Asperger`s Syndrome, and NVLD - Dartmouth

Asperger’s Syndrome,
and N V L D:
Academic Function and SchoolBased Interventions
A r t Maerlender, Ph.D.
Clinical School Services and Learning
Disorders Program
Child and Adolescent Psychiatry
NVLD
Characteristics
RELATIVE STRENGTHS
auditory-verbal perception and
memory,
• good phonological skills early in
development, and
• adequate motor skills that can be
learned by rote.
•
A . M a e r l e n d e r, 2 0 0 1
RELATVIVE
WEAKNESSES
•
•
•
•
•
A . M a e r l e n d e r, 2 0 0 1
poor visuo-spatial skills,
attention difficulties,
socio-emotional difficulties,
abstract thought weaknesses
sensory abnormalities
NLD vs Asperger’s Syndrome
NLD & Asperger’s
• No consensus about
differences
• Very similar
• Treatments overlap &
similar
A . M a e r l e n d e r, 2 0 0 1
NLD/AS:
Brain mechanisms
• left side motor findings
• mild diffuse EEG
• some imaging data showing
right frontal deficits
A . M a e r l e n d e r, 2 0 0 1
NP Profiles
• PIQ lower than VIQ
• Nonverbal mem. < verbal mem.
• visuoconstruction < auditorylinguistic
• motor & tactile worse on left
A . M a e r l e n d e r, 2 0 0 1
NP Assets
• auditory-verbal perception
• simple motor and tasks that can be learned by
rote
• good phonological skills are seen early
• verbal reception, repetition, storage, and
associations from early school years on
• high volume of verbal output is characteristic
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NP Deficits
•tactile and visual perception deficits early
in development
•
(includes attention to and memory for
material introduced through these
modalities)
•complex psychomotor tasks except those
that can be that can be learned through
extensive repetition
•language often used for inappropriate
purposes
A . M a e r l e n d e r, 2 0 0 1
NP Deficits, cont.
• aversion for novel experiences
impacts exploratory behavior
• age-appropriate concept formation
and problem solving
• linguistic deficits in content and
pragmatic dimensions of language
A . M a e r l e n d e r, 2 0 0 1
Socioemotional
findings
•
•
•
•
•
A . M a e r l e n d e r, 2 0 0 1
shyness
depression
anxiety
social isolation
deficits in eye contact,
gestures, prosody
Developmental Profile of
NVLD Through the Lifespan
No single, uniform
presenting picture of a
child with nonverbal
learning disorders.
A . M a e r l e n d e r, 2 0 0 1
In general
Delays in:
ü motor,
ü language,
ü exploratory behavior,
ü pragmatic language,
ü peer relations
ü over dependency on parents
A . M a e r l e n d e r, 2 0 0 1
into adulthood
• continued social/emotional
difficulties
• jobs often below ed. level
• internalization & higher
suicide rates
A . M a e r l e n d e r, 2 0 0 1
Prognosis
§ However, the prognosis is good for
these disorders
§
§
§
individuals can work
have meaningful relationships
be productive citizens
§ Higher functioning = better
prognosis
A . M a e r l e n d e r, 2 0 0 1
Academic
Prognoses:
sWord decoding and spelling
often develop to superior
levels.
sVerbatim memory, especially
for auditory-verbal material
often well developed (see
above).
A . M a e r l e n d e r, 2 0 0 1
Areas of emerging and
continuing concern
• reading comprehension,
mechanical arithmetic,
mathematics and science;
• difficulties often apparent
when reasoning, deduction,
etc. are required.
A . M a e r l e n d e r, 2 0 0 1
Written Language
Skills
•Enhancing connections to
specific interests in
vocabulary and
comprehension
development
A . M a e r l e n d e r, 2 0 0 1
Math and Science Skills
• Some dimensions of math and
science can be learned if
material is presented and
practiced in rote fashion
• Use formulas, algorithms
mnemonic devices
• Can learn to apply information to a
routine formula but might have
difficulty knowing which formula to
use.
A . M a e r l e n d e r, 2 0 0 1
A . M a e r l e n d e r, 2 0 0 1
Prognoses:
Psychosocial
Basic problems in
perception, judgment,
problem-solving, and
reasoning lead to
difficulties in social
competence.
A . M a e r l e n d e r, 2 0 0 1
At risk for...
• moderate to severe
psychopathology,
• especially of the
internalized variety;
• suicide.
• usually beginning in
adolescence
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Prognosis:
Psychosocial, cont.
• Activity levels tend to
decline to hypoactive levels
by late childhood.
• Long-term prognosis for
socio-emotional
development is guarded
A . M a e r l e n d e r, 2 0 0 1
Poor candidates for
insight therapies
• Individuals often are very persistent,
and frequently unaware of their
disability
• Behavioral tx. is needed
• BUT not necessarily CBT
• Establishing relationship is crucial
• Supportive therapy is helpful
A . M a e r l e n d e r, 2 0 0 1
School focused Treatment
&
Recommendations
The School’s Role
§ responsible for providing
educational opportunity
§ not solving all problems
§ IT IS IMPORTANT TO KEEP THE
FOCUS ON THE ACTIVITY AND
ASSESSMENT OF THE
EDUCATIONAL PROCESS
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Structured Teaching:
General Principles for
Teaching HFA/AS/NVLD
Kunce, L. & Mesibov, LB (1998).
•
•
•
•
•
routines
schedules
individual work systems
visual structure
physical organization of materials
• (might require specifically designed
classroom)
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1. Make the world (classroom
environment) as meaningful as
possible
child should understand
• expectations,
• arrangements,
• routines
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2. teaching requires BOTH:
• developing skills and
competencies,
and
• environmental modifications
to maximize strengths,
minimize weaknesses
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Primary Strategies for
Structuring the Environment
A . M a e r l e n d e r, 2 0 0 1
1. understand the
disorder
Issues include
• language understanding and
usage (incl. literal
interpretations)
• sensitivity to stimuli
• over-reaction to change
• repetitive behaviors
A . M a e r l e n d e r, 2 0 0 1
2. understand the unique child
(formal and informal
assessment)
Issues include:
• variability
• specific interests
• use of language
• strengths and weaknesses
• reaction to stress and frustration tolerance
• intellectual functioning and learning ability
*what works - what doesn't
A . M a e r l e n d e r, 2 0 0 1
Understanding the
Child/Student
§ each adult who works with child MUST FIND
SOMETHING TO LIKE ABOUT THIS PERSON
§ even though they do not process nonverbal info well, they can detect when
not liked
§ teachers may need to work on this
§ parable of the tooth
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3. make events consistent and
predictable
Issues include
a. practical, productive daily routines
throughout the day • rote behaviors best,
• systematic routines for things such as
washing hands before lunch,
• putting completed work in a specific
box,
• playing with specific person for 1st 5
minutes of recess.
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b. individualized, pictured and/or
written daily schedules - at
developmental level,
3don't include unnecessary info,
check off spaces, name, etc.,
3use notes for reminders on
schedule
• (e.g., "raise hand if questions",
specific rules)
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4. clarify instructions and
expectations
compensate for receptive
language problems
A . M a e r l e n d e r, 2 0 0 1
Issues include:
Structuring teaching strategies to
include both:
•a. developing skills and
competencies, i.e., target
specific language impairment
(help from SLP)
and
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b. environmental modifications
to maximize strengths, minimize
weaknesses;
3e.g., preferential seating
3adjusting level of spoken language
• syntax, semantics, prosody, volume:
• simplify, be concrete
3rely on written text
• e.g., provide notes; "turn to page 37";
refer to posted rules, schedules, etc.
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5. structure tasks and
assignments to promote
success
Issues
Ùchild focuses on details • missing big picture, prioritizing,
etc, slow output.
ÔPoor EF: planning, choosing,
integrating, organizing,
anticipating, inhibiting,
emotional control.
A . M a e r l e n d e r, 2 0 0 1
a. create an organizational
work system
communicate work
expectations:
• what needs to be done,
• how much work there is,
•when they will be finished
and
•what to do when finished.
A . M a e r l e n d e r, 2 0 0 1
Example Structure/schedule
___ turn in homework
___ group lesson p. 47
___ do problems p. 50, #1,3, 5
___ fill out homework sheet
___ have teacher sign
___ 10:15 leave for science
Use of baskets for younger kids, written
instructions for older ones.
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b. written task directions
vstep by step for both content
and general instructions
v operationalizes parts to whole
instruction
vtext or pictures
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c. additional supports
ü less info on pages,
ü larger print,
ü highlighting,
ü use of visual models,
ü reduced number of problems,
ü examples,
ü containers,
ü 2 sets of books,
ü good school-home communication
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d. structure assignments in
line with conceptual ability
• typically skills are in learning procedures,
mechanical skills
*(e.g., word identification, naming, rote
learning, associative memory).
• typical weaknesses in comprehension and
interpretation (abstract thinking, verbal
reasoning, complex memory - recall).
A . M a e r l e n d e r, 2 0 0 1
structure assignments
O assistance
Ø with importance (what is important),
amount of work,
Ø questions to answer,
Ø even sentence stems might be necessary.
O these skills (higher level, abstract) tend to
be more important in higher grades (why
these kids often do well in elementary).
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e. provide help and create helpasking routines
k observe progress
k provide help-asking scripts
or routines (even written
reminders)
k assertiveness training in
adolescents (social skills
scripts)
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6. cultivate and fully utilize
students' interests
vpair with students with
similar interest
vutilize for broadening
knowledge and skills
vreinforce less preferred
activities
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01
A Maerlender,
When to Use an Aide
Some ideas…
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Strongly consider a
MAINSTREAM AIDE if Child is
MARKEDLY:
4unable to focus, attend, sequence,
and organize
4disruptive without VERY close adult
attention
4needy of much help fitting into
classroom routine
4able to become very frightened
quickly unless rapidly reassured
A . M a e r l e n d e r, 2 0 0 1
BUT STUDENT HAS GOOD
ü General Intellectual Ability
(average to above IQ),
ü LEARNS FROM IMITATING
PEERS,
ü CAN GENERALLY TOLERATE
SIZE, ACTIVITY AND LOCATION
OF CLASSROOM, etc.
A . M a e r l e n d e r, 2 0 0 1
SOME QUALITIES OF AN AIDE
J WARM, CREATIVE, FLEXIBLE
J INTELLECTUALLY CURIOUS
J WILLING TO TALK TO PARENTS
J KNOWS WHEN TO GET HELP
J SOME BACKGROUND TRAINING
J BUILT-IN SUPERVISION FROM
J SOMEONE KNOWLEDGEABLE ABOUT
DISORDER
J NOT COMPETITIVE WITH PARENTS
A . M a e r l e n d e r, 2 0 0 1
J NOT AN ENABLER
Fading Interventions
/ Dependence is not as big an issue as often
made out to be
/ Important to deal with dependence issues
/ Support should be faded as mastery is
demonstrated
/ BUT, need for
• Follow-up
• Review
• Refresher
• May require several times
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Dealing with Explosive &
Inflexible Behaviors
A . M a e r l e n d e r, 2 0 0 1
Typical consequencereward systems do not
work
> too late in the chain of
behaviors
> assumes child needs
motivation and structure
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Motivation likely not an
issue
>Although often accused of ‘bad
attitudes’ & poor motivation
>kids know who’s boss
>know the consequences
>want to please
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A Lack of Developmental
Skills
Flexibility and frustration
tolerance are critical
developmental skills.
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In the School and
Classroom
_General ideas still apply
_Adopt a problem solving
approach
_often these children are less
explosive in school
Some General
Principles
¯ Consistency and
regularity
¯ Structure (be the frontal
lobes)
¯ Reduce goals, objectives
A . M a e r l e n d e r, 2 0 0 1
Consistency
_work to develop
consistency with parents
around:
k
k
specific language usage
identification of behaviors and
strategies
_ Make school day as predictable as
possible
A . M a e r l e n d e r, 2 0 0 1
Words, words, words
v adapt
consistent language for
elements of behavior
v tie-in with home for maximum
consistency
v include in notebook
v everyone child comes in contact
with
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IEP’s
üPrioritize objectives and
goals
üConsider cutting by 50% or
more
üUse the basket approach
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Make school
‘User-Friendly’
>adults must understand child’s
unique difficulties
•
as a team, review all cases that fall
into the category of inflexibleexplosive
*do NOT focus on diagnoses
•
A . M a e r l e n d e r, 2 0 0 1
obtain in-service training to help
staff understand these kids
User friendly schools
>reduce over-all demands for
flexibility and frustration tolerance
>team must review importance
levels
•
what is needed, what is child
capable of
>prioritize
>Repeat: the reality of IEP’s
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Identify situations
and triggers in advance
+ establish a notebook of important
information:
+
known triggers
• baskets and behaviors
• procedures for handling stages
(who as well as what)
•
A . M a e r l e n d e r, 2 0 0 1
Front-line teachers
need to be able to read warning
signals and take immediate action
• real
training
• one role of the aide
• use consultant, behavior specialist,
counselor psychologist to review
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Attitude and
interpretations
>incoherent behavior is incoherent
behavior
•
A . M a e r l e n d e r, 2 0 0 1
not oppositionality, poor parenting,
psychosis, etc.
What’s my line?
>teachers need to have a forum for
being able to honestly and nonjudgmentally recognize their role
that fuels inflexible-explosive
behavior
>this is often a personal style issue
A . M a e r l e n d e r, 2 0 0 1
Fair does not mean
equal
>students actually understand this
>no-one is ‘getting away’ with
anything
>everyone gets th help they need
other students can often be most
helpful
• but not their defined role
•
A . M a e r l e n d e r, 2 0 0 1
Alienation and deviance
ø once a pattern of alienation and
deviant behavior has been
established it is difficult to stop
ø the milieu maintains the
behavior
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Consider a change
in venue...
“Sometimes it’s best to cut yer
losses…”
mother placement where a new
start can be made
mcan return when healing has
occurred, kids have developed,
enough time has passed
A . M a e r l e n d e r, 2 0 0 1
Two Tracks to
Treatment:
I. creating better general
environments
II. direct training to improve
skills
A . M a e r l e n d e r, 2 0 0 1
Track I: The general
environment
“User Friendly”
>understand child’s unique
difficulties
>identify specific factors that
fuel inflexibilityexplosiveness
A . M a e r l e n d e r, 2 0 0 1
Understanding helps
maintain coherence
3recognizing that this is not a willful,
manipulative tactic is an important
first step
3demonstrate understanding of how
debilitating it is for her/him
3AGAIN: must be able to
demonstrate some level of likink
and respect for the person
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Anticipate frustrating
situations
B be
more careful and
judicious about
frustrating situations we
choose or allow for
her/him
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Eliminate unnecessary,
unimportant frustrations
è adult concerns about being ‘too
easy’, fostering dependence, being
a ‘push-over’
è eliminate unnecessary
roadblocks, known flash points
è most kids know who is in charge
but unable to respond due to
competing neurophysiological
processes
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Reduce overall level
of known frustrating
experiences
Such as:
changes in routine
homework
demands for independence
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#1 GOAL when the
pattern begins: Keep the
student/child coherent
†so he /she can think rationally
†allows for appropriate
responses and thinking through
situation
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Repeat: Much of this
requires Anticipation
a user-friendly environment is
one in which the adults have
identified
in advance
specific frustrating situations that
lead to inflexible-explosive
situations
A . M a e r l e n d e r, 2 0 0 1
Read the signs,
take quick action
K words,
tones, body language,
specific circumstances
§ are signals of early vapor lock
H start
with empathy and gentle
persuasion
H distractions
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Distractions
>should be enjoyable and require
minimal brain-power
µhumor
µmagic
cream
>these are short-term ‘de-icers’
µkeep
child from going into further
vapor lock
µremember - you can return to what
you were doing (and often SHOULD
signal: ‘let’s come back to this later’)
A . M a e r l e n d e r, 2 0 0 1
Downshift
>gradually change
agendas, expectations,
cognitive demands
• ‘rather
than do all those
problems right now, how
about we ...’
A . M a e r l e n d e r, 2 0 0 1
Self-Awareness
>adults must learn how to
recognize how they fuel
inflexible-explosive behaviors
• ignoring
warning signs
• demonstrating short-fuse
behavior
• being stressed
A . M a e r l e n d e r, 2 0 0 1
Use accurate, common
language to describe
v using consistent terms for stages and
behaviors will facilitate communication
and
v later processing
v Important to be consistent with home
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Create a culture of
mutual support
>Staff need to feel safe to accept
feedback about their own behavior
•
A ‘user friendly’ environment
applies to staff as well
> Modeling problem solving requires
•
•
•
A . M a e r l e n d e r, 2 0 0 1
Making mistakes
Accepting feedback
Trying new things
Track II:
Learning Frustration Tolerance
Frustration tolerance IS a skill to be
learned
Within a more ‘user-friendly’
environment, specific skills for
enhancing frustration tolerance can
now be -
taught,
3 modeled and
3 reinforced
3
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Priorities
step back for a moment
« Goals and priorities must be set
ahead of time
«
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Survival
Typical priorities:
8reduce the number of meltdowns
8help child maintain coherence in midst
of frustration
8prevent vapor lock
8restore coherence during meltdowns
A . M a e r l e n d e r, 2 0 0 1
Step 1:
Choosing Battles
>teaching inflexibleexplosive kids requires
constant decision:
“Is this behavior important
enough to risk a
meltdown?”
A . M a e r l e n d e r, 2 0 0 1
In short >reducing frequency of meltdowns
starts with choosing among
priorities and needs.
>short-term avoidance can be
important for long-term success
>This is about preventing a
runaway train.
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3 levels of importance
1. not important
2. important but not capable or
possible to address
3. important and capable with extra
help
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Management VS Teaching
§ every moment requires a
conscious decision: Is this a
teachable moment, am I trying to
meet learning goals (Basket B
later), OR
§ is this management and I/we need
something to happen now
§ learning takes a back seat to
getting the task done, such as a
safety issue.
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Specific Situations
and Factors
>When deciding if a situation,
factor or behavior needs
planned intervention,
consider:
•
A . M a e r l e n d e r, 2 0 0 1
importance levels -high priority?
If Important:
a Can child master demands
immediately?
a If not, can she/he with help?
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Letting go...for now
>Assumption: all kids WANT to be
independent, functional and
productive
>making decisions about
importance levels demonstrates
adult prioritization skills
A . M a e r l e n d e r, 2 0 0 1
Of all the important
behaviors to work on, how
to choose?
>Greene’s simple
approach to prioritizing
behaviors
>Using baskets A, B, & C
A . M a e r l e n d e r, 2 0 0 1
Basket A
>Non-negotiable items
• not
many
• recall that #1 priority is to reduce
overall number of meltdowns
>Safety (management)
• still
utilizing least intense,
antagonistic, restrictive methods
A . M a e r l e n d e r, 2 0 0 1
Basket A items
must
>be behaviors important enough to
induce or endure a meltdown over
>be behaviors the child can
demonstrate appropriate (within the
range of improvement)
>be things parent/teacher is willing
and able to enforce
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Basket B
>high priorities
>but not willing to induce endure
meltdowns over
>the most important basket
A . M a e r l e n d e r, 2 0 0 1
Goal of Basket B
>identifying behaviors that require
new skills for handling better
hanging in in the midst of
frustration
• taking another’s perspective
• generating alternative solutions
• thinking things through
•
>showing child that you are able to
help him/her learn these things
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What to do when a Basket
B behavior happens...
in a word:
COMPROMISE
A . M a e r l e n d e r, 2 0 0 1
Compromise
.each side gives up demands
or makes concessions
.the pathway to staying
coherent
.persistence is NOT
compromise
A . M a e r l e n d e r, 2 0 0 1
The art of
compromising
>help child re-state the problem
>does solution make everyone a
little happy?
•
A . M a e r l e n d e r, 2 0 0 1
might need skills in how to ask
And if no compromise is
possible...
>it might move to Basket C
>remember goal of reducing
meltdowns
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Basket C
rvery full
rbehaviors to forget about...for
now
rhelp achieve the goal of reducing
global frustration level
A . M a e r l e n d e r, 2 0 0 1
Who decides?
>what behaviors go into what
baskets
• parent
• school
team
• responsible adult
A . M a e r l e n d e r, 2 0 0 1
Details that might require
additional
thought/planning
7communication
patterns
7identifying specific situations
7social skills
7other kids in classroom
~ Remember:
equal
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fair is not necessarily
The Need for
Performance Indicators
PGood IEP’s do not
guarantee delivery of
service
PHow can a parent/school know if the
plan is being implemented?
PAnd, are strategies working?
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Build accountability
indices into the plan
sSpecify regular monitoring
monthly, bi-monthly, etc.
sTWO STRATEGIES
(not mutually exclusive)
1. Advocacy
2. Work products and performance
indicators
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Performance Indicators
þ Teacher/aide checklists
þ Outside observations of target behaviors
for implementation of strategy
þ Summaries of sessions
þ Work system products
• completed checklists, schedules, homeschool communications log, etc.
§ Attendance
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Advocacy
J Parents are the first line
J Use of the cognitive
coach/therapist/mentor
4as ‘case manager’
4as communications link
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Thank you
A . M a e r l e n d e r, 2 0 0 1
Specific Content Areas
§This presentation will be posted at:
www.dartmouthpsychiatry.org/
healthinformation.htm
“NVLD 2/8/01”
A . M a e r l e n d e r, 2 0 0 1
References
Greene, RW (1998). The explosive child: A new approach to
understanding and parenting easily frustrated, “chronically
inflexible” children. NY: HarperCollins
Fisher, NJ & DeLuca, J (1997). Verbal learning
strategies in adolescents and adults with the
syndrome of Nonverbal Learning Disabilities.
Child Neuropsychology, 3, 192-198.
Gross-Tsur et al (1995). Developmental righthemisphere syndrome: Clinical spectrum of the
nonverbal learning disability. Journal of
Learning Disabilities, 28, 80-86.
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