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ASPERGER's DISORDER
AND NONVERBAL
LEARNING DISABILITIES:
How are These Two
Disorders Related to Each
Other?
by David Dinklage, PhD
There is clearly a great deal of overlap
between Asperger’s Disorder (AD) and
Nonverbal Learning Disabilities (NVLD) – so
much so that it is possible that the symptoms
of each diagnosis describe the same group of
children from different perspectives, AD from
either a psychiatric/behavioral perspective,
and NVLD from a neuropsychological
perspective. The specific conventions of
these diagnoses may lead to a somewhat
different group of children meeting diagnostic
criteria, but it is not clear that this reflects
something “true” in nature. That is, it may
only be convention that separates these two
groups.
One is reminded of the story of the six blind
men who were asked to describe an
elephant. Each man grabbed a different part
of the creature (the snake-like trunk vs. the
tree-like leg), and gave an accurate
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description from his own particular
perspective – but each man thought the
others were completely mistaken!
Studies conducted by the Yale Child-Study
Group suggest that up to 80% of children
who meet the criteria for AD also have
NVLD. While there are no studies on overlap
in the other direction, most likely children
with the more severe forms of NVLD also
have AD. Children from both groups are
socially awkward and pay over-attention to
detail and parts, while missing main themes
or underlying principles. However, by
convention, the two groups differ in the
range of severity. Professionals reserve an
AD diagnosis for children with more severe
social impairment and behavioral rigidity;
some symptoms may overlap with high
functioning autism. There are degrees of
severity within AD but not to the extent that
is acceptable in diagnosing NVLD. These
degrees can range from extreme autistic
behavior to cases where the social difficulties
are very subtle and the academic/cognitive
difficulties are more prominent.
Here is a brief outline of the diagnostic
criteria for AD and the pattern of
neuropsychological findings in NVLD. While
the overlap is apparent, the emphasis is
different because criteria for NVLD focuses on
academic issues as well as specific test
findings and is not purely descriptive. This
also results in different means of making the
diagnosis (testing vs. observing).
Asperger's Disorder (AD) is characterized
by:
A.
Qualitative impairment in social
interaction, including:
1. Failure to use non-verbal
social skills (i.e. eye contact,
gestures, body posture, facial
expressions).
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2. Developmentally inappropriate
peer relationships.
3. Lack of spontaneous sharing
of enjoyment and interests
with other people.
4. Lack of social and emotional
reciprocity.
B.
Restricted, repetitive and
stereotyped patterns of behavior,
interests, and activities:
1. Preoccupation that is overly
intense and narrow.
2. Inflexible adherence to nonfunctional or peripheral
routines.
3. Stereotypic or repetitive motor
movements.
4. Persistent preoccupation with
parts of objects.
C.
These problems taken together (A
plus B) present significant
challenges in the lives of people
with AD as they attempt to live in a
“neurotypical” world and meet the
expectations of others.
D.
There is no general language delay.
E.
There is no severe global cognitive
impairment.
Nonverbal Learning Disabilities (NVLD)
A.
NVLD can be conceptualized as an
imbalance in thinking skills – intact
linear, detail oriented, automatic
processing with impaired
appreciation of the big picture,
gestalt or underlying theme.
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B.
It is not nearly as common as
language-based learning
disabilities, but this may be a
phenomenon created by
environmental demands (i.e., our
societal demands for precision skills
in reading assure that even the
most subtle language-based LD
cases are identified).
C.
Typically social/psychiatric concerns
are raised before academic
problems are identified.
D.
While the overlap is not complete,
NVLD children may meet the
criteria for Pervasive
Developmental Disorder – Not
Otherwise Specified (PDD-NOS),
Asperger’s Disorder, or Schizotypal
Personality.
Neuropsychological Profile
•
Full range of IQ
•
Visual/spatial deficits are most
pronounced: poor appreciation of
gestalt, poor appreciation of body
in space, sometimes left side
inattention/neglect, may have
highly developed but ritualized
drawing skills that are extremely
detail oriented.
•
Rote linguistic skills are normal
(i.e., repetition, naming, fluency,
syntactic comprehension), but
pragmatic use of language is
impaired: weak grasp of
inference, little content,
disorganized narrative despite
good vocabulary and grammar.
Rote recall of a story may be
good, but the main point is
missed. Rhythm, volume, and
prosody of speech are often
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disturbed.
•
Motor and sensory findings are
common: usually poor fine and
gross motor coordination, left
side worse than right.
•
Attention is usually reported to
be impaired and testing supports
this, but the affect is desultory as
opposed to distractingly
impulsive, as in ADHD. It is as if
people with NVLD do not now
what to attend to, but once
focused, can sustain attention to
detail. The distinction between
figure and ground is disturbed,
resulting in attention errors.
Academics
•
Difficulties are often picked up
late because decoding and
spelling may be quite strong.
•
Inferential reading
comprehension is weak relative
to decoding and spelling skills.
•
Math is often the first academic
subject to be viewed as
problematic. Spatial and
conceptual aspects of
mathematics are a problem;
math facts may be readily
mastered (i.e., a student may
know the answer to a simple
multiplication problem, but not
understand what multiplication
is).
•
Due to spatial and fine motor
problems, handwriting is usually
poor.
•
Organization skills are weak,
particularly in written work.
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Social/Emotional Issues
•
Peer relations are typically the
greatest area of impairment;
child may play with much older or
younger children rather than with
same age peers, where they
must manage give and take.
•
People with NLVD often lack
basic social skills: they may stand
too close, stare inappropriately or
not make eye contact, have
marked lack of concern over
appearance, be oblivious to
others’ reactions, change topics
idiosyncratically.
•
Children with NLVD are seen as
“odd” children who “just don’t get
it” socially. They may do better
with adults, where they act
dependent and immature, but
may not be seen as “odd.”
•
They may show poorly
modulated affect, not matched to
verbal content.
•
Lack of empathy and social
judgment may shield them from
fully experiencing the hurt of
peer rejection, while the same
factors increase the likelihood of
being rejected.
•
History of unusual thinking can
often be obtained: rituals,
stereotypic behaviors, rigid
routines, and magical/bizarre
beliefs.
Assessment of NVLD Compared with
Assessment of AD
•
NVLD should be diagnosed in the context
of a comprehensive neuropsychological
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evaluation. It is not simply a matter of
Performance IQ being less than Verbal IQ,
since there may be many reasons for such
a discrepancy besides NVLD. Furthermore,
NVLD can be present even if no
discrepancies between strong verbal ability
and poor performance show up on the
Wechsler Intelligence Scale for Children
(WISC-III). One does not need to have
every characteristic of NVLD in dramatic
form for the diagnosis to be helpful in
delineating the pattern of strengths and
weaknesses.
•
NVLD can be complicated by an array of
psychiatric and social/familial problems, so
it is important to assess the whole child
and his or her family system and social
world, not just the child’s cognitive status.
•
NVLD should be diagnosed in the context
of a comprehensive neuropsychological
evaluation. It is not simply a matter of
Performance IQ being less than Verbal IQ,
since there may be many reasons for such
a discrepancy besides NVLD. Furthermore,
NVLD can be present even if no
discrepancies between strong verbal ability
and poor performance show up on the
Wechsler Intelligence Scale for Children
(WISC-III). One does not need to have
every characteristic of NVLD in dramatic
form for the diagnosis to be helpful in
delineating the pattern of strengths and
weaknesses.
•
AD is best diagnosed from a detailed
history, school reports, and observing the
child. As parents vary in how they report
symptoms, one good marker is whether or
not the child had engaged in symbolic play
as a toddler. Children with AD tend not to
play with toys as the “thing” they
represent. For example, they may collect
fire trucks but not play “fire.” Parents may
also report that their children use language
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instrumentally, rather than using it to share
ideas. The children do not seem to realize
that the “other” may have different ideas.
•
Because AD is diagnosed descriptively, one
does not need neuropsychological testing
to diagnose it. However, since there is so
much overlap between AD and NVLD,
neuropsychological testing is strongly
recommended. Testing will identify any
specific interference with academic
functioning, and confirm imbalances in
thinking skills that may have been
observed.
In my practice I have seen a number of
children with AD who would not meet the
criteria for NVLD in any previous research
studies. If these children had participated in
the Yale study mentioned earlier in this
article, they would probably have been in the
20% of the AD children who did not meet the
NVLD criteria. It is possible that the AD
children in that 20% may have had very high
visual/spatial scores, thus masking their
over-attention to detail in problem solving.
For example, they may have scored very high
on the Block Design subtest of the IQ
measure (using colored blocks to match a
pattern given to them) despite having little or
no appreciation of the gestalt; their
considerable skill and speed at analyzing
detail would have allowed them to use this
inefficient strategy effectively. With these
very bright children, it may be that the tests
are not sufficiently sensitive to discern a
pattern of NVLD. On the other hand, some
children with AD show diffuse difficulties in
language and attention domains, but may not
exhibit the pronounced discrepancies
associated with NVLD. Nonetheless, they
may still struggle with the cognitive
difficulties similar to those of someone with
NVLD. Conversely, a child meeting the
criteria for NVLD may not meet the
Asperger’s Disorder criteria “C,” even though
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subtle characteristics of AD may be present.
A case example best illustrates how children
who clearly have NVLD may not meet the
criteria for AD as it is presently understood.
I evaluated an eighth grade girl whose
parents were concerned about her math
performance. She had above average overall
ability, but a 24-point discrepancy between
her verbal and visual/spatial skills on the IQ
measure. On the neuropsychological
measures, she clearly had the pattern of
visual/spatial deficits, left sided motor
slowing, and poor math ability, while
language skills were intact. She did not have
any problems with inferential comprehension
in reading. One would not even have
considered Asperger’s Disorder. She had had
many good friends through elementary
school and felt herself to be part of her peer
group. Symbolic play development had been
normal and she exhibited no repetitive
behaviors. This is unusual in NVLD as well,
but since many of the criteria for this
neuropsychological diagnosis are cognitive
and test-based, it was determined that she
met enough of the criteria for a diagnosis of
NVLD. I commented in the report that,
unlike this girl, most children with NVLD have
more social problems, tend to miss the point
in social interactions, and have trouble in
content areas in school because of inferential
reading comprehension problems.
The parents came back to me when the girl
was a senior. Now things looked rather
different. She was now isolated from her
peers, who complained that she was too
literal. She was struggling in literature and
social studies; her papers tended to be more
like lists, less integrated than those of her
peers. I don’t believe she was developing a
new disorder. She had classic NVLD, but it
was relatively subtle and it required more
high-powered peer and academic demands to
highlight her social perception and inferential
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reasoning weaknesses. (This is similar to the
way that some mildly dyslexic individuals
compensate reasonably well and go unnoticed
until they go to college and flunk out during
their freshman year.) Given her history of
good social adjustment, one would never
diagnose this student with AD. Still one has
to wonder whether her neurocognitive
functioning indicated AD, but in a much
milder form.
Asperger’s Disorder was not originally thought
of as having a continuum of severity that
included these subtle forms, whereas NVLD
did not start with the assumption of more
extreme difficulties. As information about AD
becomes more widely circulated, and
increasingly more subtle cases are being
identified, the culture is in some manner
changing the original “intention” of the
category. While that may dilute the clarity of
the diagnosis, it will more accurately reflect
the variety of developmental presentations in
nature. As humans, we naturally want to
categorize. The complex relationship
between NVLD and AD may be an example of
how categorizing too rigidly can confuse,
rather than clarify, our thinking.
~~~~~~~~~~
© 2001, David Dinklage.
This article first appeared in
the Spring 2001 issue of the
AANE (Asperger's Association
of New England) newsletter. It
is posted on NLD on the Web!
with the express permission of
the author, who retains all
rights. Reproduction
of
this
material in any form other than
for
individual
educational
purposes, without the express
written
permission
of
the
author,
is
prohibited.
Distribution or sale of this
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material is strictly prohibited.
About the author - David
Dinklage, PhD, is Director of
Neuropsychology and CoDirector of Training in Child
Psychology at Cambridge
Hospital in Massachusetts. He
is also an Instructor in
Psychology at the Harvard
Medical School, and carries on
a private clinical practice in
Belmont, Massachusetts.
€
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