Deficits of Nonverbal Communication in Children With Language

DEFICITS OF NONVERBAL

COMMUNICATION Diana Ignatova

Sofia University “St. Climent Ohridski”

DefinitionA Nonverbal Learning Disability (NVLD) is a developmental brain based disorder that impairs a child’s capacity to perceive, express, and understand nonverbal (nonlinguistic) signs.

The disorder is generally expressed as a pattern of impaired functioning in the nonverbal domains, with higher functioning in the

verbal domain.

Definition- The neuropsychological deficits associated with this disorder constrain children’s capacity to function in the academic, social, emotional, or vocational domain and lead to a heterogeneous set of neurobehavioural symptoms.

- The brain dysfunctions affect children’s behaviors their social interactions, their feelings about themselves and others, and their emerging personality patterns – all of which may manifest as symptomatic behaviours.

Discovery Johnson & Myklebust (1967) coined the term

nonverbal learning disability. The term referred to a residual group of children

who did not have verbal language problems but did have a range of symptoms that interfered with their school functioning.

Initially used the term “disorders of social imperception”, referring to: “a child’s lack of ability to understand his social environment, especially in terms of his own behaviour.”

Concluded that these children have a hard time understanding the meanings of other people’s social cues.

Gender Ratio

Reports have changed over time:- 1960’s – 5:1 (Rourke , 1989)- 1970’s – 2,8 :1 (Rourke & Strang, 1978)- 1989 – 1:1 (Rourke , 1989)

Changes thought to be due

to different evaluation criteria

Behavioural Perspective

Primary Assets

Simple Motor Skills – Simple repetitive motor skills are generally intact, especially at older age levels (middle childhood and beyond).

Auditory Perception – After a very early developmental period when such skills appear to be lagging, auditory – perceptual capacities become very well developed.

Rote Material – Repetition of auditory stimulus, is well appreciated.

Simple motor acts, including some aspects of speech and well practiced skills such as handwriting, eventually develop to average or above – average levels.

Secondary Assets

Attentional skills – deployment of selective and sustained attention for simple, repetitive verbal material (especially that delivered trough the auditory modality) becomes very well developed.

(Rourke, 2008)

Tertiary Assets Memory – Rote verbal memory and memory for material

that is easily coded becomes extremely well developed. Verbal Assets: Speech and Language

- Following an early developmental period when linguistic skills appear to be lagging, a number of such skills emerge and develop in a rapid fashion. These include good phonemic hearing, segmentation, blending, and repetition.

- Very well-developed receptive language skills and rote verbal capacities are evident, as are a large store of rote verbal material and verbal associations, and a very high volume of speech output. All of these characteristics tend to become more prominent with advancing years.

Academic Assets

Following initial problems with the visual-motor aspects of writing and much practice with a writing instrument, grapho-motor skills (for words) may reach good to excellent levels.

Following initial problems with the development of the visual-spatial feature analysis skills necessary for reading, good to excellent single-word reading skills also develop to above – average levels.

Misspellings are not specific. They are similar to the type seen most often in normal spellers.

Verbatim memory for oral and written verbal material can be outstanding in the middle to late elementary school years and thereafter.

Primary deficits Tactile Perception – Bilateral tactile-perceptual deficits are

evident, often more marked on the left side of the body. Deficits in simple tactile perception and suppression may become less prominent with advancing years, but problems in dealing with complex tactile input tend to persist.

Visual perception – There is impaired discrimination and recognition of visual detail and visual relationships, and there are outstanding deficiencies in visual-spatial-organization skills. Simple visual discrimination, /especially for material that is verbalisable/ usually reach normal levels with advancing years. Complex visual-spatial-organizational skills, especially when required within a novel framework, tend to worsen relative to age-based norms. (Rourke, 2008)

Primary deficits Complex psychomotor skills – Bilateral psychomotor

coordination deficiencies are prominent; these are often more marked on the left side of the body. These deficits, except for well-practiced skills such as handwriting, tend to increase in severity with age, especially when they are required within a novel framework.

Novel material – As long as stimulus configurations remain novel, they are dealt very poorly and inappropriately. Difficulties in age-appropriate accommodation to, and a marked tendency toward over-assimilation of novel events increase with the advancing years. There is an over-reliance on prosaic, rote ( inappropriate) behaviour in novel situations. The capacity to deal with novel experiences often remains poor and may even worsen with age. (Rourke, 2008)

Secondary deficits

Attention – Attention to tactile and visual input is poor. Relative deficiencies in visual attention tend to increase over the course of development, except for material that is programmatic and over-learned (e.g., printed text). Deployment of selective and sustained attention is much better for simple, repetitive verbal material (especially that delivered though the auditory modality) than for complex, novel nonverbal modality (especially that delivered through the visual or tactile modalities).

The disparity between attentional deployment capacities for these two sets of materials (simple, repetitive verbal material and novel nonverbal modality) tends to increase with age.

(Rourke, 2008)

Secondary deficits

Exploratory behaviour

During early phases of development, there is little physical exploration of any kind. This is the case even for objects that are immediately within reach and could be explored through visual or tactile means. A tendency toward sedentary and physically limited modes of functioning tends to increase with age.

(Rourke, 2008)

Tertiary Deficits Memory – Memory for tactile and visual stimuli is poor.

Relative deficiencies in these areas tend to increase over the course of development, except for material that is programmatic and over-learned (e.g., spoken natural language). Memory for non-verbal material, whether presented through the auditory, visual, or tactile modalities, is poor if such material is not easily coded in a verbal fashion.

Relatively poor memory differences between good to excellent memory for rote material and impaired memory for complex material and/or that which is not easily coded in a verbal fashion tend to increase with age.

(Rourke, 2008)

Tertiary Deficits

Deficits in concept-formation, problem-solving, strategy-generation, and hypothesis-testing/appreciation of informational feedback. Marked deficits in all of these areas are apparent, especially when the concept to be formed, the problem to be solved, and/or the problem –solving milieu is novel or complex. Also evident are significant difficulties in dealing with cause-and-effect relationships and marked deficiencies in appreciation of contrasts (e. g., age-appropriate sensitivity to humor).

Most noticeable when formal operational thought becomes a developmental demand (i.e., in late childhood and early adolescence), relative deficits in these areas tend to increase markedly with advancing years, as is evident in the often widening gap between performance on rote (over-learned) and novel tasks.

Linguistic Deficits

Speech and Language – Mildly deficient oral-motor praxis i.e. purposeful oral-motor movements), little or no speech prosody, and much verbosity of a repetitive, simple, rote nature are characteristic.

Content disorders of language , characterized by very poor psycholinguistic content and pragmatics (e.g., “cocktail party speech”) and reliance upon language as a principal means for social relating, information gathering, and relief from anxiety.

“Memory” for complex verbal material is usually very poor , probably as a result of poor initial comprehension of such material.

All of these characteristics, except oral-motor praxis, tend to become more prominent with advancing the years.

Academic Deficits

Grapho-motor – In the early school years, there is much difficulty with printing and cursive script; with considerable practice, handwriting often becomes quite good. However, some avoid practice and remain deficient in such skills.

Reading Comprehension

Reading Comprehension is much poorer than single-word reading (i.e., decoding). Relative deficits in reading comprehension, especially for novel material, tend to increase with advancing years.

(Rourke, 2008)

Academic Deficits

Mechanical Arithmetic and Mathematics

There are outstanding relative deficiencies in mechanical

arithmetic as compared to proficiencies in reading (word-recognition ) and spelling.

With advancing years, the gap between good to excellent

single-word reading and spelling and deficient mechanical

arithmetic performance widens.

Mathematical reasoning, as opposed to programmatic arithmetic calculation, remains poorly developed.

(Rourke, 2008)

Academic Deficits

Science Persistent difficulties in academic subjects involving

problem-solving and complex concept-formation (e.g.,

physics) are prominent.

Problems in dealing with scientific concepts and theories

become apparent by early adolescence.

The gap between deficiencies in this type of complex

academic endeavor and other, more rote, programmatic

academic pursuits widens with age.

(Rourke, 2008)

Psychosocial /Adaptational Deficits Adaptation in novel situation - There is extreme

difficulty in adapting to (i.e., countenancing, organizing, analyzing, and synthesizing) novel and otherwise complex situations.

An over-reliance on prosaic, rote (or inappropriate) behaviors in such situations is common. These characteristics tend to become more prominent and problematic with advancing years.

Social Competence – Significant deficits are apparent in social perception, and social interaction skills; these deficits become more prominent and problematic as age increases. There is a marked tendency toward social withdrawal and even social isolation with advancing years.

Psychosocial /Adaptational Deficits

Psychosocial Disturbance – Often characterized during early childhood. Such children are very much at risk for the development of internalized forms of psychopathology. Indications of excessive anxiety, depression, and associated internalized forms of psychosocial disturbance tend to increase with advancing years.

Activity Level – Children who exhibit the syndrome are frequently perceived as hyperactive during early childhood. With advancing years, they tend to characterized as normo-active and eventually hypoactive.

The Neuropsychological Perspective

History and Models

Early Studies Generaly pursued a hypothesis of right hemisphere

dysfunction. Focused on brain – damaged individuals who

displayed symptoms similar to NLD. Major validity questions:

- No uniformity among samples- No precise way to indentify type or location of brain

lesion

(Palombo, 2006)

Early Studies

Applied various labels :- Disorders of social perception (Johnson & Mykelbust,

1967)- Non-verbal Learning disability (Rourke, 1989; Johnson,

1987)- Social–Emotional learning disability (Denckla, 1983;

Voeller, 1986)- Right parietal lobe syndrome/developmental learning

disability of the right hemisphere (Weintraub & Mesulam, 1982)

- Right hemisphere deficit syndrome (Semrud – Clikeman & Hynd, 1990)

Rourke and Finlayson (1978)

GROUP 1 (RELATIVE ARITHMETIC WEAKNESS)

NVLD

GROUP 2

Performed worse on visuo-spatial skills measures.

Performed better on rote verbal and auditory processing measures.

Performed worse on rote verbal and auditory processing measures

Performed better on visuo – spatial skills measures.

Rourke & Finalson (1978)

Concluded that the arithmetic deficit group

(Group 1) represented a distinct population with a unique profile of neurological assets and deficits.

Suggested that the difference between Group 1 and Group 2 had to do with brain hemispheres

These Group 1 difficulties were due to dysfunction in the right cerebral hemisphere

The other group’s difficulties were related to left hemisphere skills.

Rourke (1987)

Found the NLD neuropsychological profile in children with other neurological conditions such as hydrocephalus, moderate to severe head injury, congenital absence of the corpus callosum, and post-radiation survival of childhood cancer.

The common feature of this group is not right hemisphere dysfunction, but white matter damage or dyfunction.

Rourke’s White Matter Model

NLD occurs when there is a problem with:

- The white matter in the brain- In the right brain hemisphere

Adverse conditions in early childhood are more likely to affect right hemisphere processing abilities because:

- The right hemisphere contains a greater proportion of white matter to grey matter then does the left hemisphere

- The right hemisphere is dominant in infancy

(Rourke, 1987; Rourke et al., 2002)

Hemispheric Specialization/Hemispheric Lateralization

Because many NLD symptoms appear to be the products of right hemisphere dysfunctions, that doesn’t necessarily mean that the left hemisphere and sub-cortical regions do not also contribute to those problems.

(Palombo, 2006)

Specializations of the Right Brain

Complex and Nonlinguistic Perceptual Tasks - Auditory abilities to recognize pitch and melody.

- Visual Discrimination such as the ability to recognize

faces, identify complex geometric shapes

- Visual-Spatial abilities necessary for depth perception,

spatial location, mental rotation, visual perspective

taking

-Visual-Motor abilities such as tracing mazes and block

design

-Spatial memory to recall complex spatial relationships

- Time perception

Many of these abilities are essential to successful social

communication

Specialization of the Right Brain

Paralinguistic Aspects of Communication

Decoding: the ability to read social signs such as

facial expressions and vocal intonation

Encoding: the ability to form mental representations

of social signs and store them in memory

Processing: understanding what the signs

communicate within the context in which they occur

Expression: retrieving the sign from memory

and producing it through some motor output

Specialization of the Right Brain

Emotional Perception

- Processing the perception of affect states

- Coordinating the expression of emotional tone

through paralinguistic communication

- Identifying the emotion behind other’s prosody and facial expressions

- Modulating affects involved in the development of social skills

Developmental Profile

NLD Through the Lifespan

(from Thomson, 1997)

Infant and Toddler Years

- Doesn’t explore the world motorically- Speech and Language develop early- Wants a verbal label for everything- No strong evidence of non-motor

developmental delay- Difficulties in early attempts to walk- Does not automatically assume a position

of balance when set down after being held- Clings to objects and people for balance- Constantly bumps into things

Preschool Years

- Exceptional rote verbatim memory skills

- Extremely verbose, talking “like an adult”

- Early reading skills, strong letter and

number recognition and spelling skills

- Understands statements and reading

very literally, views things as black and white

-Poor gross motor development and

motor planning skills

Middle School Years (11-14)

- Often excluded, teased, and persecuted at school

- Often are misunderstood by both teachers and peers

- Have difficulty meeting age-appropriate behaviour; /these difficulties may be attributed to

“emotional” issues/

- Have problems with work and study habits;

/these problems may be attributed to

“motivational” issues/

- Have visual-spatial-organizational difficulties,

difficulty using a locker,

finding the way around school or home is often lost or too tardy

High School Years (15-18)

- Peer Tolerance usually increases;

- One or two close friendships may develop or continue

- If an Individual Educational Program has been put

into place to accommodate the student, academic

achievement, which typically drops in middle school,

makes an encouraging comeback; if no IEP, this student

is at risk for dropping out of school

- Children still think in concrete and literal terms

- Slow to interact with the opposite sex

High School Years

- Early job experience and performance problems

are common

- Difficulty learning to drive

- Socially immature; may be seen as “weird”

by classmates

- Have low self-esteem; are prone to

depression, withdrawal, anxiety, and suicide

Child filters context through his/her unique neuropsychological

profile

Children with NLD :-Have difficulty with reciprocal exchanges

-Are socially immature

-Are argumentative and socially disruptive

-Have difficulty maintaining friendships

-Are often rejected by their peers

Clinical Data suggests that:

These children typically desire friends and relationships

with others. They are not capable of

deception and imaginary play.

A case study Alex, age 11, complained bitterly to his therapist that

kids continually teased him. When asked what they

said, he reported that they accused him of being cruel

and sadistic to his beloved cat. They said that

he enjoyed hurting the pet or that he had set fire to

his cat’s tail, none of which was true. His response

was to protest loudly that he was not that kind of

person and would never do such things to his pet.

However, his reaction only inflamed the other kids,

inciting them to escalate their teasing.

Why are these children so

often helpless to defend

themselves against taunting?

Where is the deficit?

Alex couldn’t get beyond the literal meaning of what his peers said; he

couldn’t see through their remarks to discern their motives Once these

motives were pointed out to him, he was able to take what the other kids said as

a “joke” and respond with his own brand of humor.

Differential Diagnosis

Is NLD really different from Aspergers?

NLD/Asperger Syndrome (AS)

NLD and AS are very similar in behaviors,

Neuropsychological profiles, and commorbid conditions.

“The process of differentiating the characteristics of

AS, and NLD, and a pragmatic language disorder, is arguable and may be the most challenging diagnostic task in developmental-behavioral pediatrics.

There is a lack of agreement of core definitions of

both disorders.

I. The following chart helps differentiate NLD children from children with AS or Pervasive

Developmental Disorder

Nonverbal Learning Disability

Asperger’s Syndrome

Pervasive Developmental

Disorder

Early Speech and Vocabulary

No Language Delay Speech develops, then forms plateau

Poor pragmatics and prosody

Poor pragmatics and prosody

Absence of pragmatic and prosody skills

Normal to superior I.Q.VI.Q.>NVI.Q.; verbal can be notably developed

Normal to superior I.Q. VIQ>NVIQ

Normal I.Q., then fails to maintain commensurate with peers

The following chart helps differentiate NLD children from children with AS or Pervasive

Developmental Disorder

Nonverbal Learning Disability

Asperger’s Syndrome

Pervasive Developmental

Disorder

Significant gross, fine and visual-motor problems; dysphagia

Clumsiness; gross motor is generally with normal line; fine motor is poor;

Coordination develops normally and generally remains with normal line;

Lacking Verbal Communication skills (receptive and expressive); poor social skills

Perserverating behaviors; restrictive areas of interest; hyper-focus on details

Restrictive; repetitive; stereotypical patterns of behavior

The following chart helps differentiate NLD children from children with Attention-

Deficit/Hyperactivity DisorderNonverbal Learning Disability Attention-Deficit/Hyperactivity

Disorder

Difficulty with spatial relationships and perceptions; frequently bumps into objects; may have difficulty with maintaining balance in seat.

Often fidgets or squirms; difficulty remaining still or seated when sustained visual attention is required.

Slow motor performance on non-verbal tasks with hyper-vigilance to details

Easily distracted and impulsive; poor planning and follow-through with details.

Talkative; reliant on verbal mediation; may not be aware of manipulation or deception.

Talks excessively; impatient and often loses things; may be manipulative and deceptive.

Poor social skills; frequent avoidance of novel situations.

Seeks out novelty with enthusiasm; risk-taking behaviors.

Comorbidity with depressive or anxious symptoms.

Comorbidity with oppositional and deviant behaviors.

Interventions

Psychomotor and Perceptual Motor Deficits

Remedial Interventions

Specific Training/practice in handwriting

accuracy and speed

Direct instruction in functional perceptual skills

such as:

- Reading facial expressions

- Understanding gestures

- Reading maps and graphs


Compensatory Interventions- Extended time for completing written work;

Using of keyboards for written work,

- Providing multiple choice rather than essay questions

when testing content knowledge

- Organizing worksheets with a limited number of

well-spaced prompts

- Providing teacher-prepared lecture guides

to minimize need for note-taking

- Use of oral or written directions and explanations

instead of visual maps and schemes.


Instructional/Therapeutic Interventions

- Adapted physical education with emphasis

on developing functional recreational activities.

- Early and sustained training and practice in

keyboard skills.

- Occupational therapy to enhance perceptual

and psychomotor deficits.

Arithmetic Deficits

Remedial Interventions:

- Direct instruction in computation using

verbal mediation to rehearse sequential steps

- Color-coded arithmetic worksheets to cue

left- right directionality

- Direct instruction in organizational schemes

and checking strategies

- Pre-teaching/re-teaching to reinforce and

distinct relationships among concepts.

Arithmetic Deficits

Compensatory Interventions

- Graph paper to assist in column alignment when

completing arithmetic problems

- Use of a calculator or matrix of arithmetic facts

- Chapter summaries or study guides

- Rehearsal strategies that rely on verbal mnemonic

devices

Instructional/Therapeutic Interventions

- Strategy training in specific skill areas, such as written

expression

- Graphic organizers, especially with sequential/linear

components

Problem-Solving Skills

- Remedial Interventions

- Direct Instruction and rehearsal of appropriate

responses in various situations

-Compensatory Interventions

-Reference List of rote “rules” to direct behavior

- Instructional/Therapeutic Interventions

Interpersonal Skills


- Direct instruction in social pragmatic skills, such as

making eye contact, greeting others, and requesting

assistance.

- Teaching strategies for making and keeping friends.


- Vocational guidance toward careers that minimize

interpersonal skill requirements.

- Choosing structured, adult-directed, individual or

single-peer social activities over unstructured or large

group events.

Social and Interpersonal Skills

- Instructional/Therapeutic Interventions

- Social Skills Training using published curricula

- For best results: target critical skills, match training to

individual behavioral deficits/excesses, train in

naturalistic settings and use practical oriented approach to

generalization.

- Teaching of interpersonal rules, training of social stories

- Pragmatic Language Therapy to address skills related to

topic maintenance, verbal self-monitoring, and appropriate

social communication.

Psychosocial Adjustment Problems


- Self-monitoring to reduce symptoms of inattention and

impulsive behavior.


- Investigation of the features of NLD syndrome in

preschool/primary age children who display ADHD

- Relaxation skills to compensate for pervasive anxiety.

- Increasing access to pleasant events to address depressive

symptoms

Psychosocial Adjustment Problems

Instructional/Therapeutic Intervention

- Educator/parent awareness training concerning risk

for depression and suicide.

- Student/parent counseling about NLD features,

interventions, and prognosis.

Cognitive/behavioral interventions to enhance

positive self-schema and reduce

cognitive distortions.

A General List of Recommendations for Children

with NLD- Provide extra time for in-class tests and assignments

- Provide extra assistance with understanding material (break it down, assist with highlighting, note general area and page numbers to assist with referencing, alphabet grid on desk to use as a quick reference for writing).

- Provide enough time for the student to respond, in order to compensate for the slow processing speed, both verbally and in writing.

- It is not uncommon for children to want to say something socially, or raise their hands to give an answer, but forget what they were going to say once it’s their turn.

A General List of Recommendations for Children with NLD

- Provide help with note taking to compensate for thedecrease in mental processing speed and organizational skills.-Modifying of the homework- Keep requirements for written output to a minimum. - Try not to let motor deficits block learning and academic success.- Preview material and use supplemental aids, such asoutlines, study guides, and highlighting, to allow thechild to benefit from instruction.


- Specifically teach study skill techniques.

- Use organizational techniques for keeping track of

material. A daily system of monitoring organization must be in place on a daily basis.

- Use verbal strengths to help with organization, problem-solving, and learning (such as self-talking).

- Encourage learning and using cognitive enhancement techniques.

- Provide a structured, predictable environment.

- Specifically discuss and prepare the child for transition and changes. It is often helpful to write out changes in the schedule so the child can refer to this when there is a question. This aids independence (because the child can refer to the schedule on his or her own) and also saves the

teacher or parent from repeating the plan again and again.


Accommodations for testing:- Minimize visual confusion on tests and answer

sheets. (e.g. remove decorative graphics and non-relevant visuals).- Use verbal testing as needed- Modify or eliminate timed tests.- Eliminate or break down abstract essay questions to a concrete

level with extraneous information eliminated.- Provide encouragement to participate in structured extracurricular

peer groups.- Verbally teach the child things that other students learn intuitively

or from observing.- Provide verbal interpretation of visual cues to help the child

understand social situations. Movies can offer good practice for this.

References

1. Lerner, J., (2000). Learning Disabilities:Theories,Diagnosis, and teaching strategies. Boston: HoughtonMifflin.

2. Palombo, J., (2006). Nonverbal Learning Disabilities: AClinical Perspective. NY: W.W. Norton & Company.

3. Rourke, B., (1989). Nonverbal Learning Disabilities: TheSyndrome and the model. N.Y: Guilford Press.

4. Shapiro, J. R. & Applegate, J. S., (2000). CognitiveNeuroscience neurobiology and affect regulation:

Implicationsfor clinical social work. Clinical Social Work Journal, 28, 9-21.

References

5. Stein, M. T., Klin, A., Miller, D., Goulden, K., & Coolman, R. (2004). When Asperger’s Syndrome and a Nonverbal Learning Disability look alike. Journal of Developmental & Behavioral Pediatrics, 25 (3), 190-195.

6. Telzrow, C. & Bonar, A. (2002). Responding to students with nonverbal learning disabilities. Teaching Exceptional Children, 34 (6) pp 8-13.

7. Thomson, S., (1997). The source for nonverbal learning disorders. East Moline, IL: Lingui Systems

NVLD Links

1. http:// www. nldline.com

2. http:// www. nldontheweb.org

3. http:// www. Udel.edu/bkirby/asperger

4. http:// www. Nimh.nih.gov/anxiety

5. http:// Idonline.org

Deficits of Nonverbal Communication in Children With Language

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