand for more abstractthinking and to apply learning to new abilitiesMajor problems with visual-spatial organizationalabilities and visual memory are characteristic of with NLD have difficulty forming visual imagesand, therefore, don't revisualize as a strategy forlearning (Thompson, 1997).

8 The Child will focus on thedetails of what he or she sees and fail to grasp thewhole picture. These children also have very poorvisual memory, so they don't remember what they'veread or seen. This makes copying from a blackboardand recognizing people's faces difficult, and getting lostis very common. It also means that by middle school,homework takes more time as more writing andreading are required. As a result of visual-spatialproblems, many children with NLD meet the clinicalcriteria for attention deficit disorder (ADD) (Gross-Tsur,Shalev, Manor, & Amir, 1995). These children havedifficulty moving their bodies in space; they bump intopeople, stand too close, and have difficultyunderstanding spatial coordinationChildren with NLD exhibit gross and fine motorclumsiness as a result of poor proprioception andkinesthesia, often marked on the left side of the may have problems with reflexes, gaitabnormalities, tremors, and lack of coordination(Harnadek & Rourke, 1994).

9 The Child or adolescentwith NLD may spill and knock things over, bump intothings and fall, and bump into others beyond an agewhere this is appropriate. Problems using scissors andfastening buttons are common. The inability to learnhow to tie shoelaces is considered a pathognomonicsign (Heller, 1997). The Child with NLD frequently hasa faulty sense of balance, which affects his/her abilityto learn how to ride a bike, skate, and perform anyactivity that demands good balance. Standing on onefoot may not be possible. These children frequentlyavoid slides and Jungle-Gyms at an early tactile discrimination is another sign of NLD. Thechild may have less sensitivity for touch in his/herfingers and, therefore, have problems holding a pencilto functioningChildren with NLD have problems processing emotionalinformation. They have a difficult time interpretingemotional experiences of others and themselves.

10 Theirrisk for depression, isolation, and self-esteem problemsis high because they are unable to learn from pastexperience, including social interactions (Heller, 1998;Voeller, 1995).A Child with NLD may misinterpret a mild criticism orreproach from a parent as a major rejection and cryinconsolably for hours. A Child may get very excited,then suddenly become overwhelmed and cry. Theemotional intensity of the excitement and complexity offeelings may lead the Child to feelings of panic andsevere distress. These children are overwhelmedeasily by feelings. Children with NLD are oftendescribed as easily frustrated and chronically inflexible(Greene, 1998).Identifying Children with NLDTwo decades have passed since the early research onchildren with NLD (Thompson, 1997). Nonetheless,very few professionals today outside the fields ofneurology and neuropsychology understand orrecognize NLD. Presently there isn't a medical orpsychiatric diagnosis for NLD, although research isbeing conducted to clarify and refine a diagnosis(Rourke, 1995).