Asperger s Syndrome, and NVLD:

Asperger’s Syndrome, and N V L D: Academic Function and SchoolBased Interventions A r t Maerlender, Ph.D. Clinical School Services and Learning Disord...
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Asperger’s Syndrome, and N V L D: Academic Function and SchoolBased Interventions A r t Maerlender, Ph.D. Clinical School Services and Learning Disorders Program Child and Adolescent Psychiatry

NVLD Characteristics RELATIVE STRENGTHS auditory-verbal perception and memory, • good phonological skills early in development, and • adequate motor skills that can be learned by rote. •

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RELATVIVE WEAKNESSES • • • • •

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poor visuo-spatial skills, attention difficulties, socio-emotional difficulties, abstract thought weaknesses sensory abnormalities

NLD vs Asperger’s Syndrome NLD & Asperger’s • No consensus about differences • Very similar • Treatments overlap & similar A . M a e r l e n d e r, 2 0 0 1

NLD/AS: Brain mechanisms • left side motor findings • mild diffuse EEG • some imaging data showing right frontal deficits

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NP Profiles • PIQ lower than VIQ • Nonverbal mem. < verbal mem. • visuoconstruction < auditorylinguistic • motor & tactile worse on left

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NP Assets • auditory-verbal perception • simple motor and tasks that can be learned by rote • good phonological skills are seen early • verbal reception, repetition, storage, and associations from early school years on • high volume of verbal output is characteristic

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NP Deficits •tactile and visual perception deficits early in development •

(includes attention to and memory for material introduced through these modalities)

•complex psychomotor tasks except those that can be that can be learned through extensive repetition •language often used for inappropriate purposes

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NP Deficits, cont. • aversion for novel experiences impacts exploratory behavior • age-appropriate concept formation and problem solving • linguistic deficits in content and pragmatic dimensions of language

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Socioemotional findings • • • • •

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shyness depression anxiety social isolation deficits in eye contact, gestures, prosody

Developmental Profile of NVLD Through the Lifespan

No single, uniform presenting picture of a child with nonverbal learning disorders.

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In general Delays in: ü motor, ü language, ü exploratory behavior, ü pragmatic language, ü peer relations ü over dependency on parents A . M a e r l e n d e r, 2 0 0 1

into adulthood • continued social/emotional difficulties • jobs often below ed. level • internalization & higher suicide rates

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Prognosis § However, the prognosis is good for these disorders § § §

individuals can work have meaningful relationships be productive citizens

§ Higher functioning = better prognosis A . M a e r l e n d e r, 2 0 0 1

Academic Prognoses: sWord decoding and spelling often develop to superior levels. sVerbatim memory, especially for auditory-verbal material often well developed (see above). A . M a e r l e n d e r, 2 0 0 1

Areas of emerging and continuing concern • reading comprehension, mechanical arithmetic, mathematics and science; • difficulties often apparent when reasoning, deduction, etc. are required.

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Written Language Skills •Enhancing connections to specific interests in vocabulary and comprehension development

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Math and Science Skills • Some dimensions of math and science can be learned if material is presented and practiced in rote fashion • Use formulas, algorithms mnemonic devices • Can learn to apply information to a routine formula but might have difficulty knowing which formula to use. A . M a e r l e n d e r, 2 0 0 1

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Prognoses: Psychosocial Basic problems in perception, judgment, problem-solving, and reasoning lead to difficulties in social competence. A . M a e r l e n d e r, 2 0 0 1

At risk for... • moderate to severe psychopathology, • especially of the internalized variety; • suicide. • usually beginning in adolescence

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Prognosis: Psychosocial, cont. • Activity levels tend to decline to hypoactive levels by late childhood. • Long-term prognosis for socio-emotional development is guarded

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Poor candidates for insight therapies • Individuals often are very persistent, and frequently unaware of their disability • Behavioral tx. is needed • BUT not necessarily CBT • Establishing relationship is crucial • Supportive therapy is helpful

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School focused Treatment & Recommendations

The School’s Role § responsible for providing educational opportunity § not solving all problems § IT IS IMPORTANT TO KEEP THE FOCUS ON THE ACTIVITY AND ASSESSMENT OF THE EDUCATIONAL PROCESS A . M a e r l e n d e r, 2 0 0 1

Structured Teaching: General Principles for Teaching HFA/AS/NVLD Kunce, L. & Mesibov, LB (1998).

• • • • •

routines schedules individual work systems visual structure physical organization of materials • (might require specifically designed classroom)

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1. Make the world (classroom environment) as meaningful as possible child should understand • expectations, • arrangements, • routines

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2. teaching requires BOTH: • developing skills and competencies, and • environmental modifications to maximize strengths, minimize weaknesses

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Primary Strategies for Structuring the Environment

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1. understand the disorder Issues include • language understanding and usage (incl. literal interpretations) • sensitivity to stimuli • over-reaction to change • repetitive behaviors A . M a e r l e n d e r, 2 0 0 1

2. understand the unique child (formal and informal assessment) Issues include: • variability • specific interests • use of language • strengths and weaknesses • reaction to stress and frustration tolerance • intellectual functioning and learning ability *what works - what doesn't

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Understanding the Child/Student § each adult who works with child MUST FIND SOMETHING TO LIKE ABOUT THIS PERSON

§ even though they do not process nonverbal info well, they can detect when not liked § teachers may need to work on this § parable of the tooth

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3. make events consistent and predictable Issues include a. practical, productive daily routines throughout the day • rote behaviors best, • systematic routines for things such as washing hands before lunch, • putting completed work in a specific box, • playing with specific person for 1st 5 minutes of recess. A . M a e r l e n d e r, 2 0 0 1

b. individualized, pictured and/or written daily schedules - at developmental level, 3don't include unnecessary info, check off spaces, name, etc., 3use notes for reminders on schedule • (e.g., "raise hand if questions", specific rules)

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4. clarify instructions and expectations compensate for receptive language problems

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Issues include: Structuring teaching strategies to include both: •a. developing skills and competencies, i.e., target specific language impairment (help from SLP) and A . M a e r l e n d e r, 2 0 0 1

b. environmental modifications to maximize strengths, minimize weaknesses; 3e.g., preferential seating 3adjusting level of spoken language • syntax, semantics, prosody, volume: • simplify, be concrete

3rely on written text • e.g., provide notes; "turn to page 37"; refer to posted rules, schedules, etc. A . M a e r l e n d e r, 2 0 0 1

5. structure tasks and assignments to promote success Issues Ùchild focuses on details • missing big picture, prioritizing, etc, slow output.

ÔPoor EF: planning, choosing, integrating, organizing, anticipating, inhibiting, emotional control. A . M a e r l e n d e r, 2 0 0 1

a. create an organizational work system communicate work expectations: • what needs to be done, • how much work there is, •when they will be finished and •what to do when finished. A . M a e r l e n d e r, 2 0 0 1

Example Structure/schedule ___ turn in homework ___ group lesson p. 47 ___ do problems p. 50, #1,3, 5 ___ fill out homework sheet ___ have teacher sign ___ 10:15 leave for science Use of baskets for younger kids, written instructions for older ones. A . M a e r l e n d e r, 2 0 0 1

b. written task directions vstep by step for both content and general instructions v operationalizes parts to whole instruction vtext or pictures

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c. additional supports ü less info on pages, ü larger print, ü highlighting, ü use of visual models, ü reduced number of problems, ü examples, ü containers, ü 2 sets of books, ü good school-home communication

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d. structure assignments in line with conceptual ability • typically skills are in learning procedures, mechanical skills *(e.g., word identification, naming, rote learning, associative memory).

• typical weaknesses in comprehension and interpretation (abstract thinking, verbal reasoning, complex memory - recall).

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structure assignments O assistance Ø with importance (what is important),

amount of work, Ø questions to answer, Ø even sentence stems might be necessary.

O these skills (higher level, abstract) tend to be more important in higher grades (why these kids often do well in elementary).

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e. provide help and create helpasking routines k observe progress k provide help-asking scripts

or routines (even written reminders) k assertiveness training in adolescents (social skills scripts) A . M a e r l e n d e r, 2 0 0 1

6. cultivate and fully utilize students' interests vpair with students with similar interest vutilize for broadening knowledge and skills vreinforce less preferred activities A . M a e r l e n d e r, 2 0 2000 01 A Maerlender,

When to Use an Aide

Some ideas…

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Strongly consider a MAINSTREAM AIDE if Child is MARKEDLY: 4unable to focus, attend, sequence, and organize 4disruptive without VERY close adult attention 4needy of much help fitting into classroom routine 4able to become very frightened quickly unless rapidly reassured A . M a e r l e n d e r, 2 0 0 1

BUT STUDENT HAS GOOD ü General Intellectual Ability (average to above IQ), ü LEARNS FROM IMITATING PEERS, ü CAN GENERALLY TOLERATE SIZE, ACTIVITY AND LOCATION OF CLASSROOM, etc. A . M a e r l e n d e r, 2 0 0 1

SOME QUALITIES OF AN AIDE J WARM, CREATIVE, FLEXIBLE J INTELLECTUALLY CURIOUS J WILLING TO TALK TO PARENTS J KNOWS WHEN TO GET HELP J SOME BACKGROUND TRAINING J BUILT-IN SUPERVISION FROM J SOMEONE KNOWLEDGEABLE ABOUT DISORDER

J NOT COMPETITIVE WITH PARENTS A . M a e r l e n d e r, 2 0 0 1

J NOT AN ENABLER

Fading Interventions / Dependence is not as big an issue as often made out to be / Important to deal with dependence issues / Support should be faded as mastery is demonstrated / BUT, need for • Follow-up • Review • Refresher • May require several times

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Dealing with Explosive & Inflexible Behaviors

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Typical consequencereward systems do not work > too late in the chain of behaviors > assumes child needs motivation and structure

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Motivation likely not an issue >Although often accused of ‘bad attitudes’ & poor motivation

>kids know who’s boss >know the consequences >want to please A . M a e r l e n d e r, 2 0 0 1

A Lack of Developmental Skills Flexibility and frustration tolerance are critical developmental skills.

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In the School and Classroom _General ideas still apply _Adopt a problem solving approach _often these children are less explosive in school

Some General Principles ¯ Consistency and regularity ¯ Structure (be the frontal lobes) ¯ Reduce goals, objectives A . M a e r l e n d e r, 2 0 0 1

Consistency _work to develop consistency with parents around: k

k

specific language usage identification of behaviors and strategies

_ Make school day as predictable as possible A . M a e r l e n d e r, 2 0 0 1

Words, words, words v adapt

consistent language for elements of behavior v tie-in with home for maximum consistency v include in notebook v everyone child comes in contact with A . M a e r l e n d e r, 2 0 0 1

IEP’s üPrioritize objectives and goals üConsider cutting by 50% or more üUse the basket approach A . M a e r l e n d e r, 2 0 0 1

Make school ‘User-Friendly’ >adults must understand child’s unique difficulties •

as a team, review all cases that fall into the category of inflexibleexplosive *do NOT focus on diagnoses



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obtain in-service training to help staff understand these kids

User friendly schools >reduce over-all demands for flexibility and frustration tolerance >team must review importance levels •

what is needed, what is child capable of

>prioritize >Repeat: the reality of IEP’s A . M a e r l e n d e r, 2 0 0 1

Identify situations and triggers in advance + establish a notebook of important information: +

known triggers • baskets and behaviors • procedures for handling stages (who as well as what) •

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Front-line teachers need to be able to read warning signals and take immediate action • real

training • one role of the aide • use consultant, behavior specialist, counselor psychologist to review

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Attitude and interpretations >incoherent behavior is incoherent behavior •

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not oppositionality, poor parenting, psychosis, etc.

What’s my line? >teachers need to have a forum for being able to honestly and nonjudgmentally recognize their role that fuels inflexible-explosive behavior >this is often a personal style issue

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Fair does not mean equal >students actually understand this >no-one is ‘getting away’ with anything >everyone gets th help they need other students can often be most helpful • but not their defined role •

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Alienation and deviance ø once a pattern of alienation and deviant behavior has been established it is difficult to stop

ø the milieu maintains the behavior

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Consider a change in venue... “Sometimes it’s best to cut yer losses…” mother placement where a new start can be made mcan return when healing has occurred, kids have developed, enough time has passed A . M a e r l e n d e r, 2 0 0 1

Two Tracks to Treatment: I. creating better general environments II. direct training to improve skills A . M a e r l e n d e r, 2 0 0 1

Track I: The general environment “User Friendly” >understand child’s unique difficulties >identify specific factors that fuel inflexibilityexplosiveness

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Understanding helps maintain coherence 3recognizing that this is not a willful, manipulative tactic is an important first step 3demonstrate understanding of how debilitating it is for her/him 3AGAIN: must be able to demonstrate some level of likink and respect for the person A . M a e r l e n d e r, 2 0 0 1

Anticipate frustrating situations B be

more careful and judicious about frustrating situations we choose or allow for her/him

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Eliminate unnecessary, unimportant frustrations è adult concerns about being ‘too easy’, fostering dependence, being a ‘push-over’ è eliminate unnecessary roadblocks, known flash points è most kids know who is in charge but unable to respond due to competing neurophysiological processes A . M a e r l e n d e r, 2 0 0 1

Reduce overall level of known frustrating experiences Such as: changes in routine homework demands for independence

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#1 GOAL when the pattern begins: Keep the student/child coherent †so he /she can think rationally †allows for appropriate

responses and thinking through situation A . M a e r l e n d e r, 2 0 0 1

Repeat: Much of this requires Anticipation a user-friendly environment is one in which the adults have identified

in advance specific frustrating situations that lead to inflexible-explosive situations A . M a e r l e n d e r, 2 0 0 1

Read the signs, take quick action K words,

tones, body language, specific circumstances § are signals of early vapor lock

H start

with empathy and gentle persuasion H distractions A . M a e r l e n d e r, 2 0 0 1

Distractions >should be enjoyable and require minimal brain-power µhumor µmagic

cream

>these are short-term ‘de-icers’ µkeep

child from going into further vapor lock µremember - you can return to what you were doing (and often SHOULD signal: ‘let’s come back to this later’) A . M a e r l e n d e r, 2 0 0 1

Downshift >gradually change agendas, expectations, cognitive demands • ‘rather

than do all those problems right now, how about we ...’

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Self-Awareness >adults must learn how to recognize how they fuel inflexible-explosive behaviors • ignoring

warning signs • demonstrating short-fuse behavior • being stressed A . M a e r l e n d e r, 2 0 0 1

Use accurate, common language to describe v using consistent terms for stages and behaviors will facilitate communication and v later processing v Important to be consistent with home A . M a e r l e n d e r, 2 0 0 1

Create a culture of mutual support >Staff need to feel safe to accept feedback about their own behavior •

A ‘user friendly’ environment applies to staff as well

> Modeling problem solving requires • • • A . M a e r l e n d e r, 2 0 0 1

Making mistakes Accepting feedback Trying new things

Track II: Learning Frustration Tolerance Frustration tolerance IS a skill to be learned Within a more ‘user-friendly’ environment, specific skills for enhancing frustration tolerance can now be -

taught, 3 modeled and 3 reinforced 3

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Priorities step back for a moment « Goals and priorities must be set ahead of time «

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Survival Typical priorities: 8reduce the number of meltdowns 8help child maintain coherence in midst of frustration 8prevent vapor lock 8restore coherence during meltdowns A . M a e r l e n d e r, 2 0 0 1

Step 1: Choosing Battles >teaching inflexibleexplosive kids requires constant decision: “Is this behavior important enough to risk a meltdown?” A . M a e r l e n d e r, 2 0 0 1

In short >reducing frequency of meltdowns starts with choosing among priorities and needs. >short-term avoidance can be important for long-term success

>This is about preventing a runaway train. A . M a e r l e n d e r, 2 0 0 1

3 levels of importance 1. not important 2. important but not capable or possible to address 3. important and capable with extra help

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Management VS Teaching § every moment requires a conscious decision: Is this a teachable moment, am I trying to meet learning goals (Basket B later), OR § is this management and I/we need something to happen now § learning takes a back seat to getting the task done, such as a safety issue. A . M a e r l e n d e r, 2 0 0 1

Specific Situations and Factors >When deciding if a situation, factor or behavior needs planned intervention, consider: •

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importance levels -high priority?

If Important: a Can child master demands immediately? a If not, can she/he with help?

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Letting go...for now >Assumption: all kids WANT to be independent, functional and productive >making decisions about importance levels demonstrates adult prioritization skills A . M a e r l e n d e r, 2 0 0 1

Of all the important behaviors to work on, how to choose? >Greene’s simple approach to prioritizing behaviors >Using baskets A, B, & C

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Basket A >Non-negotiable items • not

many • recall that #1 priority is to reduce overall number of meltdowns

>Safety (management) • still

utilizing least intense, antagonistic, restrictive methods

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Basket A items must >be behaviors important enough to induce or endure a meltdown over >be behaviors the child can demonstrate appropriate (within the range of improvement) >be things parent/teacher is willing and able to enforce A . M a e r l e n d e r, 2 0 0 1

Basket B >high priorities >but not willing to induce endure meltdowns over >the most important basket

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Goal of Basket B >identifying behaviors that require new skills for handling better hanging in in the midst of frustration • taking another’s perspective • generating alternative solutions • thinking things through •

>showing child that you are able to help him/her learn these things A . M a e r l e n d e r, 2 0 0 1

What to do when a Basket B behavior happens... in a word:

COMPROMISE

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Compromise .each side gives up demands

or makes concessions .the pathway to staying coherent .persistence is NOT compromise A . M a e r l e n d e r, 2 0 0 1

The art of compromising >help child re-state the problem >does solution make everyone a little happy? •

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might need skills in how to ask

And if no compromise is possible... >it might move to Basket C >remember goal of reducing meltdowns

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Basket C rvery full rbehaviors to forget about...for

now rhelp achieve the goal of reducing global frustration level

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Who decides? >what behaviors go into what baskets • parent • school

team • responsible adult

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Details that might require additional thought/planning 7communication

patterns 7identifying specific situations 7social skills 7other kids in classroom ~ Remember:

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fair is not necessarily

The Need for Performance Indicators PGood IEP’s do not guarantee delivery of service PHow can a parent/school know if the plan is being implemented? PAnd, are strategies working?

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Build accountability indices into the plan sSpecify regular monitoring monthly, bi-monthly, etc.

sTWO STRATEGIES (not mutually exclusive) 1. Advocacy 2. Work products and performance indicators A . M a e r l e n d e r, 2 0 0 1

Performance Indicators þ Teacher/aide checklists þ Outside observations of target behaviors for implementation of strategy þ Summaries of sessions þ Work system products • completed checklists, schedules, homeschool communications log, etc.

§ Attendance

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Advocacy J Parents are the first line J Use of the cognitive coach/therapist/mentor 4as ‘case manager’ 4as communications link

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Thank you

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Specific Content Areas §This presentation will be posted at: www.dartmouthpsychiatry.org/ healthinformation.htm “NVLD 2/8/01”

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References Greene, RW (1998). The explosive child: A new approach to understanding and parenting easily frustrated, “chronically inflexible” children. NY: HarperCollins Fisher, NJ & DeLuca, J (1997). Verbal learning strategies in adolescents and adults with the syndrome of Nonverbal Learning Disabilities. Child Neuropsychology, 3, 192-198. Gross-Tsur et al (1995). Developmental righthemisphere syndrome: Clinical spectrum of the nonverbal learning disability. Journal of Learning Disabilities, 28, 80-86.

Kunce, L. & Mesibov, LB (1998). Educational approaches to education and high functioning autism and Asperger Syndrome. In E. Schopler, GB Mesibov, LJ Kunce (Eds.) Current issues in Autism: Asperger syndrome of high-functioning autism. NY: Plenum.

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Nowicki and Duke (1992). Helping the Child Who Doesn’t Fit In. Peachtree Publishing. Rourke, B.P. (1994). Neuropsychological assessment of children with learning disabilities.