Understanding Nonverbal Learning Disability

A Guide to Symptoms, Management and Treatment

Irene C. Mammarella, Ramona Cardillo, Jessica Broitman

• Publisher: Routledge
• Year: 2021
• ISBN:
  9780429677809
• Edition: 1
• Topic: Education
• Subtopic: Learning Disabilities

This essential book offers an accessible, evidence-based guide to Nonverbal Learning Disability (NVLD) informed by the most current research, and clinical and educational practice. It provides a thorough explanation of the science behind the condition, alongside ideas, support, and practical tips for managing the everyday challenges of the disorder at school and in family life.

Mammarella, Cardillo, and Broitman describe the main characteristics of the condition from both theoretical and practical points of view, as well as examining the similarities and differences between NVLD and other neurodevelopmental disorders. They explore the cognitive and academic weaknesses and strengths of children with NVLD, and the emotional and social difficulties they may experience. The book also provides a systematic review of scientific studies in this field whilst focusing on issues of diagnostic criteria, as well as assessment and intervention strategies. Practical examples are given for teachers and parents to help support children with NVLD in improving their visuospatial and motor skills, as well as peer-social relations, and in promoting the child's individual abilities.

Understanding Nonverbal Learning Disability is essential reading for parents and practitioners in clinical and educational psychology, and health and social care, and students in these fields.

Chapter 1

What Is Developmental Visuospatial Disorder (or Nonverbal Learning Disability)?

Signs and Symptoms

1.1 Nonverbal Learning Disability (Developmental Visuospatial Disorder)

We begin with a description of the main characteristics of nonverbal learning disability (NVLD) through the depiction of two Italian children, Fabrizio and Alex (names and identifying details changed to protect their privacy), throughout this chapter, and we will follow them in other chapters of this book.

Fabrizio is a brown-haired, 9-year-old child. He has a good vocabulary, and he likes to read children’s books and watch scientific documentaries (mainly regarding animals) on TV. During the first years of primary school, he encountered some problems with his handwriting skills. He wrote slowly, the shape of his letters was irregular, and he was not able to keep them correctly aligned on the page. His parents also reported that Fabrizio was confused by new places and encountered difficulties when orienting himself in new environments. In light of these difficulties, his school teachers suggested to Fabrizio’s parents that he have a neuropsychological evaluation. Initially, he was referred to a specialized clinical developmental center when he was 7 years old. At that time, the staff immediately noticed his visuospatial processing difficulties with copying complex figures and in fine-motor skills (i.e., grasping small objects and fastening clothing). However, his gross-motor abilities, including walking, running, sitting, and other activities, were in line with other children of the same age. He also showed some difficulties in interacting with peers; he was described as sensitive and insecure, without confidence when playing with peers, and uncomfortable and concerned about his performance due to his visuospatial and fine-motor difficulties.

Alex is a 14-year-old eighth grader who seems older than his age and is passionate about rowing. He loves learning new languages and hates mathematics. Alex likes to talk and describes his thoughts in detail. He is well aware of his weaknesses, naming them as drawing, mathematics, interpreting graphs and diagrams, and fine-motor skills. He was referred for a neurodevelopmental assessment because of his difficulties with school achievement, which were described as slow, labored penmanship, difficulties in solving advanced mathematical problems, and difficulties in recognizing geometric concepts and figures. In fact, during the neuropsychological assessment, his performance was poor in all these domains. Unlike most of his peers, he does not like video games or using social media but prefers to talk with “real” people. In addition, he sometimes appears lost in his own thoughts. Both Fabrizio and Alex received a diagnosis of NVLD. Although there are age differences between the two children, it is clear from these brief descriptions that they share some characteristics: good verbal and language skills, and poor visuospatial processing and fine-motor abilities. We suggest that these are, in fact, the main characteristics of children with NVLD. However, as you will see, we believe that the characteristics of NVLD are quite varied and more nuanced, and we intend to explain the reasons why. We do, however, see a consistent pattern of strengths and challenges. Assets of children with NVLD often include early speech and vocabulary development, a relative strength in auditory/verbal rote memory, often early reading skills, and excellent spelling skills. Difficulties usually include problems in visual–spatial processing (the main deficit), organizational/executive function challenges, academic struggles (typically math), social functioning, and fine-motor coordination issues. Associated difficulties could include psychological issues, specifically during adolescence (Cornoldi, Mammarella & Fine, 2016).

Although many experts and practitioners, working around the world, frequently encounter children with characteristics similar to those described in Fabrizio and Alex, they often fail to use the diagnostic label of NVLD. A recent study by Margolis et al. (2020), for example, found that 3–4 percent of the population of children in the United States are likely to have NVLD. We hypothesize that one possible reason why NVLD is undiagnosed might be because it is not yet fully recognized by the scientific community. In several scientific publications (Broitman et al., 2020; Cornoldi, Mammarella, & Fine, 2016; Mammarella, & Cornoldi, 2019), we explained that this disorder is still not listed in the international diagnostic manuals (such as the Diagnostic and Statistical Manual of Mental Disorders [DSM 5]; APA, 2013). Briefly, the history of NVLD is quite recent. Dyslexia, for example, was described for the first time in 1881. However, the concept of a nonverbal learning disability only dates back to 1967, when Johnson and Myklebust (1967) in their insightful work presented a description of children with an average verbal intelligence who had difficulties in the nonverbal aspects of their environment.

Moreover, it is worth noting that a nonverbal learning disability is a complex disorder. From the beginning, the description of these children suggested the presence of mainly visuospatial processing deficits, but some of their other symptoms resembled different clinical profiles such as autism spectrum disorder, developmental coordination disorder, specific learning disorders, or attention-deficit hyperactivity disorder (ADHD), making their diagnosis challenging (Broitman et al., 2020; Cornoldi, Mammarella, & Fine, 2016). In 2011, Spreen strongly criticized the validity of the nonverbal learning disability diagnosis and concluded that there was little evidence to support its use in clinical practice. In particular, he observed that contrary to expectations, it seems that this disorder occurs only quite rarely, and he disapproved the inclusion of socioemotional symptoms as a core symptom of this profile.

It is worth noting that it is currently acceptable to describe complex clinical profiles with various symptoms involving different neuropsychological domains. Now, both researchers and clinicians agree on the existence of a dimensional approach (DSM-5; APA, 2013), which considers the functioning of a given individual along different dimensions. For example, the idea that children with ADHD, mainly showing attention and hyperactivity deficits, often present socioemotional difficulties is broadly accepted (Hodgens, Cole, & Boldizar, 2000; Hoza et al., 2005; Mrug, Hoza, Pelham, Gnagy, & Greiner, 2007). Peer and teacher reports reveal that children with ADHD like other children more than they are liked (Hoza et al., 2005; Capodieci, Crisci, & Mammarella, 2019) and have fewer friends, appear lonelier, and engage in fewer activities relative to their typically developing peers (Heiman, 2005). In addition, children with autism spectrum disorders often show attention (Murray, 2010; Bühler, Bachmann, Goyert, Heinzel-Gutenbrunner, & Kamp-Becker, 2011) or motor coordination problems (see, for a meta-analysis, Fournier, Hass, Naik, Lodha, & Cauraugh, 2010).

However, while comorbidity is now well accepted, it still remains a significant problem in the field inhibiting the use of the diagnosis of a nonverbal learning disability, as there are currently no “official” shared diagnostic criteria for this disorder. Trying to move a step forward toward finding a consensus on the inclusion and exclusion criteria for nonverbal learning disability, based on a systematic review of the literature, Cornoldi, Mammarella, and Fine (2016) suggested some criteria for its diagnosis.

In May 2017, a conference was held at Columbia University Irving Medical Center (CUIMC). This conference, sponsored by The NVLD Project, was led by Dr. Prudence Fisher and hosted at CUIMC. The consensus group included NVLD global experts, such as Drs. Jessica Broitman, Joseph Casey, John (Jack) M. Davis, Jodene Fine, Irene C. Mammarella, Amy Margolis, Doug Riis, and Margaret Semrud-Clikeman. The scientific advisors to the consortium included Drs. Geraldine Dawson, Michael Furst, Stephen Hinshaw, James McCracken, Mark Riddle, Peter Satzmari, Benedetto Vitiello, and Agnes Whitaker. They were joined by educators from Mary McDowell School and Winston Preparatory School in NYC, which offer programming for students with NVLD, and policy makers from the National Center for Learning Disabilities (NCLD).

Members of The NVLD Project’s Board of Directors and Advisory Board also attended these meetings, and all together, they formed a consensus work group. The group’s objective was to find a consensus definition of nonverbal learning disability and to have this diagnosis included in future editions of the international diagnostic manuals. Additionally, the conference focused on generating a name for NVLD that would be descriptive and would delineate NVLD based on its defining deficits rather than a description focusing on what it is not (nonverbal). The consensus group arrived at the name developmental visual–spatial disorder and generated a definition written within the style of Diagnostic and Statistical Manual 5 (DSM5) diagnostic criteria. In contrast to previous research definitions, wherein criteria are defined by the neuropsychological test profile, the clinical definition is based largely on behavioral features. Like several other neurodevelopmental disorders in DSM5 (language disorder, specific learning disorder, and intellectual disability), NVLD does require some psychological testing to make a diagnosis (Broitman et al., 2020).

The attendees agreed to change the name from nonverbal learning disability to developmental visuospatial disorder (DVSD) to reflect that visuospatial processing difficulty is what differentiates these children from others and to disconnect it from the term nonverbal, which is confusing, as the label usually reveals the nature, rather than the absence, of the problem (Cornoldi et al., 2016). Another reason for changing the name was that also the term learning disability is misleading. It is true that some symptoms concern academic achievement (i.e., mathematical skills and reading comprehension), but children with nonverbal learning disability may have academic weaknesses that are not always associated with dramatically poor school results (see Cornoldi et al., 2016). Moreover, they may fail in academic areas as a consequence of their weaknesses in visuospatial processing.

The group defined a set of behavioral criteria for NVLD that could be submitted to the Diagnostic and Statistical Manual 5 (DSM5) for consideration of NVLD as a distinct disorder.

As stated in Broitman et al. (2020), inclusion of NVLD in the DSM5 could potentially improve a number of things for individuals with NVLD. Inclusion in DSM would provide improved identification of individuals with NVLD and thus, comm...