by David B. Goldstein, PhD
Parents: Please answer all of the following questions.
NAME OF CHILD: _________________________________
DATE OF BIRTH: __________ AGE: ______ SEX: ______
GRADE: ______ SCHOOL: _________________________
HANDEDNESS: RIGHT _____ LEFT ______ BOTH _____
This questionnaire has been completed by:
MOTHER _______ FATHER _______ OTHER * _______
* (Please describe): ______________________________
1. Motor Skills
a. My child has problems with balance (e.g. never learned to ride a bike).
Never/Rarely ___ Sometimes
___ Often/Always ___ I don’t know ___
b. My child displays impaired fine motor
skills (e.g. significant difficulties learning to tie shoes).
Never/Rarely ___ Sometimes
___ Often/Always ___ I don’t know ___
c. My child has problems writing or
extremely slow writing.
Never/Rarely ___ Sometimes
___ Often/Always ___ I don’t know ___
d. My child seems unusually clumsy.
Never/Rarely ___ Sometimes
___ Often/Always ___ I don’t know ___
2. Visual-Spatial Skills
a. My child has difficulty remembering
and organizing visual or spatial information (e.g. has difficulty lining up
numbers to do a math problem or lining up words neatly on a page).
Never/Rarely ___ Sometimes
___ Often/Always ___ I don’t know ___
b. My child appears disoriented, lost,
or confused when entering a new situation.
Never/Rarely ___ Sometimes
___ Often/Always ___ I don’t know ___
c. My child is slow to become familiar
with new physical locations (e.g. continues to appear lost or disoriented after
repeated exposures to the same location).
Never/Rarely ___ Sometimes
___ Often/Always ___ I don’t know ___
d. My child has difficulty remembering the faces of people he or she has met.
Never/Rarely ___ Sometimes
___ Often/Always ___ I don’t know ___
e. My child has an auditory memory like
a tape recorder.
Yes ____ No ____
I don’t know ____
f. My child loses his or her way and
needs help finding his or her way around.
Never/Rarely ___ Sometimes
___ Often/Always ___ I don’t know ___
g. My child has unusually strong verbal
skills (e.g. an impressive vocabulary or early speech).
Yes ____ No ____
I don’t know ____
3. Interpersonal Skills
a. My child often does not get the humor
in a joke because he or she interprets everything so literally.
Never/Rarely ___ Sometimes
___ Often/Always ___ I don’t know ___
b. When interacting with others my child
has difficulty reading the other person’s non-verbal cues, such as tone of
voice or facial expression.
Never/Rarely ___ Sometimes
___ Often/Always ___ I don’t know ___
c. My child interprets what I say very
literally (for example, if I tell my child ‘to pick themselves up by his or
her bootstraps’, they appear confused).
Never/Rarely ___ Sometimes
___ Often/Always ___ I don’t know ___
d. My child has difficulty transferring
what he or she learns in one social situation to similar social situations. For
e.g. my child appears confused when confronted with slight changes in a
frequently encountered social situation.
Never/Rarely ___ Sometimes
___ Often/Always ___ I don’t know ___
Guidelines for Scoring the
Children’s
Nonverbal Learning Disabilities Scale
The syndrome of NVLD includes a number of specific symptoms. Rourke (1995) has organized these into three primary areas: neuropsychological deficits, academic deficits, and social-emotional/adaptational deficits. Neuropsychological deficits include difficulties with tactile and visual perception, psychomotor coordination, tactile and visual attention, nonverbal memory, reasoning, executive functions, and specific aspects of speech and language. Deficits in mathematical reasoning, math calculations, reading comprehension, specific aspects of written language, and handwriting are primary academic concerns. Deficits in social expertise include problems with social cognition and perception as well as difficulties in social interaction.
Some of the symptoms identified with Nonverbal Learning Disabilities are similar to those described for other disorders. Individuals with right hemisphere dysfunction, Asperger's syndrome, and sensori-motor deficiencies each possess a number of characteristics that overlap with those of a Nonverbal Learning Disability. An evaluation by a Neuropsychologist can often assist in differential diagnosis.This questionnaire is a checklist of characteristics that may be indicative of a Nonverbal Learning Disability. A referral for a more detailed evaluation by a pediatric neuropsychologist to rule in or rule out a Nonverbal learning disability requires that the parent report symptoms in all three spheres noted in the Developmental Screening and Referral Inventory (DSRI); deficiencies in motor-skills, visual-spatial skills, and interpersonal skills.
A referral to a neuropsychologist or for a more in-depth evaluation of a Nonverbal Learning Disability could be considered if the parent reports deficits "Sometimes" or "Often" on over half the items examining motor skills (at least 3 of the 4 items), visual-spatial skills (at least 4 of the 7 items), and interpersonal skills (at least 3 or the 4 items).
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Reference
Rourke, B. P. (1994). Neuropsychological Assessment of Children with Learning Disabilities: Measurement Issues. In G. Reid Lyons (ed.), Frames of Reference for the Assessment of Learning Disabilities: New Views on Measurement Issues. Baltimore, MD: Paul H. Brooks.
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The Children’s Nonverbal Learning Disabilities Scale© was excerpted, with permission from the author, from the Developmental Screening and Referral Inventory (DSRI) by David B. Goldstein, PhD, 1999.
About the author - David B. Goldstein, PhD, is a clinical psychologist in independent practice in Memphis, Tennessee, and the Director of Mind-Steps®. His practice highlights the assessment and treatment of children, adolescents, and their families. Dr. Goldstein has a particular interest in working with children struggling with difficulties in self-control, learning, and social relationships