Evidence-Based Reviews

Does your patient have a psychiatric illness or nonverbal learning disorder?

Current Psychiatry. 2011 May;10(5):17-36

References

1. Altarac M, Saroha E. Lifetime prevalence of learning disability among US children. Pediatrics. 2007;119(suppl 1):S77-S83.

2. Cooper S, Smiley E, Morrison J, et al. Mental ill-health in adults with intellectual disabilities: prevalence and associated factors. Br J Psychiatry. 2007;190:27-35.

3. Rourke BP, Young GC, Leenaars AA. A childhood learning disability that predisposes those afflicted to adolescent and adult depression and suicide risk. J Learn Disabil. 1989;22(3):169-175.

4. Little SS. Nonverbal learning disabilities and socioemotional functioning: a review of recent literature. J Learn Disabil. 1993;26(10):653-665.

5. Hubbard A, Smith Myles B. NLDA. Nonverbal learning disabilities. 2005. Available at: http://www.partnerstx.org/Resources/LD/NVLD.html. Accessed August 11 2010.

6. Drummond CR, Ahmad SA, Rourke BP. Rules for the classification of younger children with nonverbal learning disabilities and basic phonological processing disabilities. Arch Clin Neuropsychol. 2005;(20):171-182.

7. Palombo J. Nonverbal learning disabilities: a clinical perspective. New York NY: W.W. Norton & Company, Inc; 2006.

8. Wechsler D. Wechsler Intelligence Scale for Children. 3rd edition. San Antonio TX: The Psychological Corporation; 1991.

9. Wechsler D. The WISC-IV technical and interpretive manual. San Antonio TX: The Psychological Corporation; 2003.

10. Woodcock RR, Shrank FA, McGrew KS, et al. Woodcock-Johnson III Normative Update technical manual. Itasca, IL: Riverside Publishing; 2007.

11. Frazier TW, Demaree HA, Youngstrom EA. Meta-analysis of intellectual and neuropsychological test performance in attention-deficit/hyperactivity disorder. Neuropsychology. 2004;18(3):543-555.

12. Torres IJ, Boudreau VG, Yatham LN. Neuropsychological functioning in euthymic bipolar disorder: a meta-analysis. Acta Psychiatr Scand Suppl. 2007;(434):17-26.

13. Rourke BP. Neuropsychology of learning disabilities: past and future. Learning Disability Quarterly. 2005;(28):111-114.

14. Dhar M, Been PH, Minderaa RB, et al. Information processing differences and similarities in adults with dyslexia and adults with attention deficit hyperactivity disorder during a Continuous Performance Test: a study of cortical potentials. Neuropsychologia. 2010;48:3045-3056.

15. Gross-Tsur V, Shalev RS, Manor O, et al. Developmental right-hemisphere syndrome: clinical spectrum of the nonverbal learning disability. J Learn Disabil. 1995;28(2):80-86.

16. Strakowski SM, Adler CM, Holland SK, et al. Abnormal FMRI brain activation in euthymic bipolar disorder patients during a counting Stroop interference task. Am J Psychiatry. 2005;162(9):1697-1705.

17. Goldberg JF, Chengappa KN. Identifying and treating cognitive impairment in bipolar disorder. Bipolar Disord. 2009;11(suppl 2):123-137.

18. McDonough-Ryan P, DelBello M, Shear PK, et al. Academic and cognitive abilities in children of parents with bipolar disorder: a test of the nonverbal learning disability model. J Clin Exp Neuropsychol. 2002;24(3):280-285.

19. Mokros HB, Poznanski EO, Merrick WA. Depression and learning disabilities in children: a test of an hypothesis. J Learn Disabil. 1989;22(4):230-233,244.

20. Vieta E. Maintenance therapy for bipolar disorder: current and future management options. Expert Rev Neurother. 2004;4(6 suppl 2):S35-S42.

21. Stein MT, Klin A, Miller K. When Asperger’s syndrome and a nonverbal learning disability look alike. Pediatrics. 2004;114(suppl 6):1458-1463.

22. Klin A, Volkmar FR, Sparrow SS, et al. Validity and neuropsychological characterization of Asperger syndrome: convergence with nonverbal learning disabilities syndrome. J Child Psychol Psychiatry. 1995;36(7):1127-1140.

23. Volkmar FR, Klin A. Asperger syndrome and nonverbal learning disabilities. In: Schopler E, Mesibov GB, Kunce LJ, eds. Asperger syndrome or high-functioning autism? New York, NY: Plenum Press; 1998:107–121.

24. Lord C, Rutter M, Goode S, et al. Autism diagnostic observation schedule: a standardized observation of communicative and social behavior. J Autism Dev Disord. 1989;19(2):185-212.

25. Gilliam JE. Gilliam Asperger’s disorder scale: second edition. Austin TX: Pro-Ed; 2005.

26. Pennington BF. Diagnosing learning disorders: a neuropsychological framework. 2nd ed. New York NY: The Guilford Press; 1998.

27. Sundheim ST, Voeller KK. Psychiatric implications of language disorders and learning disabilities: risks and management. J Child Neurol. 2004;19(10):814-826.

28. Fletcher J. Nonverbal learning disabilities and suicide: classification leads to prevention. J Learn Disabil. 1989;22(3):176-179.

29. Williams KA, Kolar MM, Reger BE, et al. Evaluation of a wellness-based mindfulness stress reduction intervention: a controlled trial. Am J Health Promot. 2001;15:422-432.

30. Sanders KM. Mindfulness and psychotherapy. Focus. 2010;8:19-24.

31. Fisher NJ, DeLuca JW. Verbal learning strategies of adults and adolescents with syndrome of NVLD. Child Neuropsychol. 1997;3(3):192-198.

32. Thompson S. Developing an educational plan for the student with NLD. 1998. Available at: http://www.ldonline.org/article/Developing_an_Educational_Plan_for_the_Student_with_NLD. Accessed March 25 2011.

In adults, many of these subtle differences in language and thought process may be masked by years of difficult and frustrating communication, making definitive diagnosis challenging. Semistructured interviews, such as the Autism Diagnostic Observation Schedule²⁴ or the Gilliam Asperger’s Disorder Scale,²⁵ may help in differentiating Asperger’s disorder from NLD. However, these 2 disorders may be comorbid, thus complicating the diagnostic process.²¹

Table 2

Differences among NLD, ADHD, and bipolar disorder

Clinical features	NLD	ADHD	Bipolar disorder
Cognition	Impairment stable	Impairment fluctuates with attention	Impairment fluctuates with mood episodes
IQ	1.5 to 2 standard deviations between verbal and performance IQ	Full scale IQ within one standard deviation of healthy subjects	Independent of disorder
Experiential learning	Deficits present	Successful with treatment	Experiences influence behavior
Social competency	Mostly aware of shortcomings, a degree of mind sharing, empathy	Generally good, attentive to others	Generally good, when manic patients are ‘the life of the party’
Peer relationships	Often lack friends, victims of bullying	Often have friends	Often have friends
Motor coordination	Multiple impairments	No impairments (may be good at sports)	No impairments
ADHD: attention-deficit/hyperactivity disorder; IQ: intelligence quotient; NLD: nonverbal learning disorder Source: References 11,12

Table 3

Differences between NLD and Asperger’s disorder

Clinical features	NLD	Asperger’s disorder
Spatial cognition	Poor sense of direction	Precise sense of direction
Reading and math comprehension	Good word recognition and ‘word attack,’ with poor reading comprehension	Good
Interests	Intense interest in 1 topic for short periods, frequent changes	Idiosyncratic, repetitive, inflexible
Social competency	Mostly aware of shortcomings, a degree of mind sharing, empathy	Blames others for social difficulties, poor empathy
Regulation of affect	Often impaired, unaware when infringing on others’ personal space	May be impaired when anxious; fear of being in close proximity to nonfamily members
NLD: nonverbal learning disorder Source: References 21-23

Treatment implications

Clinical Point

Early recognition of NLD may, in some cases, prevent internalized psychopathology and loss of self-esteem

The day-to-day care of patients with NLD and a comorbid psychiatric disorder may include systems-level interventions, supportive psychotherapy, and psychopharmacologic treatments that are informed by the comorbid condition (Table 4).^7,26 Open, honest dialogue about strengths and challenges for individuals with NLD will help reframe expectations and frustrations. Early recognition of NLD may, in some cases, prevent internalized psychopathology and loss of self-esteem.^27,28

Children and adolescents with NLD require early intervention to help them function socially and academically. Involving family and school personnel is important to develop accommodations to improve functioning. Comprehension problems associated with NLD often become more noticeable as the student moves into upper elementary grades, where abstract thinking and the ability to manage novelty (eg, unfamiliar content or situations) are required. Many students with NLD can manage rote memorization and concrete facts, but have trouble with inference, integration, and reasoning. Academically appropriate classroom placement, limited writing, and use of voice recognition software may aid success. Parents can help by teaching and modeling social skills such as appropriate expression of emotions, which can be facilitated by watching movies or attending group activities together.

Clinical Point

Individuals with Asperger’s disorder will demonstrate restrictive interests or repetitive behaviors, a characteristic typically not seen in NLD

Adults. Patients with NLD may be late for appointments and often forget what is discussed. They may be at increased risk for noncompliance with pharmacotherapy for comorbid disorders and may require written instructions, frequent reminders, and reviews of treatment plan. In addition, interactions with clinicians may seem shallow and unsatisfying, despite the clinician’s best efforts to empathize. The pattern of feeling misunderstood likely exists in the patient’s other relationships, including significant others and employers. Although no systemic evaluations exist, mindfulness-based therapies might help alleviate this deficit.^29,30

Clinical Point

NLD patients’ interactions with clinicians may seem shallow and unsatisfying, despite the clinician’s best efforts to empathize

Treatment plans may involve family-focused modalities where NLD patients learn to rely on family members to interpret others’ motives and intentions.³¹ Education of the patient and family and friends should emphasize the need for consistent daily schedules and frequent verbal feedback, such as taking turns in conversations. Academic accommodations in college are crucial for success. Education experts have advocated for increased use of technology for students with NLD, including voice recognition software, laptop computers, and audio recordings of class notes.³²

Table 4

Treating patients with NLD

Remember that treating patients with NLD can be challenging
Clinical neuropsychological and psychoeducational assessments often are necessary
Employ open dialogue with patient and family about need for multifaceted approach
Recognize a patient’s individual strengths and weaknesses
Suggest academic and workplace accommodations
Provide written instructions and discuss your patient’s understanding of them
Suggest the use of frequent visual cues and reminders of scheduled tasks and appointments
Provide supportive psychotherapy and review the treatment plan frequently
Recognize the increased risk of suicide and develop a safety plan appropriate to your patient’s cognitive abilities
NLD: nonverbal learning disorder Source: References 7,26