Diagnosing LD

Why Nonverbal Learning Disorder Is So Often Mistaken for ADHD

Nonverbal learning disorder (NLD) might be the most overlooked — and underdiagnosed — learning disability, in part becuase it’s symptoms look so much like ADHD. Poor social and fine-motor skills, inattention, trouble organizing thoughts — learn if these might be signs of NLD in your child.

A young girl with nonverbal learning disorder, not ADHD, yelling in front of her house
Girl yelling in front yard of house outside, brown hair

Marci G. started talking when she was 15 months old. By age three, she was reading The Cat in the Hat. Her parents started calling her their “little professor” because of her incessant questions and articulate chatter.

“She soaked up words like a sponge,” her mother, Irene, recalls. But unlike other children her age, Marci, who lives in New York City, never liked the sandbox or the playground. More interested in talking to her parents than playing with her peers, she preferred asking questions to physically exploring the world around her.

Marci did well academically in grades one and two, although she didn’t have many friends. Her third-grade teachers said she seemed inattentive in class, blurted out inappropriate comments, and bumped into classmates clumsily when they lined up for recess. Later that year, Marci was diagnosed with attention deficit hyperactivity disorder (ADHD). But Ritalin didn’t help. Neither did Adderall.

By sixth grade, Marci was all but friendless. She had stopped finishing classroom assignments and often left her homework incomplete. Given her obvious intelligence, her teachers considered her C average evidence of laziness or defiance. At this point, Marci was diagnosed with oppositional defiant disorder (ODD). But behavioral therapy — the standard treatment for ODD — was no more helpful to her than Ritalin or Adderall had been.


Think You Know Learning Disabilities? Think Again!


Not until seventh grade did Marci and her parents learn the true problem: Marci has a nonverbal learning disorder, or NLD — a condition that doesn’t respond to the treatment regimen commonly used to treat ADHD.

What is a Nonverbal Learning Disorder?

Nonverbal learning disorder (NLD) is a constellation of brain-based difficulties. Once considered rare, NLD is now thought to be as prevalent as dyslexia. Strongly genetic in origin, NLD affects girls as frequently as boys and is characterized by poor visual, spatial, and organizational skills, poor motor performance, and difficulty recognizing and processing nonverbal cues — body language, facial expression, and the nuances of conversation.

Like Marci, most children with NLD have large vocabularies, outstanding memory and auditory retention, and average to superior intelligence. Also like Marci, kids with NLD are often misdiagnosed with ADHD.

“Virtually every child I’ve seen with NLD was first diagnosed with ADHD,” says the late Marcia Rubinstien, who was the founder of the Nonverbal Learning Disability Association. “Pediatricians ought to be able to recognize NLD and refer children for an evaluation, but teachers and medical professionals are more aware of language-based learning disabilities. That’s why every parent of a child with NLD has to become a full time advocate for their child.”

Despite their facility with language, kids with NLD often have poor reading comprehension. A child with NLD may miss the forest and the trees because of his intense focus on the leaves. After reading a book about the Civil War, for instance, the child might be able to name and describe each battlefield — yet fail to recognize that the conflict was about slavery and federalism.

Young children with NLD are often good at compensating for their limitations. But once those kids hit puberty, they often experience severe anxiety. In adulthood, mood disorders — combined with trouble picking up social cues and setting priorities — make it hard for people with NLD to hold on to jobs and relationships. The earlier the correct diagnosis is made and appropriate interventions begin, the better the outlook for a person with NLD.

No Conception of Deception

Far more than other children, kids with NLD rely mostly on language to learn about their world. Yet because they have trouble with abstract concepts, their language comprehension and speech lack nuance.

When an exasperated mom says, “Don’t let me see you playing with that toy any more,” her child with NLD might continue to play with it, but turn away — so his mom cannot see him. No wonder kids with NLD are often considered smart alecks.

Because they’re literal-minded, children with NLD tend to be naïve and virtually incapable of deception. These traits are often endearing, but they can cause heartbreak when a child reaches adolescence. For example, a teenage girl who cannot comprehend lying may not hesitate to befriend a stranger who offers her a ride home.

Easily Mistaken

At first glance, children with NLD seem to behave like those with ADHD, but the appropriate interventions are not the same. A child with NLD may have trouble sitting still and may bump into people. But this isn’t due to hyperactivity — it’s due to his poor balance and coordination, and trouble with visuospatial relationships.

Some children have both ADHD and NLD. “You can miss NLD in children with ADHD if you don’t have a thorough neuropsych evaluation,” cautions Ruth Nass, M.D., professor of pediatric neurology at the New York University School of Medicine.

Making the Diagnosis

NLD varies from child to child, and is not defined as a separate entity in the fifth edition of the Diagnostic and Statistical Manual. For diagnosis, a child must undergo neuropsychological testing, speech and language assessment, and educational and occupational therapy evaluations.

As measured by the Wechsler Intelligence Scale for Children, kids with NLD usually demonstrate a verbal I.Q. that’s 20 or more points higher than their performance I.Q. (Verbal I.Q. is a measure of a child’s language ability. Performance I.Q. measures how well he makes use of what he knows.) Another test, the Brown ADHD Scales, can help differentiate NLD from ADHD.

ADHD and NLD: Overlapping Signs

One reason doctors have trouble diagnosing NLD is because it shares similar symptoms with ADHD such as…

  • Poor social skills
  • Academic difficulties
  • Inattentivness
  • Overfocusing on certain tasks
  • Excessive talking
  • Speaking without thinking about it first

Given the complexities of NLD, children do best when they get help from a team of professionals, including a neuropsychologist, occupational therapist, education specialist, and a speech and language therapist.

“As a parent of a child with NLD, you are your child’s primary therapist,” said Sue Thompson, the late author of The Source for Nonverbal Learning Disorders.

Unlike ADHD, NLD usually does not respond to medication. But children with NLD often do well with various other kinds of intervention:

  • Social skills groups can help teach kids how to greet a friend, how to greet a stranger, and how to recognize and respond to teasing.
  • Occupational therapy builds a child’s tolerance for tactile experiences, improves balance, and enhances fine motor skills.
  • Typing instruction software, like Jump Start Typing, can help kids compensate for poor handwriting.
  • Recorded books are key for kids who learn by listening. Recording classroom lectures may also be helpful.
  • Using a daily planner can help students improve organizational skills.

Sound daunting? According to Rubinstien, “Helping a child with NLD is like learning a new language. Once you learn it, you can give your child the tools he needs to win.”

How’s Marci Now?

Marci, now 15, is in tenth grade. Her academic performance has improved, and she finished her freshman year of high school with a B average. But Marci still needs help with organization and, especially, with social skills.

As recommended in her Individualized Education Program, Marci is now “shadowed” by an education specialist for several school periods. Because auditory memory is one of her strengths, Marci tapes classroom lectures to listen to later and subscribes to a “books on tape” service. Several afternoons a week, Marci participates in a social skills group.

Now that her parents, classmates, and teachers recognize the biological basis of her behavioral problems, she’s treated with understanding. “She even has a best friend now,” says her mom, smiling. “It’s wonderful to hear the two of them complaining to each other, just like typical teenagers.”


NLD Resources

  • Raising NLD Superstars (Jessica Kingsley Publishers), by Marcia Brown Rubinstien.
  • The Source for Nonverbal Learning Disorders (LinguiSystems), by Sue Thompson.

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