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Understanding Nonverbal Learning Disability (NVLD)

 

 

by Wendy Heller, PhD

 

 

 

 

Developmental Processes and Dysfunction of the Right

Hemisphere: Implications for Learning and Social Perception

 

 

The Right Hemisphere and Emotional Information Processing

 

It is well-known that the left hemisphere of the brain is specialized to process verbal information, and to control the production of speech. It is also relatively well-known that the right hemisphere of the brain is specialized to process visuo-spatial information. The right hemisphere of the brain is also specialized to process a variety of other kinds of information. This fact is less well-known, partly because for many years the left hemisphere was considered the "dominant" hemisphere for all or almost all kinds of information processing. Therefore, not enough research was carried out on right hemisphere functions for us to understand fully its importance in everyday cognitive, social and emotional functions.

 

One of the most important aspects of right hemisphere function has to do with the ability to understand emotional information. The right hemisphere excels in the recognition, interpretation, and expression of emotion. These functions are interwoven with the visuo-spatial functions that are specialized in the right hemisphere. For example, it requires complex visuo-spatial processing to decipher the meaning of a facial expression or to understand a series of complex gestures.

 

Most of us take for granted the knowledge that when we notice a person frowning at us, it means something very different from a smile, say, or a wrinkled nose. Sometimes, a frown might mean puzzlement, suggesting a need for clarification or explanation. Often, a frown will signal displeasure or disapproval. It might cue us that something we have said or done has annoyed or disturbed another person. That facial expression then becomes an important piece of information that we can take into account as we engage further in the interaction. We can decide to ignore the frown and continue on our path, knowing we are in danger of a confrontation; or we can decide to avoid the confrontation and steer clear of the disturbing conversation or behavior. Human beings, who coexist with each other in highly complex social structures, depend on such nonverbal signals to communicate effectively.

 

There are several channels for such nonverbal signals, including facial expression, tone of voice (often referred to as prosody), and gestures. It turns out that when investigators compare the ability of left (LBD) versus right brain damaged (RBD) patients to make sense of emotional information conveyed through any of these channels, they typically conclude that the right hemisphere is specialized for these skills. Patients with right hemisphere lesions in parietal and parietotemporal regions are significantly impaired relative to patients with left hemisphere lesions in comprehending emotional tone of voice. RBD patients also perform more poorly than LBD patients when asked to discriminate between emotional faces and to name emotional scenes, when matching emotional expressions, and when grouping both pictorially presented and written emotional scenes. RBD patients are also impaired in the comprehension and appreciation of humorous or affective aspects of cartoons, films, and stories.

 

According to Dawn Bowers and her colleagues, who have studied many patients with damage to the right hemisphere, these kinds of tasks rely on a nonverbal affect lexicon, a knowledge base coming under the rubric of "cold cognition", so-called because it involves judgments and knowledge about emotion that are independent of an emotional state or experience. The nonverbal affect lexicon is contrasted with another type of cold cognition, referred to by Bowers and colleagues as emotional semantics, which is the understanding of the link between certain situations and specific emotions. They make a distinction, therefore, between the ability to comprehend the meaning of a facial expression, a gesture, or a tone of voice, and the ability to know that 'fear' is likely to be the response to a hold-up, or 'sadness' the response to a death. Whereas the nonverbal affect lexicon appears to be housed in the right hemisphere, the mechanisms that mediate emotional semantics seem to be distributed widely, and are not hemisphere specific. Bowers and Heilman described an interesting case that suggested that disconnections between different emotional functions can occur from damage to the right hemisphere. They evaluated a 54-year-old man with a large glioma located in the deep white matter of the posterior parietotemporal region in the right hemisphere (Bowers and Heilman, 1981, 1984). Note that the cortex itself was not damaged-- just the fiber pathways that carry information from the posterior parietotemporal areas of the right hemisphere to other parts of the brain. This patient had no difficulty matching different views of facial emotions. However, he was unable to name an emotion depicted on a face, nor could he understand labels for facial emotions. Thus, when the task involved translating the meaning of a facial expression into a verbal label, his performance was impaired. It is important to note that his anomia (inability to name) did not extend to other kinds of stimuli, including the ability to identify familiar faces. Furthermore, his ability to express emotion was not disrupted, nor was his ability to describe his emotional experience.

 

Nonverbal Affect Lexicon and Emotional Semantics

 

Bowers and Heilman believe that the damage to the fiber pathways in the right hemisphere caused a roadblock between the nonverbal affect lexicon located in the right hemisphere and the language areas in the left hemisphere that are needed for naming. Thus, although the nonverbal affect lexicon was not inherently damaged, the lesion blocked the access route between that knowledge and the generation of a verbal label for it.

 

How important is it to be able to identify emotional signals? The significance of these right hemisphere skills is highlighted when we examine the impact of their loss on the quality of a person's life. Right brain damaged patients can be extremely difficult to deal with on a daily basis. They often seem to have lost the most basic social skills--simple things such as knowing when to take turns in a conversation (typically cued by facial expression and voice intonation), or how close to get to someone while engaged in a conversation. They tend to be very talkative but the things they say are often described by listeners as shallow and inconsequential. They laugh during inappropriate moments, or display other emotions that don't seem to fit the context. To the dismay of those around them, they seem to have difficulty putting themselves in someone else's shoes and often alienate their family members and friends. It seems likely that the inability to comprehend nonverbal signals is at the root of many of these problems. Thus, in trying to help these patients and their families adjust, one focus of rehabilitation is to modify these behaviors and to help the brain injured patient to become more sensitive to emotional and social cues.

 

Anosognosia and "Plausibility" Assessment

 

Even more problematic, they often seem to be unaware of their disabilities, a syndrome called anosognosia. Patients with anosognosia don't realize that they aren't thinking clearly, or that they can't do all the things they used to do. For example, an airplane pilot with a right hemisphere stroke and a left hemiparesis talked about going back to work the very next day, ignoring the fact that he was even in the hospital.

 

This problem may be related to another important specialization of the right hemisphere. The difficulty that right brain damaged patients have in understanding social situations seems to extend to a difficulty in contextualizing all sorts of information. In an interesting study, Howard Gardner and his colleagues had right and left brain damaged patients listen to a series of narratives. The narratives were designed so that each one included something that didn't make sense in the context of the story. When asked to recall the story, the left brain damaged patients and the non brain damaged control subjects either changed the nonsensical detail to fit the story or simply left it out. In contrast, the right brain damaged patients not only remembered the detail but tried to make the rest of the story fit. This process caused them to sacrifice the essence of the narrative and end up with a highly implausible construction. On the basis of these results, Gardner and his colleagues suggested that the right hemisphere houses a system that assesses the 'plausibility' of events. This system, they suggest, is important to the ability to judge the likelihood or probability that an event could actually take place. This notion fits well with some other data showing that right brain damaged patients violate the contextual reality of objects (drawing things like a 'potato bush', for example). These results might be related to the anecdotes about right brain damaged people who seem to be unaware of the magnitude of their deficits--here, they seem "out of touch with reality" in another way.

 

The fact that the right hemisphere would be in a special position to judge the 'reality' of something seems to be compatible with its other specializations, such as the ability to judge spatial relationships and the ability to distribute attention across both sides of space. The fact that right brain damaged patients have difficulty getting the gist of a narrative suggests that the right hemisphere is also good at judging relationships between other kinds of concepts as well, a skill that would be needed to put things in an appropriate context i.e. to assess how realistic they might be.

 

Schema Construction

 

Another way to apply these concepts is in the domain of schema construction. The right hemisphere seems to be specialized to understand how things fit into categories and what the normative schema are for an event or an object. The inability of RBD people to understand jokes and metaphors reflects their difficulty in understanding how things normally fit together, interact, or intersect. They therefore fail to be surprised by an unexpected ending or twist to a story. They also have difficulty seeing how the characteristics of one situation might explain or describe the characteristics of another situation, as happens in metaphor e.g. "my job is a jail". Not surprisingly, RBD people have great difficulty with novelty, and are highly dependent on sameness and routine.

 

Studies have shown that no matter how young the child, there is evidence that even at the earliest stages of development the two sides of the brain are different. Since patterns of lateralization are appearing at very early ages, it seems likely that right hemisphere specialization for various aspects of nonverbal function plays an important role in infant development.

 

The right hemisphere may thus be of greater importance than the left hemisphere in infant development. Much of the prelinguistic child's learning consists of the perception of visuo-spatial relations, patterns, environmental sounds, etc. The child's perception of the world is organized at this time on the basis of nonverbal information.

 

Many studies have shown the importance of the attachment between the child and a caregiver for the future social, emotional, and cognitive adjustment of the child. Children who have strong attachments with their caregivers are more likely to explore the environment and develop their cognitive skills accordingly. They are also more likely to have good peer relations in early grades and to be rated as popular children. Other studies have emphasized the importance of the caregivers facial expression and tone of voice in establishing attachment bonds with the child. It is not unreasonable to expect that problems with processing the facial or prosodic information that goes along with parent-child interaction could result in a variety of detrimental outcomes for a child. In fact, we found in a study of brain damaged babies that RBD infants showed less reciprocity in their interactions with their mothers.

 

These processes form the foundation for social learning throughout childhood. It is thus likely that a fundamental problem with the right hemisphere may set a child up for being at risk for early difficulties in social functions. These early difficulties are likely to lead to long-lasting problems, since the basic skills are not available to be built upon.

 

Some authors have argued that deficits in right hemisphere functions may also interfere with the development of a cohesive sense of self. This could manifest in a variety of ways, depending on the severity of the problem. It is conceivable that some children could be at risk for thought disorder and psychotic disorders. Some children with right hemisphere dysfunction have also been reported to have disruptions in body image.

 

 

Characteristics of Nonverbal Learning Disability

 

Myklebust was probably the first person to describe the characteristics of children with problems processing visuo-spatial information. Subsequently, these children have been studied extensively by Byron Rourke and his colleagues, who have described a syndrome they call a nonverbal learning disability (NVLD). Sometimes, there is no known damage to the right hemisphere, but neuropsychological assessment suggests a dysfunction of the right hemisphere. Often, individuals who fit the criteria for a NVLD have some left-sided signs of brain damage (suggesting a right hemisphere impairment). They also tend to have a big discrepancy between their verbal skills, which are often excellent (at least at first appearance) and their visuo-spatial skills, which can be much lower. These children share many characteristics of the adults we described with right brain damage.

 

For example, they talk a lot but tend to go on about little of importance. They also have difficulty getting the main idea from a story or a movie, and get caught up in the details. As a result, they have difficulty reading for meaning, and thus do more and more poorly in school as they progress through the grades.

 

Above and beyond their academic difficulties, however, they also have serious problems in their social functioning. As young children, adults describe them as 'not fitting in'. They want to play with other children, but can't seem to figure out how to interact. Their difficulties in understanding nonverbal cues are a real handicap in social situations with other children, where much of the action is taking place on a nonlinguistic level. Often, they revert to maladaptive ways of getting attention, like clowning or acting out, or become withdrawn and depressed. It seems likely that many of these social and behavioral problems are related to a difficulty in comprehending the meaning of emotional information.

 

As discussed above, the cues that most people use to guide their behavior in a social situation, such as facial expressions, or gestures, are not likely to be available to a person with a right hemisphere dysfunction. These problems are not trivial: although we don't know how many individuals with right hemisphere dysfunction learn to compensate and adjust, we do know that many end up seeking help from psychiatrists and psychologists. Many have significant problems in school, frequently getting labeled as lazy, unmotivated, or a behavior problem. Because they speak fluently and seem to have the fundamental skills needed for reading, writing, and other academic tasks, their failure to achieve at grade level is attributed to an 'emotional' problem, rather than a learning disability. Fortunately, as researchers have learned more about this problem, more of these children are being diagnosed correctly and treated appropriately.

 

Specific characteristics of NVLD:

 

1. Social problems:  poor peer relations; inappropriate behavior; difficulty understanding social situations; gravitate toward older/younger playmates; withdrawn in social situations; "out of place"; poor sense of territoriality and violations of personal space (touching); acting out as in "class clown" behavior

 

2. Emotional problems:  poor understanding of emotional signals from others; difficulty interpreting personal emotional experience; inability to learn from past experience including social interaction; risk for depression and isolation; possible disruptions in sense of self and in ego development

 

3. Cognitive characteristics:  well-developed verbal abilities; visuo-spatial and visuo-motor deficits; poor handwriting; problems with reading for meaning and poor composition skills; difficulty with part-whole relationships and organizing information; problems with pragmatics of language such as context, intention, plausibility; trouble understanding metaphor and humor; serious arithmetic problems (spatial orientation, misreading of visual detail, procedural errors, failure to shift operations); geographical disability such as reading maps and finding one's way around a building or town; poor adjustment to change; overly dependent on verbal rules and regulations; literal, concrete, and problems with abstract thinking and judgment; significant differences in Performance IQ versus Verbal IQ with VIQ being better; problems understanding the passage of time and telling time

 

4. Motor problems:  motor impersistence; disorders in reflexes, weakness, muscle tone, gait abnormalities, tremors, incoordination (inability to learn to tie shoes is practically a pathognomonic sign), dysarthria (problems with articulation like slurring speech etc.), nystagmus; left-sided symptoms on neuropsychological testing

 

5. Attentional problems:  distractibility, difficulty concentrating; difficulty inhibiting input, behavior, etc.; can make them look hyperactive although typically not hyperactive but NVLD can co-occur with ADHD; sometimes lethargy and apathy (also giving up easily).

 

 

Special Strategies for Intervention and Treatment

 

 

General Guidelines

 

1.  Use verbal strengths to compensate whenever possible (e.g. ask for verbal feedback, repeat instructions, describe social situations verbally, devise verbal coping strategies).

 

2.  Use mechanical devices to compensate (calendars, word processors, beeping watches, calculators) for fundamental deficits in cognitive processing. Also outlining; learning to identify priorities; learning to distinguish essential from non-essential details; identifying main ideas; extracting meaning.

 

3.  Encourage kinesthetic sports to remediate motor deficits e.g. swimming, skating, skiing. Work on body image and physical relationships to object, other people, etc.

 

4.  Build a sense of self; self-esteem development; ego structure; learn to use activity, to generate and initiate activities; develop internal control and motivation.

 

5.  Social skills remediation: teach children/adults to understand feelings and to communicate appropriately e.g. conversational turn-taking, listening skills. Can take place either in therapeutic context, educational setting, or home. Also important to organize structured and supervised peer interaction settings e.g. Girl Scouts, swim team, day camp, computer club, etc.

 

 

Specific Therapeutic Strategies for NVLD Children

 

1.  The physical environment

 

Avoid extraneous material; keep surroundings simple

 

2.  General strategies and dealing with distractibility/impulsivity

 

Make it fun. Begin in non-performance mode. Build rapport.


Structure interactions


Make expectations clear/explicit verbal instructions


Be concrete, not abstract


Make consequences clear


Reinforce positive behavior


Small steps/just manageable differences


Keep up a steady stream of pragmatic information.

 

3.  Special circumstances to keep in mind

 

Child may have trouble remembering what you say from week to week


Child may be unable to describe his/her emotions


Child may not be able to interpret your tone of voice or body language


Child may have trouble understanding what your main point is


Child may interpret what you say very literally

 

4.  Social skills remediation

 

Understanding context e.g. purpose of therapy, other social situations/contexts

How to show you're listening

Communication: talking, listening, and turn taking

Using/understanding tone of voice

Appropriate touching/physical distance from others

Other social skills

 

5.  Focus on emotions

 

Verbalize what child is doing and child's emotions:

"I know it's hard for you to tell if I'm friendly. One thing you can tell is that I'm smiling."

Acknowledge feelings of confusion and failure

 

Strategies for emotion sessions:

 

Where is emotion in the body? What does your face look like when you have this emotion? What does the tone of voice sound like? When do you feel this way?

 

Generate strategies for dealing with emotions:

 

"Maybe you're nervous. Sometimes the best thing to do when you're nervous is..."

Verbally describe the strategy

Model strategy yourself

Play act with puppets

Now you try it (Note: Parenting Press, Inc. produces a useful series: "Dealing with Feelings." Books in the series include: "I'm Mad," "I'm Frustrated," and "I'm Proud.")


Act out scenarios: (e.g., going to the store; friend takes away your toy).

"What should we do?"  "What should we do now?" "How do you think I'm feeling now?"

 

Emotion games:

Act out an emotional scene either yourself or with puppets

Find the parts of the body that have the feeling

How do other people look?

What made the character angry?

 

6.  Build a sense of self

 

Work on self-esteem e.g. identify and reinforce values, strengths, beliefs

Develop appropriate body image (e.g. use drawings)

Encourage activities that person enjoys and that are rewarding

Encourage discrimination between pretend vs. real; identify relevant information and data; help person identify realistic expectations, understand limitations

 

7.  Working with families

 

Helping parents understand NVLD

Behavioral strategies, e.g. structure time/activities to help learn strategies for internal control and motivation

 

 

Copyright:  Wendy Heller, Ph.D., 1997

 

 

Dr. Heller is an Associate Professor and Director of Clinical Training, The Psychological Services Center, Department of Psychology, University of Illinois at Urbana-Champaign, where she also sits on the faculty at the Beckman Institute for Advanced Science and Technology. Portions of this article are excerpted, with the author�s permission, from a chapter authored by Dr. Heller entitled "Emotions," which appears in Neuropsychology: The Neural Bases of Mental Function, by Marie T. Barich, 1997. Houghton Mifflin.