Byron Rourke Ph.D., LL.D., C. Psych.

, ABPP-CN,
FRSC, CM

1939-2011
“His talent, insight & courage bridged the
abyss of misunderstanding endured by
those challenged by NVLD. I had not had
the chance to meet him, nor the
opportunity to thank him for helping me to
be a better, more informed mother to &
advocate for my precious son.”
Education and training

● Windsor University – B.A. 1962

● Fordham University Ph.D., 1966
● Canada Council Pre-Doctoral Fellowships
Leadership

Founded multiple journals:

Child Neuropsychology, Journal of Clinical Neuropsychology and two more

Dedicated educator:

Clinical neuropsychology program at the University of Windsor

Served as the president of:

American Board of Clinical Neuropsychology, Division 40, the International Neuropsychological Society,
American Academy of Clinical Neuropsychology
Books

Rourke, B. P., & Fuerst, D. R. (1991). Learning disabilities and psychosocial functioning: A neuropsychological
perspective. New York: Guilford Press.

Rourke, B. P., Fisk, J. L., & Strang, J. D. (1986). Neuropsychological assessment of children: A treatment-oriented
approach. New York: Guilford Press.

Rourke, B. P., Costa, L., Cicchetti, D. V., Adams, K. M., & Plasterk, K. J. (Eds.). (1992). Methodological and
biostatistical foundations of clinical neuropsychology. Lisse, The Netherlands: Swets & Zeitlinger.

Rourke, B. P. (Ed.). (1991). Neuropsychological validation of learning disability subtypes. New York: Guilford Press.
Rourke, B. P. (1989). Nonverbal learning disabilities: The syndrome and the model. � New York: Guilford Press.
Journals
Rourke, B. P. (1987). Syndrome of nonverbal learning disabilities: The final common pathway of white-matter
disease/dysfunction? The Clinical Neuropsychologist, 1, 209–234.
Rourke, B. P., Young, G. C., & Leenaars, A. (1989). A childhood learning disability that predisposes those afflicted to
adolescent and adult depression and suicide risk. Journal of Learning Disabilities, 21, 169–175.
Rourke, B. P., Del Dotto, J. E., Rourke, S. B., & Casey, J. E. (1990). Nonverbal learning disabilities: The syndrome and a
case study. Journal of School Psychology, 28, 361–385.
Rourke, B. P. (1995c). The science of practice and the practice of science: The scientist-practitioner model in clinical
neuropsychology. Canadian Psychology, 36, 259–287.
Rourke, B. P. (1995b). Identifying features of the syndrome of nonverbal learning disabilities in children. Perspectives: The
Orton Dyslexia Society, 21, 10–13.
Rourke, B. P. (2008b). Is neuropsychology a (psycho)social science? Journal of Clinical and Experimental
Neuropsychology, 30, 691–699.
Rourke’s NLD Jeopardy

100 200 300

My 23-year-old son, who is said to exhibit NLD, is so bright!
How could he possibly have all of the problems associated
with NLD?
 “the problem here is that "brightness" defined solely in terms of well-developed language skills. Making
and maintaining friendships, adapting well to novel situations (social or otherwise), coping with changing
circumstances, and learning from experience on the job and elsewhere--all of these dimensions of
adaptive life in our society do not require a vast lexicon, endless talk regarding countless facts, or a
whole lot of school learning. These dimensions require adequate nonverbal problem-solving skills, the
capacity to utilize information of a nonverbal sort, and the self-confidence that comes with repeated
successes in adapting to changing circumstances. Unfortunately, the adult with NLD experiences very
much difficulty in developing such skills and attributes. Indeed, he usually exhibits outstanding deficits in
them. In these senses, he is not "bright"
Rourke’s NLD Jeopardy

400 500 600

What are the relationships among NLD, Asperger's
Syndrome (AS), and High Functioning Autism (HFA)?
(1) Virtually all persons with AS exhibit Definite or Probable NLD
(2) No persons with HFA exhibit Definite or Probable NLD.
Autism Spectrum Disorder
The Patient Zero - Donald T

- Leo Kanner in a 1943 paper Autistic Disturbances of Affective Contact

- The term originally was reserved for the inward and self-absorbed aspect of
schizophrenia
- Children with “extreme autistic aloneness, “delayed echolalia”, and “anxiously
obsessive desire for the maintenance of the sameness”, “intelligent”, “extraordinary
memory”
- First attempt to describe autism as a distinct syndrome.
- Emotional disturbance that does not affect cognition
Subsequent development

● 1952- included in DSM-II

○ As a form of childhood schizophrenia
○ Often thought to be related with poor parenting; “refrigerator mothers”
● 1980- updates in DSM-III
○ Pervasive developmental disorder/infantile autism- childhood disorder
○ Introduction of Pervasive developmental disorder- not otherwise specified (PDD-NOS)
○ Understanding of the condition as a spectrum and lifelong nature
● 1994- updates in DSM-IV
○ Five conditions - PDD-NOS, Asperfer’s disorder, Childhood disintegrative disorder, Rett syndrome
(primarily in girls), and autism
Current framework in DSM-5

● Autism spectrum disorder

○ Persistent impairment in social communication and social interaction
■ Atypical Social emotional reciprocity
■ Deficits in nonverbal communicative behaviors
■ Deficits in developing, maintaining, and understanding relationships
○ Restricted, repetitive patterns of behavior
■ Stereotyped or repetitive motor movements or speech
■ Adherence to routines
■ Fixated interests that are out of proportion
■ Hyper/hyporeactivity to sensory experiences
● Specifiers by level of support required
Aftermath of DSM-5 updates

● Changing terms means losing identity for some families and patients
● Continuation of treatment
● Research suggests the update can exclude people with milder traits, older
individuals, and girls.
● Allows dual diagnosis with ADHD and also with ID.
● Some people who were previously dx do not meet the diagnosis anymore criteria
Prevalence

● 1 in 54 children
● Consistently higher in boys than girls (4 x)
● Negatively correlated with intellectual disability diagnosis
● No racial difference between black and white children
○ Substantially lower in hispanic
● Diagnosis are being made earlier
○ Usually by age 4
○ Goal is to by 36 months
○ Can be as early as 18 months old
Key development milestones in infants

● 0-12 months
○ Recognizes own name
○ Plays games like peek-a-boo
○ Seeks comfort from familiar faces
○ Start to express emotions and react to it
○ May imitate sounds or facial movement
○ Stranger danger
○ First word
Key Developmental milestones in Toddlers

● 12-18 months
○ Understands no
○ Point to show something to the others
○ Sense of humor
○ Play best by themselves and do not want to share with other kids
○ Recognizes self in the mirror or from pictures
○ Imitates adults
○ Responds social overtures/pragmatics
○ Show frustrations easily
○ React to changes in daily routines
○ Wants to be independent
Different patterns of onset

1. Early onset - symptoms of unusual development emerge within the first year
2. Regression- loss of skills in one or more domains
a. 14-30months usually
b. “Nonverbal” type- loss of language skills learned previously
3. “late “ onset- normal/nearly normal development until it stops
a. Early language milestones are met, but word combination or the next level of synthesis is not happening
b. Plateau in development
Risk factors

● Family history ( a sibling with autism)

● Parental age at time of conception
● Maternal health
● Prenatal exposure to toxins and pesticides
● Birth complications
● Very low birth weight
● Epilepsy
Prognosis

● Outcome/prognosis varies
● High functioning individuals can have insights and improve their social functioning
● Early intervention is crucial
● Ritualistic behaviors and sensory sensitivities decrease with age
● Adaptive functioning also improves with age
● Less than half will attain some level of independence
● Lack of peer support networks and education/vocational program in adulthood
● The first cohort of ASD is becoming old, and research is lacking.
Neuropsychological profile

● Heterogeneity of cognitive and linguistic abilities

○ One study argued almost 2/3rds have an average or higher IQ
○ The other argued less than half of population fall within the ID range
● Higher Block Design, Matrix Reasning, Picture Concept
● Weaker Comprehension, Vocabulary and PSI
● Scores likely vary across the time
● Limited in their capacity to organize, plan, and execute movements
● Intact inhibition
● Relatively strong/intact sustained attention and CPT performance
● High perseveration and poor set-shifting
Neuropsychological profile

- Working memory is generally poor in non HFA

- Verbal working memory is better than visuospatial working memory
- But in general, verbal memory is poorer
- Recognition is generally intact
- Cues recall performance boost memories more so than in neurotypical population
- Autobiographical memory is poor
- Abnormal prosody and language pragmatics
- Semantics is often spared (vocabulary)
Molly
Molly

- Age : 3 years and 11 month

- Concern: Lack of social engagements
- No interests in playing with other kids
- No expression of desires/interests
- Extensive knowledge within the area of her interests (big cats)
- Pediatrician referred eval to assess thinking and learning abilities as well as her social and
behavioral functioning
Molly

● By 24 months, molly’s vocabulary was limited to 10 words

● Minimal progress with speech and language therapy
● Atypical language development
○ Sudden development of vocab (10 words to over 100 words) within several days
○ Repeating a lot of stuff said to her
○ Communication was off
● “Obsessive” play routine
● Molly’s own routine
● Repetitive behaviors - hold three fingers up and look at them for several seconds while tapping
two fingers together on both hands
● Tendency to eat inedible items
Molly

● Peaked interests in animals and words

○ Impressive ability to memorize details about stories, movies but not the overall pilot
● Inconsistent following of instructions
● Uncanny knack for learning and remembering the alphabet
Assessment components

● Clinical interview
● Neuropsychologist observing her play behaviors with each parent
● Tests
Behavioral observation

● Often fidgety but able to return to tasks

● Echoed many of the phrases verbatim
● Using phrases one might use in school
● Made minimal eye contact, gestures, or facial expressions
● Attention and compliance were largely adequate
Play interactions

1) Structured -
- No eye contanct
- No novnverbal communication during collaborative tasks
- No spontatenous addition to the conversation ( no rallying happening)
- Frequent echoleia

2) Less structured
- repetitive play
No joint attention
Repretitive behaviors suggesting she felt stress
Echoleia
Summary

● Intact cognitive functioning

● Motor scores were variable
● Attention and executive functioning somewhat lower than expected for her age
● Language functioning- less well developed structure in language and pragmatic use of, but intact
basic skills
● Adaptive functioning is characterized by weakness in socialization skills