Running head: A REVIEW OF NONVERBAL LEARNING DISORDER

A Review of Nonverbal Learning Disorder

Melissa Martin
University of Calgary

A REVIEW OF NONVERBAL LEARNING DISORDER

Nonverbal Learning Disorder (NLD) is a neuropsychological syndrome where

deficits occur in the nonverbal domains of communication (Tanguay, 2001). In 1967,
Doris Johnson and Helmer Mykelbust first published the term in their book Learning
Disabilities (Molenaar-Klumper, 2002). Byron P. Rourke later researched and developed
NLD from a neuropsychological perspective in 1989 at the University of Windsor,
Ontario (Molenaar-Klumper, 2002). Since the conceptualization by Rourke, NLD has
gained significant attention in the field of school psychology.
The number of designations of nonverbal learning problems in students has been
increasing in recent years (House, 2002). However, NLD is not recognized as a unique
disorder in the DSM-IV-TR since it is not formally identified in any classification system
(Casey, 2012). This has led to conflicting opinions of how to assess, diagnose and treat
cases of NLD. Similarities between NLD and Aspergers Syndrome (AS) have also
prompted experts to question whether or not NLD is a separate disorder from AS (Miller
et al., 2004). There are also concerns to be raised about the future of NLD diagnosis in
regards to the upcoming changes in the DSM-V.
Symptoms and Characteristics of NLD
The term Nonverbal Learning Disorder is often misunderstood since it implies
that individuals with NLD may be poor communicators. On the contrary, those with
NLD actually have excellent verbal skills. NLD children have an extensive vocabulary
and may converse like an adult (Tanguay, 2002). Rourke (1990) identified NLD assets to
include auditory perception, simple motor thinking skills, and memorizing rote material
at the primary neuropsychological level. At the secondary level, individuals with NLD
acquire selective and sustained attention to simple, repetitive verbal material while at the

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tertiary level of neuropsychological assets, memory skills in rote verbal memory are well
developed (Rourke, 1990). Academically, students with NLD will typically have success
with single-word reading skills (decoding) along with single-word spelling-to-dictation
skills (Rourke, 1990). Memory for oral material is typically outstanding starting in
middle elementary and can continue into subsequent school years. These successes can
be attributed to the NLD childs well-developed auditory perception skills as well as their
ability to memorize auditory and rote material.
NLD deficits occur in the nonverbal realm of communication. Rourke (1990)
characterized the primary neuropsychological deficits as a lack of tactile perception,
visual-spatial perception, psychomotor coordination, and attention to stimuli. He also
noted secondary and tertiary deficits in visual attention, physical functioning, memory for
nonverbal detail, ability to internalize feedback, poor organization and lack of problemsolving skills. These verbal deficits include repetitive and verbose commentary and poor
pragmatics of psycholinguistic skills, such as speaking out of turn, talking at increased
volume or at inappropriate times (Matte, 1998). These can lead to a variety of academic
concerns. In early school years, the lack of psychomotor coordination can result in poor
graphomotor skills with difficulty in printing and cursive script, although with practice it
can improve (Rourke, 1990). Reading comprehension level is much lower than singleword decoding due to their lack of attention to visual input and issues with psychomotor
coordination.
NLD students also have difficulties in mathematics. Outstanding relative
deficiencies in written mechanical arithmetic, such as basic operations of
addition/subtraction and multiplication/division, are apparent in middle school years
(Rourke, 1990). NLD students are able to use calculators to determine basic calculations,

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however the development of higher level mathematical reasoning is diminished.

Lucangeli et al. (2010) studied the relationship between visual-spatial working memory
and arithmetic deficits in children with NLD. They determined that NLD students had
difficulty with pattern recognition, which is crucial for solving different types of
mathematical problems that involve the use of calculation patterns. Poor spatial abilities
among NLD students can lead to difficulty solving mathematical questions involving
spatial recognition. Despite these findings, Lucangeli et al. (2010) determined that
failure in visual-spatial working memory was the best discriminator of NLD rather than
difficulty on an arithmetic task. Therefore, mathematical difficulties may not be the most
accurate indicator of NLD.
Another noticeable deficit with NLD individuals is social competence. Rourke
(1990) reported socioemotional/adaptive deficits in social perception, social judgement,
and social interaction skills; where these deficits become more apparent as age increases.
The lack of socialization can result in those diagnosed with NLD to isolate themselves.
Social withdrawal could result in an increased risk of externalizing conduct disorders or
internalizing disorders such as anxiety, depression, and socioemotional disturbance
(Rourke, 1990). Semrud-Clikeman et al. (2010) determined that children with AS and
NLD experience difficulty understanding emotional and nonverbal cues in social
interactions that contribute towards feelings of loneliness and isolation. NLD also has
been linked to difficulty processing social cues, using emotional content to make social
inferences, and deficits in identifying facial expressions and gestures (Semrud-Clikeman
et al., 2010). Bloom and Heath (2009) also noted that children with NLD are worse at
recognizing facial expressions than children with verbal learning disabilities (LD).
However, their findings indicated that adolescents with NLD deficits might not be as

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severe in the recognition of facial expression and emotional processing as they get older.
However, adolescents with NLD do continue to experience social difficulties and have
trouble interpreting and understanding general nonverbal cues. Therefore, the risk of
social isolation for these adolescents is still present during and after puberty.
Etiology of NLD and Intervention Strategies
Byron P. Rourke was the first to establish a neuropsychological connection to NLD
in 1989. Rourke (1990) determined that the groups of children with various forms of
neurological disease, disorder, and dysfunction who manifest NLD include the following
categories:
1. Many children with moderate to severe head injuries who are able to undergo a
comprehensive neuropsychological investigation.
2. Most children with a hydrocephalic condition that was not treated promptly
and/or with success.
3. Survivors of acute lymphocytic leukemia and other forms of childhood cancer
who have received very large doses (treatments) of X-irradiation over a prolonged
period of time.
4. Children with congenital absence of the corpus callosum and who exhibit no
other demonstrable neurological disease process.
5. Children with significant tissue removal from the right cerebral hemisphere.
(p.369)
In regards to the right cerebral hemisphere, Rourke determined that NLD could be caused
by damage, disorder, or destruction of neuronal white matter in the brains right
hemisphere (Rissman, 2010). This damage could be caused by brain injury, spina bifida,
or what Rissman refers to as shunted hydrocephalus. The left hemisphere of the brain is

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in control of handling routine tasks and automated one-step plans that are easy for
individuals with NLD to interpret. Right hemisphere dysfunction is believed to affect
planning, organization, problem-solving abilities, processing social cues, following
multistep directions and the ability to generalize (Rissman, 2010). The right hemisphere
is believed to integrate information simultaneously from different senses to interpret
visual gestures and facial expressions along with dialogue to determine the appropriate
social cues. The left hemisphere is better equipped for rehearsed, rote learning presented
in a simple step-by-step manner (Rissman, 2010). The tasks of the left and right
hemispheres along with the dysfunction of the right hemisphere in NLD children may
provide a foundational explanation for the cognitive strengths and weaknesses in this
disorder. Rissman states that While neuroscientists are not in complete agreement about
the cause of the disorder, Rourkes (1995) White Matter, Right Hemisphere Deficit
hypothesis is commonly accepted as a way to understand the syndromes confusing
development and presentation. (Rissman, 2010, p.210).
Despite the deficits that a child with NLD must face, interventions must be set in
place to help these individuals to improve academically and socially. Unfortunately, the
research and development of intervention programs for NLD is limited (Matte and
Bolaski, 1998). Some suggestions that Matte and Bolaski (1998) discussed were active
reading strategies where pre-reading, chunking, paraphrasing, and self-quizzing can help
NLD students retain what they are reading. Children with NLD who translate common
phrases too literally may need to receive training to interpret these expressions into
sentences they are able to understand. Role-playing may also help an NLD student to
understand nonverbal actions of others and how to respond appropriately in socially
accepted mannerisms.

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Mamen (2007) provides a more recent perspective on what strategies are helpful in
helping these students overcome their difficulties, especially in the classroom. In order to
promote organization, Mamen suggests that teachers and parents need to have an NLD
student on a schedule where their learning materials are organized and easy to access.
The routine of being on a schedule can help the student adapt to a specific pattern of
handling daily tasks that can be repeated daily, such as coming to class with required
materials, taking a specific time in the day to complete homework, etc. It is important for
the NLD childs teacher to facilitate a close relationship with this student so that they can
regularly check in to make sure that they are keeping on task with their responsibilities.
Teachers and parents need to verbally prompt the NLD child instead of giving directions.
It is also important that these prompts are simple and concrete so that NLD children are
able to remember instructions on their own. Essentially, these strategies are meant to
create more independence and responsibility. In regards to reading and writing skills, it is
important for teachers to properly adapt an NLD students coursework by allowing extra
time to complete assignments, someone to read out a story while the student follows
along, allowing printing instead of writing, or the use of a keyboard to try and improve
the students grammar and spelling.
In regards to improving the socialization skills of individuals with NLD, Maman
(2007) suggests that parents and teachers can help train these children about nonverbal
cues by using verbal explanations of their meanings in relation to different social
contexts. This can be a long process but it can prevent future misinterpretations of these
social cues and can help the child to become more confident with socializing with his or
her peers. One exercise that Maman suggests is to have an NLD child watch a television
program with the sounded muted. They must watch the actions of the characters

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onscreen in order to interpret what is happening in the program. An adult can watch the
show and help answer questions or guide their interpretation of the nonverbal actions that
are occurring on the television. Parents and NLD children can also model nonverbal
behaviors by imitating facial expressions that are associated with corresponding
emotions. Regular use of these strategies in an organized environment where routine and
support are regularly provided can help students with NLD improve and possibly
overcome their deficits to try and achieve social and academic success.
Difficulties Categorizing and Diagnosing NLD
Learning disabilities (LDs) is a broad term that covers a wide range of
heterogenous disorders, as demonstrated by various scientific studies in the past 40 years
(Casey, 2012). The DSM-IV-TR provides domain-specific categories of disorders in
reading, mathematics, and written expression (American Psychiatric Association, 2000).
Casey (2012) identified disorders involving nonverbal cognitive processes to be less
understood and with no clear definitions. There is currently no NLD diagnosis included
in the DSM-IV-TR. House (2002) mentions the increasing trend of diagnoses of NLD
and how, in regards to the framework of the DSM-IV-TR, it is coded as Learning
Disorder NOS (not otherwise specified). It is important for the examiner to be able to
clearly identify the deficits within the childs ability framework. However, this can lead
to ambiguity and confusion over diagnosing NLD under the broad realm of LD-NOS.
The DSM-IV-TR states that LD-NOS is a category for LD disorders that do not meet the
criteria for any specific LD (American Psychiatric Association, 2000). In order to ensure
accurate diagnosis, a clear set of diagnostic criteria and definitions of NLD are needed in
contrast to generalized learning disorder GLD (Bloom and Heath, 2009).

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NLD also has a conflicting relationship with AS. Culotta et al. (1999) defined AS
as a Pervasive Developmental Disorder (PDD) characterized by impairment in social
interaction, emotional reciprocity, and the perception and use of nonverbal behaviors.
Restricted interests, stereotypic behaviors, and preoccupations may also be evident
(Culotta et al., 1999). These symptoms are almost identical to those of NLD. Culotta et
al. (1999) state that AS and NLD may represent varying degrees of severity on the same
neurobehavioral continuum. This raises the issue of whether or not NLD needs to be
classified under the realm of AS or PDD-NOS (not otherwise specified). SemrudClikeman et al. (2010) also note the confusion among the diagnostic differences between
AS and NLD. A central area of controversy is the definition and examination of NLD:
Many studies utilize an approach where the child must meet a selection of
symptoms from an array of possibilities in order to qualify for a diagnosis of
NLD. Although the NLD subtype continues to be refined, it is currently
characterized by three broad areas of dysfunction including motoric skills,
visual/spatial organization skills, and social abilities. (Semrud-Clikeman et al.,
2010, p. 510).
Spreen (2011) argues that these broad areas of dysfunction in NLD have little evidence to
support its use in clinical practice. The current classification system of NLD is
insignificant if professionals do not consistently meet the guidelines regarding diagnosis.
Otherwise, resulting diagnoses of NLD will not be reliable.

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The Future of NLD

Proposed changes to the upcoming DSM-V may lead to serious implications of the
definition, classification, and diagnosis of NLD. AS and PDD-NOS are proposed to be
subsumed under Autistic Spectrum Disorder (ASD) where this classification will include
autisms entire range of those who are high functioning to the extremely disabled
(American Psychiatric Association DSM-5 Development, 2012). NLD was hypothesized
to be included in the DSM-V as a separate and distinct coded disorder, but this will not be
the case (Life Development Institute, 2012). The previous category of LD-NOS in the
DSM-IV will be subsumed to the new category of Learning Disability, which was not
previously listed in the DSM-IV. It is unclear if NLD will continue to be used as a
possible diagnosis or if it will fall under this new umbrella term of Learning Disability. A
possible identity crisis of those previously diagnosed with NLD, AS, and PDD-NOS
could occur with the DSM-V changes (Life Development Institute, 2012). It may also
threaten the credibility of NLD as being considered a legitimate disorder.
Conclusion
NLD is an emerging diagnosis that is demanding more attention from educators
and psychologists (Matte & Bolaski, 1998). Discrepancies about the definition of this
disorder have resulted in uncertainty over what constitutes a diagnosis of NLD. There is
also a lack of intervention programs, which can be attributed to the confusion of the
fundamental basis of this disorder. The upcoming DSM-V does not recognize NLD as an
independent disorder. In order to become legitimate, more large-scale empirical research
on NLD is needed as well as the development of specific guidelines and clear diagnostic
criteria. Otherwise, the classification of NLD may disappear altogether and individuals

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who were previously diagnosed may not properly fit under the more general categories of
ASD and Learning Disability in the DSM-V.

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