A New Take on Nonverbal Learning Disorder (NVLD)

Nonverbal learning disability (NVLD) been recognized for more than 60 years as an unofficial diagnosis for children who have difficulty with what’s called visual-spatial processing. Visual-spatial processing is how the brain  integrates and interprets visual information, whether you’re doing a puzzle, reading a diagram, or catching a ball. The disorder was named nonverbal learning disorder to distinguish it from language-based, or verbal deficits like dyslexia.

NVLD was recently estimated to affect 3-4 percent of North American young people — rates similar to that of autism spectrum disorder. But it is not included in official diagnostic manuals like the DSM.

That absence has led to lack of consistency in how NVLD is defined as well as in the assessments used to diagnose it. As a result, it often goes unrecognized or misdiagnosed, leaving young people with these visual-spatial challenges without access to effective supports or accommodations.

To address this situation, a group of experts has been working since 2017 to define NVLD in more precise diagnostic terms and to gain consensus on that definition among clinicians and researchers in the field, with the goal of having NVLD included in future versions of the DSM. This work has been supported by the NVLD Project, a nonprofit organization focused on raising awareness and understanding of NVLD. The first step towards DSM acceptance of the disorder is getting it accepted as a “condition for further study.” In the process, the working group has reframed and renamed NVLD as developmental visual-spatial disorder (DVSD).

“Getting NVLD reconceptualized as DVSD and into the DSM will make it much better understood and more broadly recognized,” said Prudence Fisher, PhD, a professor and researcher in child psychiatry at Columbia University who coordinated the working group. “Many more clinicians will be able to identify it, and teachers will have a clear basis to make an action plan for these kids.”

Visual-spatial processing involves understanding and mentally manipulating visual information. That means skills such as judging distances, visualizing objects in different positions, understanding how objects relate to one another in space (including one’s own body), and recognizing patterns and shapes.

Visual-spatial deficits are associated with an array of challenges that children with NVLD experience. As toddlers, they find it hard to build with blocks or do puzzles. Later, they struggle to get math concepts and understand diagrams and graphs. It’s a challenge for them to organize their backpack, clean their room, or make their bed. They have trouble navigating a school building and are prone to getting lost. They may not notice social cues, which can make it difficult to connect with peers. And they may have poor coordination and find it difficult to play sports.

The challenges kids with NVLD have are academic, social, and physical, but they are all associated with the brain’s ability to construct a spatial map from visual input, allowing it to organize information and respond effectively.

Older thinking about NVLD saw it as a sort of gestalt of problems, explains Amy Margolis, PhD, a professor of psychiatry and behavioral health at The Ohio State University who has done research on NVLD and is a member of the working group. “The real breakthrough in what we’ve done in the last 10 years is to clean up this messy approach. NVLD is a visual-spatial deficit, and there are associated functional impairments. It’s not syndromic, it’s single-deficit disorder.”

Consensus on the definition and inclusion in the DSM would have a host of benefits: 

• Eliminate confusion: The name “nonverbal learning disability” causes confusion, as the term “nonverbal” is often interpreted to mean that the child doesn’t speak, while in reality young people diagnosed with NVLD often have strong verbal abilities.

• Distinguish it from specific learning disorders: Most DSM learning disorders focus on specific academic skills, like reading or math. DVSD affects several life areas — not just academics. The new name eliminates confusion and positions it as a neurodevelopmental disorder like ADHD or autism spectrum disorder.

• Educate clinicians: “Since it’s not in the DSM, people don’t know what it is and it’s not included in clinical education, unless maybe you’re in neuropsychology,” notes Dr. Fisher.  So these problems are unknown to many mental health professionals, and young children are not screened for them.

• Improve diagnosis and treatment planning: The reframing gives clinicians a distinct diagnostic category for visual-spatial deficits, with consensus on the criteria enabling consistent screening. It would also alert them to the need to adapt treatment for other mental health disorders that involve visualizations.

• Improve access to services and insurance coverage: A DSM label facilitates reimbursement for diagnosis, neuropsychological evaluation, therapy, educational services, and accommodations.

• Stimulate research: Clear diagnostic criteria encourage studies on DVSD’s neurobiological bases, prevalence, and associated functional impairments as well as effective interventions.

In 2017, a diverse group of NVLD experts met at Columbia University to begin the process of forming a DSM-style definition of NVLD, with consensus on terminology and a set of diagnostic criteria. The gathering, as well as one that followed in 2018 and numerous conference calls and discussions, was sponsored by the NVLD Project.

Consensus was reached on an initial set of criteria centered on visual-spatial deficits, and the new name, DVSD. Over the next several years, the criteria underwent repeated refinement, informed by feedback sessions with clinicians, researchers and educators. Data was also collected on the acceptance of the new name from adults who self-identify as having NVLD, and parents of children with NVLD.

Drs. Fisher and Margolis are co-authors on a report of the process that was published in the Journal of the American Academy of Child and Adolescent Psychiatry, which lists members of the working group and other significant advisors.

In May 2022, a proposal was submitted to the American Psychiatric Association’s DSM Steering Committee to include NVLD in as a condition for further study in the DSM. The committee responded that data on the performance and utility of this newly developed criteria set was needed before it could be considered. Since 2023, Drs. Fisher and Margolis and their teams have been conducting field trials to collect real-world data on the criteria’s reliability, clinician usability, and impact in advance of another submission.

Like all neurodevelopmental disorders, symptoms of DVSD vary from one child to another, so the first step to getting help for a child is to figure out exactly what kinds of problems they are facing. To be diagnosed with DVSD, a child must have persistent deficits in processing visual-spatial information that are manifested by problems in at least four of the following areas:

• Visual-spatial construction. This could include things like putting together puzzles or models, building with blocks or LEGOS, drawing or copying shapes. It could also mean difficulties putting clothes or shoes on correctly or making a bed. And it could include problems with forming mental images when hearing or reading a book.
• Three-dimensional thinking. This involves things like imagining how something looks when rotated or visualizing how things will fit in a defined space, like packing a bookbag or suitcase. It could include problems with math that requires thinking about three dimensional shapes (such as cones, cubes, spheres) or volume, and problems with mental route finding.
• Visual-spatial memory. This involves things like remembering layouts of a school, a neighborhood, a local store, or a friend’s home. It could include difficulty remembering where they left possessions like a bookbag or bike.
• Visual-spatial estimation and/or reasoning. This could include problems with estimating length, size (whether one object is bigger than another), area, quantity, or distance, or how fast something is moving (such as knowing when it is safe to cross the street). It could also involve challenges with efficiently using space on a piece of paper or filling out a worksheet.
• Interpreting information presented pictorially. This can involve trouble making sense of figures, diagrams, or graphs; grasping how pictures in a storybook relate to the story; following instructions that use figures without text; using a map; and telling time from an analog clock.
• Visual-spatial scanning, tracking, and/or searching. This category includes having trouble physically maneuvering in situations in which people or things are moving in different directions (like playing a team sport).  It could also lead to difficulty keeping one’s place when reading dense blocks of text; tracing shapes, coloring within the lines, or cutting along a straight line.
• Self-orientation. This includes standing too close or too far away from people in conversations, bumping into people or things in tight spaces, and having a poor sense of direction. It also includes problems orienting to or finding one’s way around big stores or open spaces.
• Noticing physical attributes of people, objects, or physical surroundings. This involves such things as not noticing if a picture or painting is askew, noteworthy physical features of a person (such as a raised eyebrow), when shoes or socks are mismatched, stains; trouble detecting differences in an object or scene.

In addition to problems in at least four of these areas, for a DVSD diagnosis the visual-spatial deficits must have been present early in the child’s development, though they may not have been identified until later. Visual-spatial deficits are often masked by good verbal skills, strong intelligence, and compensatory strategies until academic and social demands become too challenging for the child to manage.

For a diagnosis, the visual-spatial deficits must also cause clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. And they must not be better accounted for by intellectual disability (intellectual developmental disorder) or global developmental delay, or another neurodevelopmental disorder or brain injury.

According to the new definition, it’s possible for a child to be diagnosed with DVSD if they also have another developmental disorder, including ADHD, a learning disorder, developmental coordination disorder, or autism. Many kids with NVLD do also have those disorders.

Historically, NVLD was often confused with autism, or considered to be a kind of autism, notes Dr. Margolis. “Autism came up because one common way that these kids were described is that they had social problems. And as soon as someone hears social problems, they think autism spectrum.”

But she notes that the social challenges of the two disorders are distinct. “We’ve worked really hard and thought very carefully about the kind of social problems these kids have, and they’re very different from the kinds of problems that people with autism have. And in fact, you could have both disorders. We’ve seen that.”

One aspect of the criteria set that was the subject of much debate in the working group is that it recommends, rather than requires, neuropsychological testing. The goal was to achieve consensus on a set of purely behavioral criteria, to make a diagnosis possible in situations in which testing is not available or affordable. “It’s very important to the group to make this a disorder that could be idenfied by “typical clincians” — for example a social worker or doctor who may not have access to a neuropsychologist to send the kids to or someone treating a child whose family can not afford testing,” explained Dr. Fisher.

Still, the working group acknowledged that there are disadvantages of diagnosis without testing. They agreed that testing is desirable, when available, to ensure that difficulties a child is having reflect an underlying visual-spatial problem.

Another decision the working group made was not to include strong verbal skills as part of the definition of DVSD, though NVLD has traditionally been described as a discrepancy between strong verbal skills and weak visual skills.

“If you look at the people who get an NVLD diagnosis, they tend to have really high verbal skills,” notes Dr. Fisher. “That’s because they’re the ones who come in to be tested because they’re so good verbally, and then they’re not good at these other things. But you don’t necessarily have to have good verbal skills to have a visual-spatial problem.”

The contrast between a child’s intelligence and verbal skills and their struggles in visual-spatial areas can lead kids’ behavior to be misinterpreted. “If you have a smart kid, and they’re not good at certain things, it’s often interpreted as being oppositional,” notes Dr. Fisher. “How can it be that you can write well and not be able to make the bed? It’s not that they’re being oppositional. It’s just they just don’t get it, or they just don’t notice things.”

Laura Lemle, the founder of the NVLD Project, who has a daughter with NVLD, found that educators often did not understand her daughter because NVLD is not recognized as an official diagnosis. “This makes it difficult for children with NVLD to receive appropriate accommodations in school and empathic understanding that is critically important to one’s development,” she adds. “It’s critical to obtain a valid diagnosis for nonverbal learning disability so that those living with this disability can be better understood, properly treated, socially engaged, and counted in.”