Early Signs of NLD in Children with Spina Bifida: Practical Interventions

1. Early Signs of NLD in Children with Spina Bifida:Practical Interventions Julie Yindra & Dr. Timothy Brei SBA National Conference Orlando, FL. July, 2009

2. The NLD Profile • Strengths- Verbal-high vocabulary, early decoding, reading and spelling skills, appears very articulate • Weaknesses- Motoric, visual/spatial perception, visual memory, poor organization and executive function, social skills, sensory impairments

3. Indicators in Young Children • Child gets lost, turned around, or can’t make logical sense of space in an age appropriate manner (such as they reach for something, or try to place an object on something that is closer or further away than it seemed) • Child will have difficulty with toys that require that items be sequenced by size, or that require that smaller items be placed inside larger item • Once a toy that the child is familiar with is taken apart, he or she cannot seem to understand how the pieces fit back together

4. Indicators (Cont’d) • The child shows excellent memory for stories, and can retell them with good detail, but will often confuse the sequence of events, or fails to see the importance of chronology in a story • When discussing stories, the child doesn’t seem to connect cause and effect • Child may not understand the pragmatic use of language-intent, motivation, tone, humor, sarcasm • Child may not recognize that facial expressions, tone and voice inflexion can completely alter the meaning of a statement

5. Indicators- (Cont’d) • The child doesn’t seem to understand that the larger size of the bowl doesn’t mean there is more ice cream in it • Even in environments that are very familiar, the child can’t seem to find items or remember that things are kept in certain places • Child may have difficulty with estimation of time, space or quantity • Child may have difficulty with abstractions such as such as am & pm, longitude and latitude, etc. at an age when his or her peers seem to grasp the concepts • Child may have great difficulty with left/right, north/south/east west

6. Indicators- (Cont’d) • Child may forget or disregard the order in which things should be done, and their approach to tasks seems to completely lack organization and forethought • Logical thinking, critical problem-solving and decision making may show marked delay by the time the child is 8 or 9 years old • Things that seem practical, logical and learned naturally by most children through experience have to be directly taught and reinforced in children at risk for NLD • The child may not understand that environments are not static

7. Indicators- (Cont’d) • The child may appear to have an inordinate difficulty making choices • The child may not understand how they are perceived (may have difficulty establishing friendships and not understand why their peers react to them as they do) • The child may lack empathy, not due to a lack of caring or compassion, but due to a lack of ability to understand alternate perspectives

8. NLD and the Child with SB • Lengthy hospitalizations and homebound periods make social interaction practice with same aged peers more infrequent • Lack of mobility makes spatial exploration and navigation more difficult • Immobility also encourages more learning through talking, reading or watching, rather than DOING (experiential learning) • Neurological, orthopedic and other physical conditions exacerbate fine motor, gross motor, visual processing skill deficits

9. What Can We Do? • Capitalize on strengths while remediating weaknesses • Go out of your way to arrange for social interaction opportunities, particularly in your own home, or other familiar surroundings • Semi-structured activities create a basis for spontaneous interaction with a predetermined topical focus • Give the child ample opportunities to play with toys that encourage development of skills that they are weak in, but in such a way that their verbal strengths can be of use to them (doing puzzles, making models, using blocks, etc. not in solitude, but in collaboration with a family member, where dialogue and verbalization can guide the activity to a successful completion)

10. What Can We Do (Cont’d) • Use word games, such as scrabble, but have the child strategize and count points out loud (example: “If I make this word, and place it here, I’ll get ___ points”) • When demonstrating how to do something, use both visual demonstration and verbal description (example: “I’m going to try to do it this way because….”)

11. What Can We Do (Cont’d) • Have the child practice estimation in fun activities such as cooking with you, and don’t just tell them what to do, ask them to engage in dialogue about what is going on “I’m putting in a little more sugar than the recipe calls for, because we like it sweet”, or “I already put in 1 cup of flour. How much more does the recipe call for?” • Begin teaching them as early as possible about abstract math concepts such as fractions and decimals in familiar daily activities such as cooking, shopping, etc. Use math related vocabulary in everyday conversation (in other words, after teaching them about money and making change in practical settings, make sure they know what “decimal” means)

12. What Can We Do (Con’t) • Encourage activities that integrate auditory and verbal strengths with fine motor and visual weaknesses such as neighborhood art lessons, music lessons, painting scenes from books they read, etc. • When you think they are old enough, which may be younger than you think, begin exposing them to the Arts, and use these experiences as learning tools for expressing and understanding social, emotional and psychological abstract concepts

13. What Can We Do • Create experiential learning opportunities • Establish routines, organization, schedules in the family environment – model time management and organizational skills • Provide opportunities for developmentally appropriate chores, responsibilities • Role play and engage in other activities that allow the child with SB to practice dealing with unexpected events

14. Educate Others • Work closely with teachers, case workers, doctors to encourage “buy in” of the need to engage in early diagnostic testing and to address learning differences • Educate your school personnel – give them literature on NLD diagnosis and interventions • Explore related services that may help remediation

15. What Can We Do (Cont’d) • Spend a lot of time talking about the how’s and why’s of things • Let them make mistakes, and when they do, talk it through with them, and help them understand how to make an alternate choice the next time they are given the opportunity, without appearing judgmental. • IN ALL THINGS, EMPHASIZE STRENGTHS WHILE ACKNOWLEDGING WEAKNESSES

16. The Assessment Problem • Typical “LD” Model: 15 pt discrepancy between IQ and achievement in either math, reading or writing • Typical SB profile: IQV 120 P 80 Full 100 Ach. Reading (dec. + comp.) 100 WL (expression + Mech) 110 Math (calc + applied) 87

17. Collaborating with School Personnel • Educate school personnel about NLD • Encourage a thorough diagnostic evaluation that includes a neuropsychological evaluation • Insist on IEP goals that address social, spatial and other deficits inherent in students with this learning profile, even if the state or system does not formally recognize NLD as a distinct diagnosis • If the student is served under the “OHI” category, insist that learning challenges not directly impacted by mobility are addressed

18. Positive Parenting Tips • Praise is good, but not when undeserved • Remember that “age appropriate” doesn’t mean “developmentally appropriate” • Always have high expectations • Always consider whether what you are doing will encourage and lead to autonomy • Apply consequences consistently • Build on special interests and strengths • Give yourselves (and your children) a break