Treatment of Non-Verbal Learning Disorder

Non-verbal learning disorder (NLD) is a complex and chronic problem. In addition to any strategies that 'treat' the current difficulties, successful treatment and management includes long term goals to build development and prevent problems,

Document Outline

  1. Adam
  2. Management strategies - short term
  3. Long term goals
  4. Summary
  5. Links to related documents

Adam

Adam (see non-verbal learning disorder) has been diagnosed with NLD. His parents understand this is caused by neurological differences, and cannot be 'cured' or overcome with therapies and medications.

We move to the discussion about what can be done. The first step is for the parents to choose goals both for the next 6 months (short-term), and also for the next 10 years (long-term). This is what they wrote down:

Short term goals

  1. Anxiety: To know what makes him anxious, and what to do about it so that his enthusiasm for school and development more generally returns.
  2. Maths: To understand Adam's current level of ability, and consolidate his current skills (before moving on with the curriculum).
  3. Handwriting: To find the easiest way for Adam to use a pencil and pen (least likely to fatigue).
  4. Social Skills: To improve his relationships in the playground, and to find a place where he is likely to make lasting friendships.
  5. Egocentricity: To know how to handle his behaviour when he is frustrated from not getting what he wants.
  6. Distractibility / poor attention / poor organisation. To do whatever is needed to improve his concentration and organisation without the use of medication.

Of this list, Adam's parents identified the maths, handwriting and anxiety as the priority issues.

Long term goals

Clearly these can only be general. Adam's parent's goals were:

  1. Learning: That he continue to progress at his optimal rate, and not become upset to the extent where he gives up learning, and drops out of school.
  2. Self Esteem: That Adam is able to like himself, feel positive about the future, and accept his limitations.
  3. Attention and organisation: That he learn ways of living with these problems so that they do not interfere with his life.
  4. Maths and Handwriting: That he learn enough skill in each of these areas to live independently without difficulty.
  5. Social: That he has friends (even just a few) who are reliable and trustworthy. That Adam loses his egocentricity enough to form good adult relationships.
  6. Employment: That he find an area of work that he likes, and where he can use his best skills.

Long term fears

These are things Adam's parents were afraid may happen in 10 years time, and would like to prevent. They tend to be the reverse of the goals.

  1. Mental health: That Adam's anxiety will worsen, that he will become depressed (and all the behaviours that go with that like drug/alcohol abuse, unemployment, social withdrawal, crime, suicide).
  2. Learning and employment: that he will drop out of school, and not be employable.
  3. Social: That he will be lonely, and have no friends.

Management Strategies - Short Term.

The short term goals reflect what is most important at the time. For Adam's parents, the most important issues were to 'get on top' of his developing anxiety and worsening self esteem. It was not clear whether this came more from his academic problems, or more from his social difficulties. For that reason they wanted to explore both areas.

There was no easy solutions within the school. In Queensland, NLD is not recognised as a 'low incidence' category for extra funding and assistance (ascertainment) even though the symmetrical opposite problem (language disorder) is. Adam's needs had to be met within existing school resources. The following are some of the decisions we made.

Maths.

Children who are verbally clever can often learn how to do step-by-step maths without fully understanding the underlying meaning of what they are doing. For this reason we decided to try and find the level of Adam's true understanding, where his skills were solid. To do this the parents hired a tutor for one afternoon a week. The tutor was a gentle, retired schoolteacher who could identify where Adam's skills were solid. During the next 6 months they consolidated his abilities to build a solid foundation.

The other strategy with maths was that the tutor talked with Adam's school teacher. As a result, the teacher modified the maths curriculum to his current true level. The school understood that from this point onwards, Adam was likely to need a modified maths curriculum where he progressed at his own, slow rate, doing different work from his peers.

Handwriting

We organised a visit with a paediatric occupational therapist (OT) to explore the question of how much Adam's handwriting problem was due to problems of finger (fine motor) control, and how much was due to spatial layout and organisation. The OT found quite significant problems - Adam couldn't write letters automatically - he had to think about each letter as he wrote it. It also meant his fingers would physically fatigue early as his grip was tense. The OT gave some suggestions about pencil grip.

With this information the next step was liaison with the school. By clearly identifying his writing (letter formation problems) they changed their expectations. Specifically they gave him exercises to practice his letters (to try and make these more automatic), and reduced the requirements for written work. For longer pieces of writing at home he was allowed to dictate to his mother who would type the work up for him. At school they managed to get a teachers aide to help him brainstorm ideas before writing them down. Finally they allowed him to use a keyboard, and began the slow process of learning to touch type.

The end result of these changes was that Adam did not feel that he was expected to produce work that was way beyond his abilities.

Social Skills

Although he was relieved to have work he could achieve, Adam did not want to be different. He objected to the modified work. With his teacher and parents they discussed this. The process of accepting that he had difficulties has not been easy for Adam, but he did understand that he could not achieve what the other children could do easily. The early solution to this problem was to include Adam in the discussions of what work he should get in the class and for homework.

These changes had the effect of reducing Adam's anxiety and childish behaviour in the classroom. The remaining social problems were in the playground. Here there was no easy answer. The problem was that other children were maturing, and leaving Adam behind. From our discussions Adam's parents realised that Adam did not have the skills to successfully manage the playground as a social equal, and it was not possible to force the other children to like and include him.

We explored three specific strategies. The first was to make sure he was not getting bullied. In the end, Adam's teacher had to explain to the other children about differences, and specifically that Adam could not help his problems with schoolwork and socially inappropriate behaviour. This reduced the teasing and allowed the other children to be more tolerant. They did not, however, go so far as to include him in their social groups.

The second strategy was to find a safe activity for lunchtime - and Adam ended up in the library. This was built upon to give him some responsibilities in the library.

The final strategy was to find something in the school where Adam could build social friendships in a structured activity that allowed his strengths to shine. For Adam this turned out to be Drama. He was quite musical, could sing in tune and was an excellent actor. He was given a responsible role in the school play, and through this process was able to establish some friendships so that at lunchtime he would either be in the library, involved with the drama, or with those friends he made at drama. The solution was not perfect - he tended to irritate the other children by 'showing off', and being childish in other ways, but with some gentle help from the teaching staff the students accepted him as part of the production.

Egocentricity

Interestingly, drama did the most to make him lose his egocentricity (a little) and be more aware of others. At home Adam's parents understood that Adam could talk like an 11 year old (he was aged 9), but understood the world more like a 6 year old. In other words he could only see his point of view, and could not easily see the perspective of others. As a result he could not take appropriate responsibility for his behaviour. They then learned not to get involved with discussions - this was his battleground.

Instead, they began to talk to him at his social developmental age. They made rules, and would only discuss these rules if Adam showed the maturity necessary to accept responsibility. When he did not, they would say things like "If you are going to behave like a 6 year old, we will treat you as one. That means rules and punishments. We won't discuss this unless you are prepared to accept responsibility like any other 9 year old".

This was hard work, because Adam continued to get frustrated, wanting his own way, and wanting to discuss it all the time. But they stuck to their chosen strategy and gradually he began to understand that he could not always get his own way. During the 6 month period, however, he did not change to the extent where he learned to see the other (particularly his parent) point of view and take this into consideration himself

Attention and organisation.

It became clear that a contributing factor to Adam's problems academically and socially was his poor attention and impulsivity. We discussed the possible use of stimulant medication, but the parents decided to hold off. They accepted that if the problems did not improve with the current strategies (or were getting worse) they may have to try this.

Adam's tutor also addressed the issue of organisation. By talking different issues through with Adam (getting ready for school, knowing what to take to school, knowing what was going to happen through the day) they broke each issue up into step-by-step tasks. Then they cut out small pictures from magazines to represent each task, and made for each a visual chart so that Adam could focus on one step at a time by following the sequence of pictures.

This strategy was used over and over, for all situations where organisation was a problem. Later, instead of pictures Adam learned to write lists of steps, and to use a diary. It was not a perfect solution (he regularly forgot to use the lists and lost his diary) but at least he had a strategy for getting through complex situations.

Again, part of the solution was explaining to the teacher that he became lost easily with complex tasks, and the teacher changing her expectations of Adam.

Anxiety

All these measures were enough to manage Adam's anxiety by the time we met again in 6 months time to review the goals. Particularly when drama was underway, his parents said the 'old' Adam was back with his enthusiasm and constant conversation. He had a few friends and was keen to go to school. He was particularly lucky as his teacher had been very understanding and supportive.

We discussed that this may not last for ever. Even with the best support and adaptation it is common for children with NLD to become problematically anxious. In this case, Adam's parents understood that it may be necessary to use medication in order to treat the underlying emotions of anxiety.

Long term goals

The major benefit of identifying long term goals is that you can start doing things now to improve chances of achieving these many years into the future. In this way they are like a superannuation - you start contributing now for something you hope to achieve many years into the future.

General strategies

To achieve long term goals, several strategies make a clear difference:

For Adam

The main early interpretation of these long term goals was to permit, and even encourage Adam's parents to take things slowly. By understanding that the journey was a marathon and not a sprint, they could take the time to learn and understand, and prepare for the future. These are some of the specific strategies and goals we set to begin now, and work towards the long term goals (as well as preventing the long term fears).

Summary

These points above summarise a process that has continued for over a year. Adam's parents are still apprehensive about the future, particularly because of Adam's poor social skills, fears and potential for a substantial anxiety problems - particularly if he doesn't like himself.

More generally, there are several key points to managing a child with NLD.

  1. The keys to long term management are compensation (changing the environment to fit the child), resiliency (building up a child's developmental strength and self esteem), prevention ( a regular process of planning ahead and stopping problems before they occur) and a constant sense of 'being in control' that comes from understanding. These must be balanced with any strategies used to treat the child in order to improve their weak areas.
  2. Remember the difference between what a child can do, and how well they talk. The problems are 'silent', and affect how a child understands and interacts with the world non-verbally. Verbally they may talk like a 12 year old. Socially they might understand the world like a 7 year old. When you talk about social and behavioural issues you need to talk to the 7 year old, not the 12 year old.
  3. Language is the child's lifeline, or umbilical cord. They can learn about the world, and about people through words. In areas where they have difficulty, words can be used to create 'scripts' or verbal messages which the children can use to talk to themselves, and talk their way through complex situations.
  4. Step-by-step. NLD interferes with seeing the whole as the sum of the parts. Children need step-by-step guidance through complex situations as they cannot work out the stepwise process from the overall goal.
  5. Anxiety. The key to good mental health is managing fear and anxiety. Anxiety can come from common situations where others would not expect it. Use the child's verbal skills to remain in touch with situations that cause anxiety. More generally, use a child's verbal skills to help them understand themselves (I get afraid in ... situation, I am good at ..., I am weak at ..)
  6. Specific strategies for specific situations. NLD interferes with the ability to generalise lessons learned in one situation to other similar situations. Problematic situation that recur need specific solutions that the child must learn, and apply within that situation.
  7. Exercise the weaknesses in a playful way - it doesn't always have to be 'therapy' or hard work. For example, play the non-verbal social game. Watch people, and discuss with the child what they are saying to each other with their body language.
  8. Do not be afraid of compensating for disability. If you could not walk you would not think twice about using a wheelchair. Similarly, if a child has problems with maths - use a calculator. If the trouble is handwriting - use a computer.

    These ideas can only be suggestions. They cannot come close to meeting the needs of every child with their individual differences and needs. This requires the regular assistance of somebody who understands, and with whom you can regularly discuss your child at an individual level.

    Specific recommendations for the classroom can be found at http://www.nldline.com/sue_educ.htm The site (nldline) is dedicated to non-verbal learning disorders, but tends to portray the more extreme clinical problems and may not be applicable to children with reasonable intelligence whose problems are more subtle.

Suggested Further Reading Document Links

Anxiety
The development of self concept and self esteem
Fine motor problems

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This article is published with the permission of the author.  Please email: http://www.childdreams.com.au/disorder/nld.html