Children with NVLD have an impaired ability to read facial, gestural, and prosodic cues in language, as well as having parallel deficits in expression, with reduced gestures, flat facial affect, and monotonous prosody. These children often misread social cues and misinterpret social situations. They have great difficulty in navigating new situations and may apply previous experience in a rote but inappropriate fashion. This often results in difficult interpersonal relationships and a tendency to withdraw socially.
The typical child with NVLD has a psychoeducational profile characterized by a verbal IQ that exceeds the performance IQ with coding and block design subtests often significantly lowered. Reading achievement exceeds mathematics achievement but in time it becomes apparent that rote reading is much better than comprehension and abstract inference.
Language is usually significantly involved in NVLD. Pragmatics (such as maintaining eye contact while talking) and prosodics are often poor in these children. Singing or following melodies are equally impaired. These children often fail to grasp verbal humor and usually are reduced to engaging in practical jokes, often inappropriate, and sometimes with disastrous social results.11 Rote language is good but complex language is often deficient.
From poor neuromotor integration to frank apraxia, these children often display a spectrum of neurological findings detectable through a careful neuromotor examination for lateralized deficits, particularly when evoking more subtle signs. The Neurological Examination for Subtle Signs12 describes a system for a structured clinical neuromotor examination that can be quantified for research purposes. Evoking any laterality (especially for motor integration) can indicate a potential for an underlying neurointegrative deficit that reveals the potential neurological basis of a child's defects.Interventions for NVLD
The ability to define that a child has an NVLD can give all who work with the child a common conceptual basis for intervention. The treatment for these children is often complex and multifaceted. Environmental modification and behavior management, including metacognitive strategies such as social stories,13 are techniques that have the greatest success in NVLD. Emphasizing strengths and developing reasonable bypass strategies are critical to the success of any program. For example, helping the child understand the linguistic context of poor prosody and the way it negatively impacts classroom relationships can open new avenues for interaction that may be more purely verbal. Finding physicians who know how to evaluate youth for NVLD and subsequently guide interventions may be difficult. Some academic child psychiatrists and pediatric neurologists may have expertise in this area, as may some academic clinical psychologists. The clinical psychologist may need to ask peers where they have successfully been able to refer patients in the area.
Pharmacological response in NVLD is variable and not well studied. The use of a-adrenergic antagonists, tricyclic anticonvulsants(such as carbamazepine(Drug information on carbamazepine)), and the second-generation antipsychotics may be more effective than psychostimulants.14 Nevertheless, the precise behavioral targets for each of these agents have not been well defined. Any treatment strategy must clearly identify the neurobehavioral component that is the target for this intervention (eg, impulsivity) before treatment is begun. Integration with other behavioral strategies is a must.13Sensory processing disorders
Sensory processing is the interpretation and organization of sensory input. It enables the child to form a response. Sensory information can be external (tactile, visual, auditory, olfactory, gustatory) or internal (vestibular, proprioceptive, interoceptive). The sophisticated structures of the sensory organs, neural pathways, and cortical organization provide an extensive amount of information on the quality, intensity, and location of the stimulus. The reticular system, right hemisphere, and limbic system provide additional prioritization and associations and also assign meaning and affective qualities.
In addition to the reception of sensory input, simultaneous information must be integrated. Competing cues are modulated and must be discriminated from each other. Some of this process is conscious, but most is not. The results have an effect on the patient whether or not he or she is aware of it. Efficiency of sensory processing can enhance a multitude of functional skills. Abnormalities in sensory processing can cause a spectrum of deficits, ranging from insignificant eccentricity to devastating dysfunction.
Many people have problems with sensory processing; often, these are fairly insignificant. However, if abnormalities cause distress and dysfunction, one is considered to have SPD. Certain patterns of pathological sensory processing have been described.15-17 Symptoms in children with SPDs may appear to be very inconsistent, fluctuating hour-to-hour, or even combining overresponsivity in one area with underresponsivity in another. Electrodermal testing can confirm poor regulation of the autonomic nervous system as at least one contributing factor.18,19
It is estimated that 5% to 15% of the general population has some type of SPD severe enough to warrant intervention.16 Postulated risk factors include family history of SPD, perinatal complication, institutionalization,20 and physical or sexual abuse. The incidence is increased in children with autistic spectrum disorders (78%), ADHD (40% to 60%), and a number of other disorders.16