NONVERBAL LEARNING DISABILITY & ASPERGER’S DISORDER
LINDA C. CATERINO, PH.D., ABPP ARIZONA STATE UNIVERSITY Objectives
1. Participants will learn the specific neuropsychological characteristics of individuals with Nonverbal Learning Disabilities (NLD).
2. Participants will learn the current status of the support for the diagnosis of NLD.
3. Participants will learn the specific diagnostic criteria for Asperger’s Syndrome (AS).
4. Participants will learn about differential diagnosis regarding NLD and AS. History - Gerstmann Syndrome
Josef Gerstmann- Austrian-American neurologist st Wrote 1 published article on Gerstmann Syndrome
Symptoms
Finger agnosia
Right-left orientation confusion
Acalculia Johnson & Myklebust
Proposed a nonverbal type of disability characterized by absence of serious language problems and adequate or above skills in reading and writing, Higher verbal than performance IQ Problems in visual-spatial processing Spatial orientation, right-left orientation, body image, motor learning Difficulties in temporal perception Handwriting Mathematics Distractible Perseveration Disinhibition
Deficiencies in social perception - “unable to comprehend the significance of many aspects of his environment”
(Myklebust, 1967;Johnson &Myklebust, 1975; Boshes & Myklebust, 1964) Byron Rourke
Neuropsychology of Learning Disabilities: Essentials of Subtype Analysis (1985)
Syndrome of Learning Disabilities: Neurodevelopmental Manifestations (1995)
Identified a group of children with a pattern of neuropsychological strengths and weaknesses Rourke’s Description of NLD
Neuropsychological assets in auditory perception, auditory attention, and auditory memory, especially for verbal material. Adequate skills in rote verbal memory & language, amount of verbal associations and language output. Poor visual-spatial organizational, psychomotor, tactile- perceptual, and concept formation skills, simple motor skills may be well developed Academic assets = single-word reading & spelling. Academic difficulties in (e.g., arithmetic, science) Difficulties in informal learning (e.g., as transpires during play and other social situations). Psychosocial deficits, primarily of the internalized variety, are usually evident by late childhood and adolescence and into adulthood. Cognitive/Neuropsychological
Deficiencies Strengths PIQ
(1) Less than two errors on simple tactile perception and suppression vs. finger agnosia, finger dysgraphesthesia, and astereognosis. Simple composite greater than 1 SD below the mean. Simple tactile-perceptual skills are superior to complex tactile-perceptual skills. (2) WRAT /WRAT -R standard score for Reading is at least 8 points greater than Arithmetic. Single word reading is superior to mechanical arithmetic. (3) Two of WISC/WISC- R Vocabulary, Similarities, and Information are highest of the Verbal scale. Straightforward and/or rote verbal skills are superior to those involving more complex processing (e.g., Comprehension).
(4) Two of WISC/WISC -R subtests Block Design, Object Assembly, and Coding subtests are the lowest of the Performance scale. Complex visual-spatial-organizational skills and speeded eye-hand coordination are impaired. (5) Target Test at least 1 SD below the mean. Memory for visual sequences is impaired. (6) Grip strength within one standard deviation of the mean or above vs. Grooved Pegboard Test greater than one standard deviation below the mean. Simple motor skills are superior to those involving complex eye-hand coordination, esp. under speeded conditions. (7) Tactual Performance Test Right, Left, and Both hand times become progressively worse vis-à-vis the norms. Complex tactile-perceptual and problem-solving skills under novel conditions are impaired. (8) WISC/WISC -R VIQ > PIQ by at least 10 points. Verbal skills are superior to visual-spatial- organizational skills.
The following criteria are currently under investigation: 7 or 8 of criteria = definite NLD
5 o 6 of criteria = probable NLD
3 or 4 of these criteria - Questionable NLD
1 or 2 of these features: Low Probability of NLD
Drummond, C. R., Ahmad, S. A., & Rourke, B. P. (2005). Rules for the classification of younger children with Nonverbal Learning Disabilities and Basic Phonological Processing Disabilities. Archives of Clinical Neuropsychology , 20 , 171 -182. Rourke’s Proposed ICD Criteria
Bilateral deficits in tactile perception, usually more marked on the left side of the body.
Bilateral deficits in psychomotor coordination, usually more marked on the left side of the body.
Extremely impaired visual-spatial-organizational abilities.
Substantial difficulty in dealing with novel or complex information or situations. A strong tendency to rely on rote, routinized approaches and memorized responses (often inappropriate for the situation), and failure to learn or adjust responses according to potentially corrective informational feedback.
Impairments in nonverbal problem-solving, concept-formation, and hypothesis-testing. Rourke’s Proposed ICD Diagnostic Criteria for NLD
Distorted sense of time. Estimating elapsed time over an interval and estimating time of day are both notably impaired. Well-developed rote verbal abilities (e.g., single-word reading and spelling), frequently superior to age norms, in the context of notably poor reading comprehension abilities (particularly evident in older children). High verbosity that is rote and repetitive, with content/meaning disorders of language and deficits in the functional/pragmatic dimensions of language.
Substantial deficits in mechanical arithmetic and reading comprehension relative to strengths in single-word reading and spelling.
Extreme deficits in social perception, social judgment, and social interaction, often leading to eventual social isolation/withdrawal. Easily overwhelmed in novel situations, with a marked tendency toward extreme anxiety, even panic, in such situations. High likelihood of developing internalized forms of psychopathology (e.g., depression) in late childhood and adolescence. Primary Neuropsychological Assets Primary Neuropsychological Deficits Auditory Perception -- Simple Motor Tactile Perception – Visual Perception Rote Material Complex Psychomotor --- Novel Material
Secondary Neuropsychological Deficits Secondary Neuropsychological Assets Tactile Attention -- Visual Attention Auditory Attention --Verbal Attention Exploratory Behavior
Tertiary Neuropsychological Deficits Tertiary Neuropsychological Assets Tactile Memory -- Visual Memory Auditory Memory --Verbal Memory Concept Formation -- Problem Solving
Verbal Neuropsychological Assets Verbal Neuropsychological Deficits Phonology – Verbal Recognition Oral-Motor Praxis-- Prosody Verbal Repetition – Verbal Storage Phonology-Semantics --Content Verbal Associations – Verbal Output Pragmatics -- Function
Academic Assets Academic Deficit Graphomotor (late)/Word Decoding Graphomotor (Early)/Reading Comprehension Spelling/ Verbatim Memory Mechanical Arithmetic/Mathematics Science Socioemotional Assets Socioemotional Adaptive Deficits Adaptation to Novelty/Activity Level Social Competence/Emotional Stability Palombo – 4 Types of NLD
1) core deficits in processing complex and nonlinguistic perceptual tasks who also develop social problems (perceptual + social) 2) meet subtype 1and also have neuropsychological deficits in attention & executive functioning ( perceptual + social + EF) 3) meet subtype 1and have social cognition impairments that manifest in reciprocal social interactions, social communication and emotional functioning (perceptual + social + emotional) 4) meet subtype 2 and have same social cognition impairments as subtype 3 (perceptual + social + EF + 4 Subtypes of NLD
Davis & Broitman (2011) All children with NLD have significant visual-spatial and executive function difficulties st 1 Core subtype have visual-spatial executive functioning, mild social and academic difficulties nd 2 Children with visual & executive functioning difficulties that significantly impact their social functioning rd 3 Children with visual & executive functioning difficulties and significant academic problems th 4 Children with visual-spatial, executive functioning, social and academic difficulties where all areas are functionally impaired Davis & Broitman
4. All areas impaired
2. Visual- 3. Visual- Spatial spatial Executive Executive Functionin g that Functionin significantl g y impact Significant social Academic functioning Problems
1. Visual –Spatial Executive functioning Mild social & Academic Difficulties Hale & Fiorello (2004)
2 types
Executive novel problem solving - frontal
Posterior visual-spatial holistic problem solving- right hemisphere Specific Characteristics - Cognitive
WISC-III - VIQ greater than PRI by 10 standard score points or more
80% have highest standard scores on Information, Similarities or Vocabulary
90% had lowest scores on Block Design, Object Assembly, Coding (Drummond, et al., 2005)
Deficits in:
Perceptual and Quantitative Reasoning,
Theory of Mind Attention
Attentional Problems – maybe due to Visual Perceptual and tactile difficulties (Rourke, 2000)
Auditory verbal attention intact
Problems with Sustained Visual & Divided Attention
Tend to be diagnosed with ADHD: Predominately Inattentive type (ADHD–PI) but may not be true ADHD (Semrud-Clikeman, 2007). Executive Functioning
Hypothesis generation
Flexible problem solving;
Self-monitoring;
Behavior regulation;
Integration of emotion with context Speed and Efficiency of Processing
Assets -- auditory verbal including sustained auditory attention, reading speed for simple words, and rapid oral word association
Deficits -- visual attention, tracking, matching, decision making speed, verbal-visual naming, color naming and writing speed Memory & Learning
Assets - auditory verbal learning and memory
Deficits - in visual-visual verbal learning, visual immediate, visual spatial working memory, delayed and long term recall of visual information, Tactile-Kinesthetic Learning and Memory; Location Memory Visual Processing Deficits
Visual Perception;
Scanning-Tracking;
Figure-ground disturbance
Visual-spatial
Constructional Sensory-Motor Deficits
Tactile-Kinesthetic;
Tactile Defensiveness;
Motor Sequencing,
Strength
Gross motor coordination (skipping, bike riding, jump roping)
Fine Motor coordination (handwriting, coloring, cutting, tracing, fastening, fine motor speed & dexterity)
Complex psychomotor tasks, Language
Asset - but language is pedantic, rote
Poor prosody and high verbal production NLD Communication Difficulties
May not under- Problem stand s Problems May Lack decodin social Concrete of g reading lack Nuances interpretation Expressiv Good gestures, Receptive prosodic facial sense vocabular facial in expressio of e expressions or y or conver- ns and of metaphors sation vocal vocal gestures intonations (lack intonation humor s of tact) Social Deficits
Facial recognition and emotional expression (visual attention/memory) (Corbett & Constantine, 2006; Fine, Semrud- Clikeman, Butcher, & Walkowiak, 2008; Rourke, 2000)
Emotional nuancing in communication; poor receptivity to feeling states and states of others;
Poor prosody and high verbal production does not promote positive social feed back
Social judgment secondary to problems with reasoning & concept formation
Adaptation to novelty
Comprehension of humor deficits observed in NLD group with social perceptual difficulties (not in NLD group with just visual- spatial difficulties)(Semrud-Clikeman et al., 2008) NLD Social Difficulties
Limited peer Problems Socially interaction, prefer Difficulty one-to-one forming reading awkward & interaction,, prefer social cues younger peers friendships inappropriate
May Bossy, withdraw Rigid, Disruptive aggressive or rule-bound play & defensive isolate with peers
Problems Problems Problems forming with close with interpersonal personal adaptability attachments intimacy Emotional
At risk for internalizing problems, e.g., anxiety & depression (Rourke, 1989; Little, 1993) Depression (Cleaver & Whitman, 1998) Children with sxs of right hemisphere white matter dysfunction had arithmetic difficulties and showed significant levels of depression Petti et al. (2003) found that children with NLD had a higher percentage of internalizing diagnoses among children at psychiatric treatment facilities.
Higher risk for suicidal behavior as compared to other LDs (Rourke,1989; Bigler,1989; Fletcher, 1989; Kowalchuk & King,1989) -based on extremely small Emotional
Greenham (1999) – evidence not clear if emotional problems are cause or consequence Most individuals with NLD do not develop psychological problems, and very few commit suicide (Greenham 1999).
Bloom & Heath (2010) compared 23 12- to 15-year olds with NLD with 23 matching children with “general learning disability” (GLD) and 23 typicals Self-report scale, an adolescent depression scale, Facial affect recognition measure, Ability to make six different facial expressions Understanding of facial expressions. GLD did more poorly on recognition, expression, and understanding of emotions NLD group did not differ from the typical group Co-morbidity- ADHD
Higher rates of ADHD (e.g., Gross-Tur, Shaleve, Manor, & Amir, 1995; Voeller, 1986) NLD Emotional Difficulties
Self critical, Lack of empathy perfectionistic, Anxious, worried or compassion lack self- confidence
Increased risk Problems Easily for depression modulating frustrated, loses & suicide affect control Academic Assets Deficits th Arithmetic (rarely achieve >6 grade level, May initially have trouble even as adults (Rourke, 1995), number with letter or number alignment recognition & learning Word problems (money, msmnt., esp. time– letter-sound relationships calendar & clock); Quantitative analysis & size, weight & then become good distance estimation readers Physics , Hypothesis testing May lose place in rdg. Organization Spatial representation of abstract nonverbal Good spelling skills concepts (graphs, diagrams) Average or above Written expression early problems with orthograhic identification of letters spelling, average in verbal graphomotor tactile and constructional language skills deficits that affect legibility & accuracy Reading comprehension for complex Good syntax reading material (e.g., main idea & inferences),problems understanding Good rote memories characters/motives Problems generating Story Retelling, question response (Worling, ideas for essays, but Humphries, & Tannock, 1995) Handwriting NLD Assets and Liabilities
Domain Assets Liabilities Sensory-Motor Auditory-Verbal Tactile-Kinesthetic; Tactile Defensiveness; Motor Sequencing, Coordination, strength Attention Sustained Auditory; Sustained Visual, Divided Attention Rote Recall, Verbal Visual-Spatial None Visual Perception; Scanning-Tracking; Constructional Language Verbal Prosody, Semantics; Content; Comprehension; phonological; Expressive, receptive, and repetitive Memory & Learning Auditory-Verbal; Visual Immediate, Working; Delayed, Learning & Memory Recognition, Visual-Verbal Learning; for Rote Information Tactile-Kinesthetic Learning and Memory; Location Memory NLD Assets & Liabilities
Domain Asset Liability Executive Verbal Problem Solving Hypothesis generation and flexible problem solving; self- monitoring; behavior regulation; integration of emotion with Context Speed & Verbal-Auditory; Word Retrieval; Visual Tracking and Matching; Efficiency of Rapid Verbal Word Association Verbal-Visual Naming; Color Cognitive Naming; Writing Speed Processing General Cognitive Verbal Reasoning Perceptual and Quantitative Reasoning, Theory of Mind
Academic Literal Comprehension; Decoding; Mechanical Arithmetic; Achievement Verbal Arithmetic; Spelling Science; Writing; Gist Reading Comprehension
Social-Emotional General Knowledge; verbal skills Language Pragmatics; Nonverbal Cues & Behavior; Social Judgment Early Signs of NLD 0-6 years
A. Delays in reaching all developmental milestones, including acquisition of speech, followed by a late, but rapid development of speech & other verbal abilities (particularly rote skills), usually to above-average levels. May speak in a monotone. B. Below normal amount of exploratory behavior. An apparent aversion for any type of exploration of new stimuli/situations. C. Impaired development of complex psychomotor skills (e.g., climbing, walking). D. Avoidance of novelty & preference for highly familiar objects, situations, & information. E. Preference for receiving information in verbal as opposed to visual format.
F. Strength in rote verbal memory (e.g., reciting the alphabet). Intelligence may be overestimated.
G. Deficits in perception and attention in both the visual and tactile domains.
H. Notably better auditory-verbal memory than visual or tactile memory.
I. Initial problems in oral-motor praxis, and longstanding, mild difficulties in pronouncing complex, polysyllabic words.
J. Frequently described as “inattentive”. Characteristic Evident in Older Children (> 7 Years)
A. Impaired capacity to analyze, organize, and synthesize information, with associated impairments in problem-solving and concept-formation. B. Despite high levels of verbosity, very significant impairments in language prosody, content, & pragmatics. “Cocktail-party" speech patterns, with high volume of verbal output but relatively little content (meaning) & very poor pragmatics. C. Strengths in single-word reading/recognition , but may have problems with tracking (30% of NLD children need to be retrained to read fluently) & reading comprehension. D. Problems in arithmetic. E. Fine motor problems, coloring, cutting,& handwriting in early school years, often improving to normal levels but only with considerable practice. F. Deficient social perception, social judgment, and social interaction. Poor perception & comprehension / interpretation of facial expressions of emotion, and marked deficits in providing non-verbal communication signals. G. May develop stress, anxiety, obsessional preoccupation, depression, self esteem, attentional problems (Palomobo & Berenberg, 1999) H. With advancing years, a tendency to become normoactive and then hypoactive. Problems in "attention" in formal and informal learning environments tend to disappear as the situational stimulus and response demands become more verbal in nature. Middle & High School
A. Social skills deficits even more important, difficulty getting along with peers & teachers
B. Math & science even more challenging
C. More emphasis on executive functioning in written expression and reading
D. Increased risk for psychiatric disorders such as depression (Mokros, Poznanski, &Merrick, 1989)
E. May do well in learning a foreign language, drama, language arts
F. Transition planning becomes essential Etiology
NLD is the phenotype that may be due to various causes
Hydrocephalus
Agenesis of the Corpus callosum
Turner’s Syndrome
Fragile X
Asperger’s Syndrome
Williams Syndrome – similar strengths & weaknesses (Don,Schellenberg, & Rourke, 1999) = WS lower cognitive
Neurofibromatosis
Velo-cardio-facial syndrome 22p-11q deletion (Lepach, A. C. & Peterman, F. 2011).
leukomalacia
spina bifida Etiology
Rourke presumed ‘right hemisphere’ dysfunction largely secondary to sub-cortical white matter differences and more association cortex
Findings from existing neurological cases does suggest involvement of the right hemisphere and possibly of white matter (Voeller, 1995).
Further study is needed to determine the validity of the right hemispheric white matter hypothesis in NLD. Etiology
Filley, 2001
“the NLD syndrome remains a theoretical construct, and there is little documentation of right hemisphere damage in white (or gray) matter in children with this disability” (p. 262).
“the relevance of the NLD syndrome to the behavioral neurology of white matter must remain conjectural” (p. 204).
“careful correlation with neuroradiologic or neuropathologic data [is necessary] . . . to confirm or deny that white matter pathology is in fact present” (p. 262). Etiology
Semrud-Clikeman &Fine (2011) found greater number of cysts on MRIs in children with NLD as compared to children with AS & controls
¼ (7) of NLD had cysts or lesions, generally in the posterior region--occipital/cerebellar or parietal regions (visual spatial perception), equally in the right and left hemispheres and bilateral in the cerebellum.
Not found as frequently in children with Asperger’s syndrome or with controls.
One child w/Turner syndrome in the sample did not have a cyst/lesion.
May be a structural abnormality or a genetic disorder that underlies the expression of nonverbal learning disability. Asperger’s Syndrome History
Described in 1944 by a Viennese pediatrician, Hans Asperger (1906-1980), Asperger Syndrome (AS) “autistic psychopathy” Asperger identified a special group of children (4 boys aged 6 to 11) with normal cognitive & linguistic development, but poor social skills Impairment in nonverbal communication, vague facial expressions, limited gestures, limited, exaggerated or inappropriate language Verbal communication idiosyncratic, precise quality Misunderstanding of humor Intellectualization of affect Clumsiness & poor body awareness Special interests Conduct problems Familial patterns Gender patterns (more males)
Increased anxiety & fear Lorna Wing, MD
British psychiatrist Coined the term “Asperger’s syndrome” & proposed formal diagnostic criteria 1979 conducted an epidemiological study in London Triad of Impairments: Impairment of social interaction Impairment of social communication
Impairment of social imagination, flexible thinking and imaginative play DSM-IV-TR Diagnostic Criteria
299.80 Asperger’s Disorder A. Qualitative impairment in social interaction, as manifested by at least two of the following: 1. marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction 2. failure to develop peer relationships appropriate to developmental level 3. lack of spontaneous seeking to share enjoyment, interests, or achievements with other people 4. lack of social or emotional reciprocity Diagnostic Criteria Continued…
B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: 1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus 2. apparently inflexible adherence to specific, nonfunctional routines or rituals 3. stereotyped and repetitive motor mannerisms 4. persistent preoccupation with parts of objects Diagnostic Criteria
C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning. D. No clinically significant general delay in language. E. No clinically significant delay in cognitive development or in the development of age appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood. F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia. AS - Social Impairments
Extremely May not like Inability to engage egocentric; self- physical contact in appropriate play centered
Failure to develop Lack of developmentally Socially awkward spontaneously appropriate peer seeking enjoyment relationships
Difficulty understanding Limited desire for other people’s social contact expressions & feelings AS - Motor Impairments
Delayed Odd Motor Acquisition of Mannerisms Motor Skills
Poor Impaired Manipulative mirror-image skills imitation
Poor Coordination & Balance AS - Sensory Impairments
Sensitivity to Sensitivity to Tactile Pain and taste and Sensitivity Temperature texture of food
Sound sensitivity- 3 types of noises: • 1. sudden, unexpected noise (telephone ringing, Visual dog barking, clicking of a pen) Sensitivity to • 2. high pitched, continuous noise (hair dryer, Certain Colors vacuum cleaner, mix-master) • 3. confusing, multiple sounds (shopping centers, large classrooms)
Synaesthesia • A sensation in one sensory system and as a result experiences a sensation in another modality • “Colored hearing” – seeing colors when hearing a sound AS – Language Impairments
Poor prosody, May have no language Adult like monotone, strange delay; Well developed intonation, rate (too speech/’little speech but poor fast), volume (too loud), communication professors poor fluency.
Poor ability to initiate Monologue type speech; Difficulty understanding and sustain egocentric metaphors/idioms/jokes conversation with peers conversational style
Lack of tact Echolalia Emotional Co-morbidities
Eating Disorders Depression ADHD
Substance Use ODD Bipolar Anxiety (GAD, PTSD, Social Phobias, Phobias, OCD, PTSD Other Co-morbidities
Seizure Tourette’s Learning Disorders & Tics Disabilities
Developmental Coordination Hyperlexia Disorder Other Characteristics
Rigidity in rituals Above Average & routines Rote Memory
Intense Interest Executive in circumscribed Function Deficits subjects Nonverbal Learning Disability & Asperger’s Syndrome NLD & AS
NLD profile is often associated with AS (@80%), but AS is not always associated with NLD Individuals with AS present with virtually all characteristics of NLD (Rourke, 2000)
Most children with AS have a NLD profile, but not all children with NLD have AS
Both NLD & AS have problems with social communication, and reciprocity, nonverbal communication, pragmatic language, and visual-spatial skills (Gunter, Ghaziuddin, & Ellis, 2002; Voeller, 1995).
Stronger verbal compared to performance skills on cognitive testing were found for children with AS or NLD (Gillberg & Billstedt, 2000; Klin et al., 1995). NLD & AS
Pennington (1991) –Rourke took 2 different groups & conflated them 1 group problems with spatial cognition 1 group problem with social emotional only first group should be called NLD Second group should be on autistic spectrum Pennington (2009)reviewed NLD again “in sum, we do not have sufficient evidence to accept it as a valid learning disorder apart from either autism spectrum disorder (ASD), mathematics disorder (MD) or developmental coordination disorder (DCD) all of which are covered in the DSM-IV-TR (ASD in the category of PDDs)” (p. 248). NLD vs. AS
Palumbo (2001)- hypothesized that AS & NLD could be 2 different subtypes of the same syndrome
Children with Asperger’s Syndrome have more profound social difficulties than children with developmental NLD (Thompson 1997).
NLD & AS could be on a continuum of severity ranging from NLD to Asperger’s and finally autism (Roman, 1998) NLD & AS (Klin, Sparrow, Cicchetti, & Rourke, 1995).
NLD & AD profiles share many characteristics
Strong verbal skills
Poor visual spatial ability
Problems with executive functioning.
NLD is evident in many with AS, but not in HFA
The NLD profile is “an adequate model of neuropsychological assets and deficits encountered in individuals with AS (p. 1133)
AS is one of several pathways including hydrocephalus, acquired brain injury and Williams Syndrome to the manifestation of NLD NLD vs. AS
Children with Asperger’s Syndrome typically have “restricted interests,” where they become obsessed with unusual interests (Stein, Klin, & Miller 2004,
The presence of stereotyped and restricted patterns of interest and the need to adhere to routines present in children with AS but not NLD (Semrud-Clikeman, 2007). NLD vs. AS
Semrud-Clikeman, Walkowiak, Wilkinson, & Minne, 2010
Compared 24 NLD, 52 AS, 27 ADHD 9- to 15-year-old children
Found no significant differences in social perception between the NLD & AS groups (both lower than controls)
Differences between AS & NLD groups on calculations
Differences on the Autism Diagnostic Interview–Revised, particularly in the area of stereotyped and restricted behaviors.
No significant difference for AS & NLD on Rey-Ostereith Complex Figure test. Both lower than norms NLD, AS & ADHD
Semrud-Clikeman, Walkowiak, Wilkinson, & Christopher, 2010
Compared NLD, AS, & ADHD-C & ADHD – PI NLD & AS – No significant differences
Semi-structured interview (SIDAC)
Behavioral Measures –BASC-2 Hyperactivity& Attention
Social Skills – (SSRS)
Math calculations
Mathematics reasoning
Reading recognition
Fluid Reasoning (WJCOG-III) (Concept formation & Analysis & Synthesis)
Motor Skills (Grooved Pegboard) NLD & AS
Visual-Spatial – NLD group significantly lower on VMI than AS (Rey-Osterreith)
Judgment of Line Orientation test (JLO) –NLD lower than AS
AS screener – AS group scored higher
WASI –
PIQ –NLD lower than AS
VIQ - no significant difference among groups
NLD group showing the largest split between VIQ & PIQ NLD, AS, & ADHD
74% of NLDs had a V > P split of more than 15 SS points & 40% had a split of 25 SS points or higher (15-55)
63% of AS group had BIQ &PIQs within 15pts.
But 37% of AS showed VIQ >PIQ in the AS group.
While children with NLD are more likely to show a VIQ > PIQ split; there is a sizable minority of children who do not.
Finding is not sufficient to provide a distinction between NLD & AS
also found in Pelletier, Ahmad, & Rourke, 2001). NLD vs. AS
• diagnosed from neuropsychological perspective • Psychological test scores NLD • learning disability, discussion of how children learn
• diagnosed from psychiatric perspective • observations Asperger’s • developmental disorder Prevalence
NLD AS
.1 – 1% 1-10 in 10,000 10% (Ozols & Rourke, 1991 Higher rates in 25% (Bender & Golden, 1990 Males 29% (Van der Vluat, 1989) Higher or equal rates in Recognized females around 3-4 yrs. 1:1 th th Recognized in 4 & 5 of age grades Neuropsychological
NLD AS VIQ>PIQ (X = 23.8 pts.) VIQ > PIQ Ghaziuddin & Mountain- Weak visuospatial Kimchi (2004) found that skills, only 82% of their AS group had VIQ > PIQ Visual motor integration Weak visuospatial skills Visual motor integration Right left confusion Visual-spatial perception Visual memory deficits Nonverbal concept formation Attentional problems Visual memory deficits Hyperactivity as child) Attentional problems More likely to have Theory May have Theory of of Mind deficits Mind deficits Visual Motor
NLD AS Psychomotor coordination problems Psychomotor coordination problems Clumsy, poor at sports Delayed Gross Motor Clumsy Milestones Fine and Gross Motor Fine Motor difficulties, drawing, handwriting delays (Tantam, 1988; Gillberg, (Frankenberger, 2005) 1990) Avoidance of graphomotor Stereotypic motor tasks mannerisms (Mamen, 2007) Difficulties dressing, problems with fasteners Do not have visual Poor organizational skills issues & may be visual May not learn from diagrams, learners (Fast, 2004) need verbal explanations (Fast, 2004) Language
NLD AS
Generally appropriate language Generally appropriate language skills skills More verbose than NLD
Verbal >Performance Verbal >performance Pragmatic language deficits Pragmatic language deficits May have early language delays Poor prosody Poor prosody Verbose, verbal with little content Monologues
Lack of appreciation of Verbose, large vocabulary
incongruities and humor Pedantic conversation, concrete speech Poor nonverbal communication Literal interpretation Difficulty understanding and Poor nonverbal communication using facial expressions, gestures Difficulty understanding and using facial expressions, gestures, vocal intonation
Repetitive speech patterns Academics
NLD AS
Inconsiste Significantl Delays nt reports Reading y of Average in relatively delayed Difficulties arithmetic arithmetic or above reading in performan intact, skills compre word written ce (some may be (Rourke, 1989; - expression 1995; Rourke & reading show good Conway, hensio voracious 1997)) n math skills readers (Kuipers, 1962) Social
NLD AS
Social delays Social delays Problems developing Problems developing friendships friendships At risk for peer rejection At risk for peer (Little, 2001) Poor social perception, rejection (Little, 2001) judgment and interaction Poor social Problems in empathy perception, judgment Lack of spontaneous & interaction sharing of enjoyment
Problems in empathy Failure to develop friendships Automatized stereotyped ways of Social problems more severe Social -- NLD Vs.AS
Children with NLD Withdrawal in NLD are easier to make a is reactive social connection with (Palumbo, Primary in 1991) Asperger’s
NLD children crave Children with NLD social contact more may ineptly reach than do children out to other people with Asperger’s Emotional
NLD AS Emotional problems Anxiety (esp. in
(internalizing anxiety & adolescence) (Klin, 2004) depression) ( Petti, Voelker, Shore & Potential of mood Hayman-Abello, 2003 ) disorders is high ( Ellis, Ellis, Fraser, MMPI - NLD group had & Deb, 1994; Gujikawa, Kobayashi, Koga, & Murata, 1987) no scores above 70 on MMPI -2 study with clinical scales , (Waldo et al., 1999) adults elevations on L High risk for suicide ( Bigler, 1989; Fletcher, 1989; Rourke, Young, & Lennars, 1989) and Depression, social Have normal emotions, introversion, social
but can’t express them discomfort (Ozonoff, Garcia, Clark & or recognizing them in Lainhart,2005 )
others (Fast, 2004) Have flatter affects (Fast, 2004) Repetitive Behaviors
NLD AS
Inability to adapt to Preoccupation with change/novelty stereotyped and Inability to established routines
Adapt to Focus on special interest Change Ritualistic Amass factual information AS & NLD
• 21 students with AS (x= 16.11 yrs.) & 19 persons with HFA (X = 15.36 yrs.) were compared Klin, Volkmar, Sparrow, Cicchetti, & Rourke, 1995 • 18 of 21 with AS presented with NLD profile
• found that only 51% of AS subjects met criteria for
Cederlund & NLD Gillberg (2004)
• NLD group did more poorly on PIQ than AS group
Semrud-Clikeman using the WASI Model
NLD AS Social Communication Neuropsychological Preoccupations Nonverbal Difficulties Communication Special Interests Psychomotor Math Emotional Facts Visual Motor Reading Executive Comprehension Functioning Ritualistic Theory of Mind Written Expression & Attention Novelty Organizational Problems Problems Assessment
Cognitive Assessment
Thinking &reasoning skills must be at least average
Although IQ does not have to be average (e.g., average WJIII Thinking ability or Cognitive Efficiency)
There must be an impairment in at least one psychological process related to learning Neuropsychological Assessment
Impairment in at least one psychological process related to learning
Visual/motor/spatial/tactile memory and attention
Visual motor or fine motor processing
Speed
Pragmatic language
Executive functioning (e.g., planning, monitoring, selective focusing, organization Possible Assessment Measures
WISC-IV
Woodcock-Johnson Cognitive Battery III (WJ- Cog III) (Woodcock, McGrew, & Mather,2001a) – esp. Analysis & Synthesis & Concept Formation)
KABC-2(Chow & Skuy, 1999) found that NLD children showed significantly higher successive than simultaneous processing
WASI Possible Assessment Measures
NEPSY (e.g., Design copying, Arrows)
Delis-Kaplan Visual Motor Integration (Beery)
Wisconsin Card Sort (Jing, Wang, Yang, & Chen, 2004)
Category Test (Strang & Rourke, 1983)
The Children’s Category Test (Boll, 1993) Ris et al. (2007) - good predictor of the NLD group (Ris et al., 2007) Possible Assessment Instruments
Rey-Osterreith Complex Figure (Osterreith, 1944)
Grooved Pegboard (Klove, 1963).
Finger Tapping Test (Reitan & Wolfson, 1985).
Purdue Pegboard
Judgment of Line Orientation (JLO) (Benton, Sivan, Hamsher, Varney, & Spreen, 2004)- (Semrud-Clikeman, yes, not Benton, Varney, & Hamsher, 1978)
VMI (Beery et al., 2006). Possible Assessment Instruments
Children’s Auditory Verbal Learning Test – 2 (CAVLT-2)
Children’s Memory Scale Possible Assessment Instruments
AS Screener (AS screener based on DSM-IV-TR Asperger syndrome criteria)
ADI-R
Asperger Syndrome Diagnostic Scale (ASDS)
Autism Spectrum Rating Scales (ASRS)
The Structured Interview for Diagnostic Assessment of Children (SIDAC) (Puig- Antich & Chambers, 1978). (K-SADS)
Behavior Assessment System for Children–2 (BASC–2) (Reynolds & Kamphaus, 2004).
Social Skills Rating Scale (SSRS) (Gresham & Elliott, 1990)/SSIS
Child and Adolescent Social Perception (1995) (Semrud-Clikeman & Glass,2008)
CBCL
Conners Parent/Teacher Rating Scales
Behavior Rating Inventory of Executive Function (BRIEF)
Children’s Depression Inventory
NLD scale http://www.nldline.com/ Possible Assessment Instruments
WJ-Ach III (Woodcock et al., 2001b) Math calculations &
Math reasoning (Forrest, 2004) didn’t find that poor mathematical reasoning predicted NLD
WIAT-III
Key Math
Gray Oral Reading-4 Is NLD a Valid Diagnosis?
Spreen (2011) NLD remains a hypothesis, but it should not be used in clinical practice unless it is supported by solid research findings. Selected References
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