Question # 45 FONT>
Are there any forensic implications for persons with NLD?
Answer: There are many; here are a few of
them. (Numbers are Q & As)
Generality of Effects (#36)
It is widely acknowledged that LD are the result of disordered brain functions
(Collins & Rourke, 2002; Stelmack, Rourke, & van der Vlugt, 1995).
LD do not start and end at the school-room door. The brains that maintain LD are
not picked up when exiting the school bus in the morning and put back in the school locker
before embarking on the trip home in the afternoon. More generally, LD usually commence well
before entry into the school system, and they tend to persist well beyond school termination
(Tsatsanis & Rourke, 2008). Along the way, they are very likely to have significant implications
for learning in venues of functioning that are quite distinct from schools and other formal learning
situations. Indeed, persons with NLD learn far better within a highly structured classroom than they
do in ambient, everyday situations.
Aversion for Novelty (#3)
The person with NLD experiences considerable difficulty in dealing with novel circumstances, whether it be an oxymoron (e.g., jumbo shrimp) or a mismatch between pictures and words. Driven by their penchant for ascribing salience to words (either spoken or written), and their tendency to interpret words concretely rather than figuratively, it makes sense to ascribe their deficit to a failure in intermodal integration. Having no previously overlearned code to deal with such situations, their interaction and capacity to deal with them are predictably nonadaptive. To complicate matters, persons with NLD often exaggerate the "newness" of a situation. Because they tend not to "catalogue" previous experiences into meaningful schemata (categories of understanding) due to deficiencies in concept-formation (a prerequisite for categorization), what may seem to the average observer to be a small and insignificant variation from a previously encountered situation may, unfortunately, strike persons with NLD as radically different from anything previously experienced. Thus, what most would consider a trivial variation of overlearned experiences may be construed as completely novel to the person with NLD. A moment's reflection will reveal that the repetition of such "newness" throughout the course of a day may lead to much confusion, anxiety, and even panic attacks.
Adaptability to novel interpersonal situations is the hallmark of socially appropriate individuals. A combination of aversion for novelty, failure sometimes even to appreciate that an event is in fact novel, poor problem-solving and hypothesis-testing skills--all of these conspire to render spontaneous, smooth adaptation to the constantly changing milieux of social groups and the interactions nascent therein all but impossible for individuals with NLD.
Problems in lntermodal Integration
Included among the difficulties that arise from limitations in the capacities of the person with NLD for intermodal integration are the following: problems in the assessment of another's emotional state through the integration of information gleaned from his/her facial expressions, tone of voice, posture, psychomotor patterns, and so on; limitations in the assessment of social cause-and-effect relationships because of a failure to integrate data from a number of sources such as is often necessary in order to generate reasonable hypotheses regarding the chain of events in social intercourse; failure to appreciate humour because of the complex intermodal judgments required for assessing the juxtaposition of the incongruous; imputing of unreasonable, trite, and/or over-simplified causes for the behaviour of others, and imparting such assignations in situations that would lead to embarrassment for the person so described.
These are but a few of the consequences that accrue for the person with NLD because of the difficulties that he/she experiences in integrating information from a variety of sources. Such unfortunate outcomes, of course, are much worse when he/she is anxious and confused (as becomes increasingly common) in novel or otherwise complex situations.
Executive Functions (#27)
Concept-formation, problem-solving, strategy-generation, and hypothesis-testing/appreciation of informational feedback: Marked deficits in all of these areas are apparent in persons with NLD, especially when the concept to be formed, the problem to be solved, and/or the problem-solving milieu(x) is/are novel or complex (Fisher, DeLuca, & Rourke, 1997; Strang & Rourke, 1983). Also evident are significant difficulties in dealing with cause-and-effect relationships and marked deficiencies in the appreciation of incongruities (e.g., age-appropriate sensitivity to humour). Most noticeable when formal operational thought becomes a developmental demand (i.e., in late childhood and early adolescence), relative deficits in these areas tend to increase markedly with advancing years, as is evident in the often widening gap between performance on rote (overlearned) and novel tasks.
One example of generally impaired capacity to appreciate cause-effect relationships: failure to appreciate the consequences of one's own behaviour (e.g., #22)
Psychosocial Dimensions (Content & Dynamics; #18)
The pattern of psychosocial disturbance exhibited by persons with NLD is considered to arise directly from the interactions among their primary, secondary, tertiary, and linguistic neuropsychological assets and deficits. For example, their deficits in social judgment and interaction appear to result from more basic limitations in reasoning, concept-formation, and intermodal integration-- problems that also lie at the root of their difficulties in mechanical arithmetic (Rourke, 1993; Strang & Rourke, 1983). Adaptability to novel interpersonal situations is the hallmark of socially appropriate individuals. A combination of aversion for novelty, failure sometimes even to appreciate that an event is in fact novel, poor problem-solving and hypothesis-testing skills--all of these conspire to render spontaneous, smooth adaptation to the constantly changing milieux of social groups and the interactions nascent therein all but impossible for the child or adult with NLD. Deficits in visual-perceptual organizational skills are thought to give rise to their problems in deciphering the meaning of various facial expressions, gestures, and other forms of paralinguistic information important for effective human communication.
In addition to the psychosocial problems associated with limitations in intermodal integration, clumsiness and poor psychomotor skills (e.g., eye-hand coordination) make it likely that such individuals will be regarded as social misfits. As a result, they are often ridiculed and ostracized. Because of these experiences, it is expected that there will be an increased likelihood of social withdrawal, isolation, and pervasive sadness on the part of the person with the NLD syndrome. It should also be clear that this state of affairs would increase greatly the probability that those individuals so afflicted will feel that others do not wish to be with them; that their behavioural expressions are seen as silly and the object of ridicule; that they are impotent in the face of what are for them challenging circumstances (but with which others seemingly deal without difficulty). Thus, it should come as no surprise that depression and suicide attempts are greater than average in individuals who exhibit this syndrome (Rourke, Young, & Leenaars, 1989).
Issues related to psychosocial subtypes more generally and the differences evident in early presentations and long-term psychosocial outcomes for children who exhibit LD and other subtypes of LD can be found in the References/Bibliography section. Two of the more important conclusions of this work are as follows: (1) children who exhibit NLD appear very much at risk for the worsening of their psychosocial status (especially the development of significant degrees of internalized psychopathology) with advancing years; (2) children who exhibit Basic Phonological Processing Disabilities (BPPD) appear to be at only slightly higher risk for psychosocial disturbance than do their normal learning peers, and there is no reliable evidence that children with BPPD are at greater risk for psychosocial disturbance with advancing years. Additional information and discussions of the psychosocial dimensions of NLD are contained in Rourke, van der Vlugt, & Rourke, 2002).
Limitations in formal reasoning, problem-solving, and the like, would be expected to render the person with NLD quite gullible. This means that the person with NLD may be led into all sorts of risky situations, and thrown into the presence of all sorts of people who are prepared to exploit the person in an unethical manner and place the person in harm's way. Furthermore, the person with NLD is usually very desirous of acceptance and affection. A moment's reflection will indicate the neuropsychological underpinnings of a prostitute (with NLD) who is content to be totally dependent upon the whims of her procurer.
Another example: It is sometimes the case that the person with NLD eagerly joins a delinquent group. After all, such a group provides guaranteed "friends" and a certain amount of structure in the chaotic world that the person with NLD experiences.
Participation in delinquent activities is part of the "price" paid for acceptance within the group. Unfortunately for the person with NLD, it is often he who is left "holding the bag" when a delinquent venture fails. Thus, the person with NLD is often the one who "takes the fall" for the delinquent group.
(b) Panic Attacks (#33)
Not immediately grasping the novel dimensions of a situation, the person with NLD is likely to feel considerable uncertainty and even threat. This perception of threat, and the immediate judgment that he has no resources for dealing with it, would be expected to lead to anxiety. Continuing in this state, and perceiving no means for exiting the situation, his anxiety may rise to the level of panic. Such an "attack" has the psychic "benefit" of distancing oneself from the situation by focussing on inner turmoil rather than the threatening external event. It is easy to see that persons with NLD are particularly prone to this sequence of events, ending in panic, because they prefer to deal with highly-overlearned situations. These are situations that they have encountered numerous times and to which they have become accustomed without any accompanying feelings of anxiety. Novel situations constitute drastic departures from these sorts of familiar, routine events and their attendant well-learned performance demands. Novel situations usually do not include a simple behavioural menu that can be followed for adaptation to them. They may require any or all of these dimensions: exploration; problem-solving/trouble-shooting; trial-and-error learning with the appreciation for informational feedback; new concept-formation; and unrehearsed/unpracticed performances. All of these are prominent deficits/limitations for persons with NLD (see NLD Content & Dynamics). Thus, it should come as no surprise that the person with NLD is particularly prone to the experience of threat in novel situations, with consequent anxiety because of no readily available behavioural rubric to deal with this threat. In such a situation, with no clear way to alter or exit it, the person with NLD is likely to experience what is commonly referred to as a panic attack.
In the midst of such an attack, the person may perform in a very nonadaptive manner, much as a drowning person might fight with his rescuer.
(c) Depression (#38)
It should be clear that persons with NLD are particularly prone to the development of Depression as part of a "package" of internalized psychopathology that often appears in late childhood and throughout adolescence (see Content and Dynamics; Question #18), The development of Depression in persons with NLD appears to result from a combination of factors that lead to fairly consistent experiences of failure, especially in social relating, and even ostracism by valued others and peers. The child/adolescent with NLD finds that he is not invited to birthday parties, not chosen on teams, not sought out for companionship and conversation, and the like. Because of his gullibility, he may also be led into compromising, even abusive, situations that result in much grief and anxiety. Developmental Dynamics. Like many young children, adults with NLD do not initially see the inherent value of social relationships beyond the pragmatic level of ensuring one's needs are met. As the young adolescent becomes more aware of the value of social relationships, this reflects improved "insight." This is a positive development, but one that can be quickly overshadowed by the personal recognition (another "insight") of not having a social network to enhance one's enjoyment of life. At this stage, one might observe increased agitation, or increased withdrawal, symptoms which should not be ignored or dismissed as simply a part of the NLD syndrome. This combination of social failures, ostracism, and/or abuse quite "naturally" leads to withdrawal from the situations in which these psychologically painful experiences usually occur. The adolescent with NLD may gravitate more and more to solitary activities and/or to those social encounters that involve much younger persons or adults. This almost certainly leads to problems in identity formation through a lack of opportunities for imitation and experimentation resulting from a lack of contact with age-mates who exhibit such roles. Instead, the adolescent with NLD is very likely to be drawn toward the kind of interactions mentioned above that tend to be quite unexciting and dull. The fact that many adolescents with NLD are described as drab, unemotional (flat affect), even sullen, is probably at least a partial reflection of this dull, prosaic world wherein they feel relatively safe, and the underlying Depression that is developing as a reaction to continued interactions with it. The absence of growth-engendering psychosocial experiences with age-mates only exaggerates and exacerbates these problems. Caveat: It is important to bear in mind the following: The prudent clinician will not attribute all symptoms of muted emotional presentation, in the individual case, to the neurodynamics of NLD. Conversely, she/he will not automatically attribute all symptoms of muted emotional presentations in a person with NLD to Depression.
With respect to the entire spectrum from influences on criminal activity, the crimes themselves, and the courtroom, persons with NLD will quite likely exhibit:
(a) Proneness to be lured and duped into criminal activity.
(b) Diminished capacity to understand the nature and consequences of their criminal activities.
(c) Diminished capacity to understand the charges brought against them, and their consequences.
(d) Reluctance to engage in their own defense.
(e) Serious limitations regarding their capacity to mount or participate in their own defense.
The interested reader may wish to consult the Q & As listed in conjunction with the following sets of circumstances. These are mentioned only as examples of the possible impact of NLD on these matters.
It is clear that there is much more research necessary to clarify such issues. The three examples cited have to do with a common reason for referral for neuropsychological assessment (traumatic brain injury), a series of incidents that often triggers medical malpractice suits (perinatal complications), and one type of potential neurotoxicity (mercury exposure).
(a) Traumatic Brain Injury [TBI] (#30, #43)
It is common for persons who have suffered significant TBI to exhibit NLD. It is sometimes the case that NLD precedes the TBI event. Sorting out what was extant prior to the TBI and what resulted from the TBI (e.g., NLD) is no easy matter.
(b) Perinatal Complications (#35)
Tracing an etiology from such complications to the evidence of NLD in adulthood is very difficult, if not impossible.
(c) In utero Mercury Exposure (#44)
The are several distinctions to be made with respect to mercury, but there is no reliable evidence that individuals exposed to high levels of mercury exhibit NLD at greater levels than those evident in the general population.
Collins, D. W., & Rourke, B. P. (2003). Learning-disabled brains: A review of the literature. Journal of Clinical and Experimental Neuropsychology, 25, 1011-1034.
Fisher, N. J., DeLuca, J. W., & Rourke, B. P. (1997). Wisconsin Card Sorting Test and Halstead Category Test performances of children and adolescents who exhibit the syndrome of Nonverbal Learning Disabilities. Child Neuropsychology, 3, 61-70.
Rourke, B. P. (1993). Arithmetic disabilities, specific and otherwise: A neuropsychological perspective. Journal of Learning Disabilities, 26, 214-226.
Rourke, B. P., & Conway, J. A. (1997). Disabilities of arithmetic and mathematical reasoning: Perspectives from neurology and neuropsychology. Journal of Learning Disabilities, 30, 34-46.
Rourke, B. P., & Tsatsanis, K. D. (1996). Syndrome of Nonverbal Learning Disabilities: Psycholinguistic assets and deficits. Topics in Language Disorders, 16, 30-44.
Rourke, B.P., Young, G.C., & Leenaars, A. (1989). A childhood learning disability that predisposes those afflicted to adolescent and adult depression and suicide risk. Journal of Learning Disabilities, 21, 169-175.
Stelmack, R. M., Rourke, B. P., & van der Vlugt, H. (1995). Intelligence, learning disabilities, and event-related potentials. Developmental Neuropsychology, 11, 445-465.
Strang, J. D., & Rourke, B. P. (1983). Concept-formation/non-verbal reasoning abilities of children who exhibit specific academic problems with arithmetic. Journal of Clinical Child Psychology, 12, 33-39.
Strang, J. D., & Rourke, B. P. (1985). Adaptive behavior of children who exhibit specific arithmetic disabilities and associated neuropsychological abilities and deficits. In B. P. Rourke (Ed.), Neuropsychology of learning disabilities: Essentials of subtype analysis (pp. 303-328). New York: Guilford Press.
Strang, J. D., & Rourke, B. P. (1985). Arithmetic disability subtypes: The neuropsychological significance of specific arithmetical impairment in childhood. In B. P. Rourke (Ed.), Neuropsychology of learning disabilities: Essentials of subtype analysis (pp. 167-183). New York: Guilford Press.
Tsatsanis, K. D., & Rourke, B. P. (2008). Syndrome of Nonverbal Learning Disabilities in adults. In Wolf, L. E., Schreiber, H.E., & Wasserstein, J (Eds.), Adult learning disorders: Contemporary issues. (pp. 159-190). New York: Psychology Press.