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Patients who present with impairment in academic, cognitive, social, and vocational functioning might be struggling with an unrecognized learning disorder. Ten percent of the US population has some form of learning disability, and up to 40% of those with learning disorders may meet diagnostic criteria for a psychiatric disorder.1,2 Some learning disorders affect a person’s ability to read, write, or do math, whereas less-recognized nonverbal learning disorder (NLD) impacts the social and emotional functioning of children, adolescents, and adults. Common features of NLD include:
- deficits in nonlinguistic information processing
- speech prosody deficits
- difficulty reading facial expressions
- associated impairment in interpersonal functioning.
The severity of these deficits varies among individuals with NLD. Patients may experience chronic low self-esteem, anxiety, and mood symptoms because of their limited ability to express their feelings within an appropriate social context. NLD may be first misdiagnosed as attention-deficit/hyperactivity disorder (ADHD), bipolar disorder (BD), or Asperger’s disorder.
In this article we review the underlying neurophysiology of NLD and present a clinical approach to these patients, including the differential diagnosis and factors that will allow clinicians to distinguish NLD from psychiatric conditions with symptomatic and syndromic overlap. We also describe treatment for patients with NLD.
The learning process
Learning is a cognitive process of acquiring and processing information and experiences from the environment that allows us to acquire knowledge, skills, and social abilities. When we learn how to relate to others, we undergo neurophysiologic changes that subsequently influence behavior and the way we understand our environment. Deficits in learning processes or the ability to acquire relational skills result in impaired affect regulation in regard to others and may lead to low self-esteem, depression, anxiety, interpersonal conflict, and anger toward others. Learning influences a person’s ability to navigate social relationships and perform academically and occupationally.
The impact of learning deficits may be magnified in adulthood after an individual has suffered years of in-securities and poor self-esteem. Adults with learning disabilities often seek psychiatric treatment as a result of their disappointment about difficulties in relationships and work. NLD may coexist with or mimic other neuropsychiatric disorders. For example, problematic behavior within a family or at the workplace is a common reason for referral to a psychiatrist. These behaviors may be influenced by a patient’s NLD symptoms, which can complicate diagnosis and treatment.
Persons with NLD are at increased risk for depression because of failures in coping, loss of self-esteem, internalized psychopathology, and other social and emotional strains. In addition, individuals with NLD may experience multiple psychosocial impairments, including difficulty maintaining employment, achieving goals, and maintaining relationships.3
A variable presentation
NLD has been associated with right hemispheric dysfunction.3 For a description of the neurophysiology of NLD, see this article at CurrentPsychiatry.com. In childhood, NLD may present as deficits in:
- processing nonlinguistic information
- expressing or comprehending nonverbal components of language such as pitch, volume, or rate of speech (aprosodia)
- reading facial expressions
- social or emotional functioning, such as difficulty understanding social situations, violations of personal space, or difficulty learning from past emotional experiences.4
The extent of these deficits varies among patients. As children, patients with NLD often show strengths in rote verbal memory, spoken language mechanics or form, and word reading. These children may be hyperverbal and use language at a level higher than expected for their age group, which may mask some learning difficulties and delay diagnosis.
Throughout life, NLD manifests as difficulty interacting with peers. Children with NLD may have difficulty playing with others and making friends and as result may feel socially isolated. Without the critical skills of social reciprocity or understanding social context, NLD patients often have many superficial friendships but lack deep relationships.4,5
Patients with NLD may rely on their verbal skills for relating socially and relieving anxiety and tend to withdraw from social situations as they become aware of their deficits.
NLD can be characterized on the basis of primary, secondary, and tertiary deficits. Primary deficits in tactile and visual perception and complex psychomotor skills lead to secondary deficits in attention and exploratory behavior, which lead to tertiary deficits in memory and executive function.6
Given NLD’s variable presentation, clinicians must remain vigilant to this possible diagnosis in patients with a history of multiple pharmacotherapy or psychotherapy failures for axis I disorders. Using clues from symptoms described in Table 17 may provide information necessary to refer for formal psychoeducational testing to diagnose NLD. Early diagnosis can help target NLD symptoms and tailor treatment of comorbid psychopathology.7 NLD is a chronic disability and—similar to other learning disabilities—early, targeted interventions initiated by parents, teachers, and clinicians can improve outcomes.