Copyright 1990 by Ine American Psychological Association, Inc. OOXV2909/90/J00.75

Psychological Bulletin 1990, Vol. 107, No. 2, 196-209

Right Hemispheric Dysfunction in Nonverbal Learning Disabilities: Social, Academic, and Adaptive Functioning in Adults and Children Margaret Semrud-Clikeman

George W. Hynd Departments of Educational Psychology and Psychology, University of Georgia, and Department of Neurology, Medical College of Georgia

Department of Educational Psychology University of Georgia

This review addresses recent research on social and nonverbal learning disabilities. Involvement of right hemispheric dysfunction in these disabilities has been hypothesized, as studies with adults have suggested that documented right hemisphere damage may lead to deficits in social skills, prosody, spatial orientation, problem solving, and recognition of nonverbal cues. Studies of children purported to evidence nonverbal learning disabilities are reviewed and compared with the results from studies of adults with right hemisphere damage. Specific subtypes of nonverbal learning disabilities are reviewed, including the nonverbal perceptual-organization-output subtype, Asperger's Syndrome, Developmental Gcrstmann Syndrome, left hcmisyndrome, right hemisphere syndrome, and right parietal lobe syndrome. Finally, implications and future research needs arc addressed. The need for a diagnostic nosology and improved and validated intervention techniques is stressed as is early identification of these types of specific nonverbal learning disabilities.

specific modality areas, with integration between these modality areas. The left hemisphere is postulated to be superior in analyzing and classifying cognitions into existing schemas. The right hemisphere is most adept at processing novel information and constructing schema that are shared with the left hemisphere for future use (Bever, 1983). Goldberg and Costa (1981) postulated that the reason for these differences in processing abilities is that the left hemisphere has more prominent modality-specific representations and the right hemisphere has more cortical areas devoted to intermodal association. Gur et al. (1980) provided neuroanatomical support for this conceptualization with their finding that the gray to white ratio is greater in the left hemisphere than in the right hemisphere, thus indicating the presence of many nonmyelinated fibers and neuronal masses. On the basis of her review of computed tomography (CT) studies, LeMay (1976) concluded that the right hemisphere was larger than the left. Goldberg and Costa (1981) suggested that this finding, taken together with the Gur et al. (1980) study, supports the speculation that the right hemisphere is made up of relatively more white matter. Goldberg and Costa (1981) concluded that the left hemisphere has more intraregional communication and the right hemisphere has more interregional connections. Most of the arborization of dendrites and mylenization occurs following birth (Hynd & Willis, 1988). This dendritic arborization and development of synapses has been found to be interdependent, sequential, and essential for integrated functioning of the central nervous system (Jacobson, 1978). If, in fact, this development is interrupted or delayed and interconnections are lost, the right hemisphere is more likely to be significantly compromised because it has a higher number of interregional connections than is found in the left hemisphere. Three implications emerge from this conceptualization. The first is that the right hemisphere is more adapted to deal with

In past literature, the left hemisphere of the brain has often been referred to as the dominant hemisphere, with the right hemisphere called the nondominant or minor hemisphere. This nomenclature was not meant to be prejudicial, but it reflects a historical emphasis on the localization of language (Hynd, 1988). Many studies have been published regarding the linguistic functions and importance of the left hemisphere (Penfield & Roberts, 1949;Ojemann& Whitaker, 1978). More typically, the right hemisphere has been seen as important for visual-spatial and lesser functions. Since the time of Jackson (1915), however, there has been an interest in the right hemisphere's function. The work of Milner (1974), Zangwill (1967), and others helped chart functional relations. Following these early investigations, more recent studies have questioned the "nondominance" of the right hemisphere for cognitive functioning (Bear, 1983; Benowitz, Bear, Rosenthal, Mesulam, Zaidel, & Sperry, 1983; Bhatnagar & Andy, 1983; Dwyer & Rinn, 1981; Safer & Leventhal, 1977). Evidence has been reported to show that the hemispheres may function in concert with each other on almost all tasks (Kupfermann, 1985; Mesulam, 1985; Tucker, 1981). In other words, the left hemisphere is not just linguistically based and the right hemisphere visual-spatially based; rather, they complement each other. Goldberg and Costa (1981) have suggested that the two hemispheres have different processing modes that arc suited for different aspects and stages of cognition. They proposed that the right hemisphere has more association areas and specializes in intermodal integration, and the left hemisphere processes by

Correspondence concerning this article should be addressed to Margaret Semrud-Clikeman, who is now at the Department of Psychiatry, ACC-816, Massachusetts General Hospital, Boston, Massachusetts 02114.

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input from several sensory modalities, and the left hemisphere deals best with a single mode of presentation and processing. Second, the right hemisphere is more able to process complex schematic information. Third, disruptions in perinatal and infant neurological development may have a significantly greater effect on right hemispheric processes. Goldberg and Costa (1981) concluded that neither hemisphere is solely responsible for particular tasks or input. Instead, the hemispheres share complementary involvement in a wide range and variety of cognitive tasks. These views are similar to the popular view of an analyticholistic dichotomy of right-left hemisphere functions. Information in the left hemisphere is thought to be processed in a step-by-step, analytical fashion, whereas the right hemisphere is believed to be adept at processing in a more global manner (Bradshaw & Nettleton, 1983; Weinstein, 1980). The differences are seen as quantitative and not qualitative. Goldberg and Costa's (1981) hypothesis fits well with these ideas, as the short fibers between modalities in the left hemisphere would seem to be most adaptable to the analyzing and categorizing of data, and the long myelinated interregional fibers of the right hemisphere would be most adaptable to integrating input from many modalities at once to form a coherent whole of novel and complex schematic stimuli. The hemispheres not only differ in structure and function, but their development appears to differ in males and females (Witelson, 1976b). The male brain matures at a slower rate than the female brain, and this slower rate appears to have a direct effect on brain specialization (Witelson, 1976b) and asymmetry (Kolb & Whishaw, 1980). That is, the slower the maturation, the more the asymmetry (Waber, 1976). Therefore, the slowerdeveloping male brains should show more asymmetry. Tachistoscopic and dichotic studies have found greater response asymmetry in male brains than in female brains (Kimura, 1969; Lake & Bryden, 1976). Moreover, electrophysiological evidence shows left asymmetry of the auditory evoked response to be more pronounced in males than in females (Harris, 1978). Therefore, it is reasonable to speculate that disruption of right hemispheric function may differentially affect males and females. These factors may relate to the frequent finding that males are at higher risk for many learning and behavioral problems than are females (Hynd & Willis, 1988) and that potentially important interactions may exist among gender, brain morphology, and neuropsychological development (Hynd & Semrud-Clikeman, 1989a, 1989b). The left hemisphere has been the focus of many studies regarding the extent to which damage will interrupt its normal functioning. Less study has been devoted to the effects of right hemisphere damage on learning and behavioral functioning. Until recently, the major emphasis has been on the reactions of adult patients with trauma or lesions in the left hemisphere. The purpose of this review is to elucidate the role of the right hemisphere with respect to social-emotional development and deficits in social perception, and its contribution to specific learning disabilities, especially, perhaps, in arithmetic. It is felt that if the right hemisphere were more adept at "reading" complex and novel situations, as the earlier conceptualization suggests, then deficits in the right hemisphere might significantly affect a person's perception of his or her environment.

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Specifically, we discuss the possible relation of right hemisphere deficits to nonverbal learning disabilities in children. An attempt is made to show in what manner right hemisphere deficits may interfere with child development and contribute to learning disabilities in the area of social perception and arithmetic. This area of study is particularly relevant as the National Institutes of Health Interagency Report to Congress recommended that significant deficits in the attainment of age-appropriate social skills be recognized as a specific learning disability (Wyngaarden, 1987). It should be pointed out that there is little documentation of right hemisphere damage in children with this disability. Hence, we compare and contrast behavioral data with what is known about adults with documented right brain damage (RBD). Caution must be stressed, as data from adults are not directly comparable to that from children: Brain injury may have different consequences for development at various ages (Hynd & Willis, 1988). However, as Denckla (1973) suggested, the utilization of analogies between childhood and adult syndromes may be both conceptually useful and productive in deriving clinical classification schemes. Nonverbal Learning Disabilities Early descriptions of nonverbal learning disabilities were presented by Johnson and Myklebust (1971). They defined this disorder as characteristic of children who are unable to comprehend the significance of many aspects of the environment; who cannot pretend and anticipate; and who fail to learn and appreciate the implications of actions such as gestures, facial expressions, caresses, and other elements of attitude. In Johnson and Myklebust's view, the nonverbal learning disabled child is unable to acquire the ability to determine the significance of basic nonverbal aspects of daily living, even though their verbal intelligence is at or above the average level. The nonverbal disability impairs perception and imagery, and therefore constitutes a more fundamental distortion of the total perceptual experience. Johnson and Myklebust termed this finding a social perception disability and found that the social quotient correlated significantly with the diagnostic findings of neurologists. Myklebust (1975) further clarified these ideas with his definition of social imperception. Social perception, or social imperception, is defined as the "child's ability or lack of ability to understand his social environment, especially in terms of his own behavior" (p. 86). Myklebust found that the child with this type of disability is often immature and unable to make many of the routine judgments needed to succeed in everyday life. He felt that the difficulty is not due to perceptual problems, per se, but rather with memory and imagery, with a basic deficiency in storage rather than in recall. This idea is consistent with the findings of Borod, Kofi", and Caron (1983) and Ross and Mesulam (1979) that the defect in right-brain-damaged adult patients was not in perception of faces but rather in the identification of expression. It seems reasonable to speculate that a person needs an intact image of an expression in order to facilitate processing by the left hemisphere. Thus, in right brain damage a deficiency may be present in the ability to match the image of an expression with a current impression. The following problems are believed to be present concomi-

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tantly with nonverbal learning disabilities: disturbed social relationships; poor self-help skills; difficulty learning right from left; difficulty learning to tell time, to read maps, or to follow directions; disturbances in math; and deficits in learning the meaning of the actions of others (Myklebust, 1975). Moreover, these children's poor social perception is believed to limit their inner experience, which consequently has a delimiting effect on reasoning and adaptive behavior (Myklebust, 1975). Presumably, nonverbal disorders may be more handicapping than verbal learning disabilities, as verbal deficits have little effect on nonverbal experience but nonverbal deficits may make major contributions to the misreading of verbalizations. Various researchers have found support for the relation between nonverbal learning disabilities and deficits in social perception of self and others (Gaddes, 1985); interpretation of emotion and visual-spatial tasks (Wiig & Harris, 1974); and deficits in differentiating and interpreting facial expressions with a defective body image (Badian, 1983). Development of Social Perception Before discussing in more detail the social perception problems of learning disabled children, it is important to determine through use of a developmental framework what social skills are necessary for success. Krudek and Krile (1982), in a study on the development of social competence skills, found that the ability to project oneself into another's place becomes more important with age. They investigated social skills and their development in third through eighth graders. It was found that popular children were most adept at communicating effectively, knowing how to initiate a conversation, and being aware of the other person's affective state and empathizing with them and, most important, having the ability to match their social skills to the demands of a particular situation. In other words, popular children are able to succeed in all the areas that the nonverbal learning disabled child shows exceptional difficulty. It has also been found that the social skills most important for development between the ages of 9-12 were the ability to conceptualize alternative scenarios, to anticipate, and to use cause-and-effect reasoning. To complete these tasks successfully, children must be able to evaluate a social situation and then make judgments based on their perceptions (Bruno, 1981). The accuracy of emotional recognition and emotional labeling has been demonstrated to increase in direct relation to age. Normally developing children will recognize emotions far sooner than they can apply appropriate labels to them. The finding of similar growth curves between cultures confirms that emotional recognition is strongly related to age and development and probably has a biological basis. In addition, studies of preschool children have found that emotional recognition and emotional labeling are positively and significantly correlated with indices of intelligence and perceptual-motor skills in both normal preschoolers and disadvantaged children. Emotional recognition skills have also been found to be a significant predictor of academic achievement in the areas of reading and arithmetic (Izard, 1977). It is, therefore, not unreasonable to suggest that children who are unable to acquire these skills because of difficulty in evaluating facial expressions, gestures, or prosody would be at high

risk for the development of significant learning difficulties in, at the very least, the social-emotional arena of competence. One might also assume that this disability may be present early in development but may not necessarily be recognized until the child begins school and moves into the age range in middle childhood where peers and peer relationships become more crucial. However, it also seems reasonable to propose that problems are most likely to be present from birth and, although of unknown etiology, unfold as the child develops. Because the right hemisphere develops faster than the left from 18-24 months of age, this faster growth may reflect greater involvement of the right hemisphere in infancy. Much of the prelinguistic child's learning consists of the perception of visual-spatial relations, patterns, environmental sounds, and rhythms. The emotional experience of the infant develops through the sounds, images, and pictures that constitute much of an infant's early learning experience, and are disproportionately stored or processed in the right hemisphere during the formative stages of brain ontogeny (Ley & Bryden. 1981). Therefore, congenital dysfunction or arrest of the right hemisphere during development could be seen as very deleterious to the child's early development. As Boll (1974) suggested, the "general developmental rate and time of onset and chronicity of the disorder, while relevant for both adults and children, appears to play a far more crucial role in the latter group" (p. 92). In a study of 1-year-old children, Ainsworth (1979) found that the way infants express themselves toward the mother will also affect the way in which they interact with their environment and organize their experiences into a meaningful and predictable framework. This organization, in turn, provides continuity in cognitive and emotional development. If a child with a dysfunctional right hemisphere has difficulty in retaining an image of his or her mother's face and thus does not respond appropriately, it is not difficult to believe that the mother-child relationship may be significantly altered. It is possible that bonding will not occur, and the child's emerging view of the world is sure to be altered. The human face is probably the primary vehicle for early development and exercise of emotions in a safe and secure environment. Accordingly, facial expression plays a critical role in the development of social responsiveness. Vision and other stimulation such as vocalization and facial expression directed toward the infant may contribute more to determining the amount of social responsiveness than does meeting the infant's physiological needs (Izard, 1977). Furthermore, the perception of the mother's face seems related to the development of attachment behaviors and social adequacy. The infant who has difficulty in processing and retaining visual-spatial and auditory stimuli and in prediction of temporal events may well experience deficits in the nuances of human form and sound. Deficits in the recognition of facial expressions will delay attachment, which will in turn delay behavior that promotes exploration, cognitive reorganization, and separation (Kaslow & Cooper, 1978). Moreover, social learning is implicated in the reproduction of facial expressions as only certain expressions appear on the adult's face with any frequency in front of the infant. The child learns from these displays how and when to display these affects (Mayo & LaFrance, 1979). It is not unreasonable to speculate as to the major developmental effect of an infant's inability

RIGHT HEMISPHERIC LEARNING DISABILITIES

to decipher facial expressions even at an early age. During the first year of life, children normally communicate through one nonverbal channel at a time. The integration of these channels emerges as part of the cognitive developmental process. In addition, children learn how to integrate their nonverbal communication with others. Thus, a child's appreciation of distance and gaze as cues to attraction and liking become well established in the preschool years (Mayo & LaFrance, 1979). Morton (1976) agreed as to the importance of children's ability to orient themselves to the mother and to "recognize" her. He believed that personality disorder is "related to or caused by in part, a disturbance in the right hemisphere" (p. 783). Because babies perceive emotional stimuli before verbal stimuli, engrams for emotional voices are more strongly imprinted in the right hemisphere (Carmen & Nachson, 1973). It may well be that the diffuseness of the communicating fibers of the right hemisphere are more suited to the processing of nonverbal material and, with early development, take initial precedence in the infant's processing of environmental stimuli (Campbell & Whitaker, 1986; Hynd& Willis, 1988). Learning Disabilities and Social Perception The learning disabled child's comprehension of nonverbal communication has been studied only in the past 10-15 years. Bryan (1974) summarized five studies and concluded that the learning disabled child was more egocentric and less attuned to the affective states of others. Children with learning disabilities have also been found to be significantly less empathic, thus suggesting that learning disabled children's perceptual problems prevent them from developing the appropriate experiences to make appropriate judgments regarding the recognition of emotion in context (Bachara, 1976). Significant differences in the interpretation of affective states between learning disabled adolescents and a normal control group have also been found (Axelrod, 1982; Bruinicks, 1978; Bruno, 1981; Bryan, 1977; Gerber & Zinkgraft, 1982; Pearl & Cosden, 1982; Wiig & Harris, 1974). In contrast, a number of studies have not found significant differences between learning disabled and normal individuals in social perception and interaction skills (Bryan, Donahue, & Pearl, 1981; Bryan & Wheeler, 1972; Bryan, Wheeler, Felcan, & Henek, 1976; Connolly, 1969; Maheady, Maitland, & Sainato, 1984; Richey & McKinney, 1978). Such inconsistency is not surprising, perhaps, as these studies vary widely in measures used, age of subjects, criteria for learning disabilities, and number of subjects. Little attempt was made in most of these studies to control for attentional or verbal variables. The learning disabled children were also seen as constituting one group. It is noteworthy that none of these studies reported how many of the children had speech and language disabilities, how many were diagnosed as also having Attention Deficit Disorder (ADD), or how many had similar family histories. Denckla (1979) provided convincing evidence that the presence of various codiagnoses, including types of language disorder or ADD with hyperactivity, is meaningfully related to subtypes of childhood learning disabilities. More recent studies have provided further support for the idea that learning disabilities frequently co-occur with other psychiatric disorders, particularly ADD without hyperactivity (Hynd et al., in press). Thus,

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the lack of this information in these reports represents a significant and shared problem in methodology. There are several difficulties with the studies comparing children with and without learning disabilities. From the 14 representative studies reviewed, a number of conclusions seem warranted. First, each study had differing criteria for defining learning disabilities. Not only is this variance in definition a problem, but in 11 of 14 studies the criteria for selection were not specified, IQ and achievement scores were not fully reported, and groups were vaguely denned. Of the 3 studies that reported IQ and achievement scores, 1 study (Wiig & Harris, 1974) used different criteria for their learning disabled group depending on the school attended. Second, few of the studies evaluated speech and language skills, and the three that did (Bachara, 1976; Bruno, 1981; Wiig & Harris, 1974) did not report appropriate scores. Language difficulties are known to influence scores on tests used to diagnose learning disabilities (Hynd & Semrud-Clikeman, 1989b). Third, no study conducted emotional assessment directly. One must rely on the author's assurance that these children were free of "primary emotional disturbance." Sociometrics, an area one would think would be particularly relevant to assess, was ignored in 11 of 14 studies, with teacher ratings used in 1 additional study. Surprisingly, both studies (Bruinicks, 1978; Siperstein, Bop, & Bak, 1978) that used sociometrics found nonsignificant correlations between their measures of social perception and sociometrics. No study supplied any developmental history; some included children with neurological soft signs and some excluded these groups. Moreover, another major oversight was that not one study assessed attention or hyperactivity. Because attention to the task would appear to be a major confounding variable, this omission in these studies must be viewed as a serious oversight. Another problem with these studies is the variation and dissimilarity between measures of social inference and actual, socially appropriate behavior. Although four studies used observation of children in their natural setting (Bryan, 1974; Bryan & Wheeler, 1972; Bryan et al., 1976; Richey & McKinney, 1978), none of these studies assessed awareness on the children's part of their own behavior and their view of their interpersonal relationships. This oversight is serious, as the studies purported to investigate the learning disabled child's social skills and social perception, yet included no assessment of related cognitions. It is not surprising that divergent results were found, considering such methodological variability. However, these studies do represent an initial effort in an area of research that had previously not been empirically addressed. Arithmetic Learning Disabilities Johnson and Myklebust (1971) originally tied dyscalculia to deficiencies in visual-spatial organization and nonverbal integration. They found that children with this disability were unable to quickly distinguish differences in shapes, sizes, amounts, and lengths. Their subjects were also not able to examine groups of objects and tell which contained the greater amount. Studies of their case histories revealed nonverbal difficulties early in life. The parents reported that their children rarely played with puzzles, blocks, or construction-type toys. Many of

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them showed extraordinary auditory skills and spoke early in development. Word reading was appropriate, but reading comprehension (especially beginning in fourth through fifth grade when inferential thinking is required) was deficient. They also found that most of these children had disturbances in body image and their human figure drawings lacked detail and organization. It is likely that some children are born with a deficiency in the ability to discriminate and manipulate spatial and numerical relations (Landsdown, 1978). Although arithmetic skills have traditionally been associated with left hemisphere functioning, subjects with right hemisphere dysfunction also show difficulties with basic arithmetic operations. For children, the acquisition of number concepts may be based on exploration of the spatial and physical attributes of objects, thus suggesting that neural mechanisms in both hemispheres contribute to math skills. Therefore, arithmetic skills may be substantially hindered by early right hemisphere dysfunction (Weintraub & Mesulam, 1983). Arithmetic underachieves have been found to have differing evoked potentials in only the right hemisphere. Moreover, these right hemisphere evoked potentials differed significantly from the findings with normal subjects (John, Karmel, & Corning, 1977). Further studies have concluded that arithmetic may well be a task shared by the hemispheres for calculation and numerical judgments about the relative magnitude of two digits (Dimond & Beaumont, 1972; Katz, 1980; Murphy, Darwin, & Murphy, 1977). In their study with right-brain-damaged, leftbrain-damaged, and control subjects, Querishi and Dimond (1979) found that more deterioration of calculation occurred when damage existed in the right hemisphere. Subcortical processes may additionally be implicated in arithmetic processing. For example, Ojemann (1974) found that electrostimulation of the right and left thalamus affects arithmetic ability differently. Left thalamic stimulation accelerates the rate of counting backwards and increases calculation errors with no increase in latency of number identification. Right thalamic stimulation slowed the rate of counting and increased the latency of number identification and calculation er-

results in inferior achievement in arithmetic, geometry, mapdrawing, graphic arts, and all types of mechanical and constructional skills. These conclusions regarding the interrelations among acalculia, social intelligence, and right hemispheric dysfunction are supported by postmortem studies of patients with Turner's Syndrome (Brun & Skold, 1968; Reske-Nielsen, Christensen, & Nielsen, 1982), as well as by neuropsychological studies of patients with Turner's Syndrome (Hynd & Willis, 1988). Therefore, it may be concluded that arithmetic skills, at least the early precursors of arithmetic, can be significantly impaired by right hemisphere dysfunction. It is not unreasonable to suggest that nonverbal social-emotional problems and arithmetic difficulties may be related to right hemisphere dysfunction, as both involve the manipulation of spatial and visuoperceptual processes. From her review of literature on social adjustment, Badian (1983) concluded that there is a positive correlation between social skills and arithmetic. High achievers in arithmetic were found to be well adjusted and sociable, and low achievers were found to have severe emotional problems. Moreover, children with deficient arithmetic skills have been found to experience difficulty in learning appropriate social generalizations (Kirby & Asman, 1984). These findings suggest that research may productively be spent on more carefully characterizing the neuropsychological profiles of children with these specific learning disabilities.

rors. Ojemann (1974) concluded that left thalamic stimulation evokes an alerting response and acceleration of higher cognitive functions, and right thalamic stimulation affects number reading and arithmetic calculations. The thalamus may well serve as a gating mechanism, in that, when stimulated, the left thalamus nol only accelerates mental arithmetic processes but also serves as an alerting system for the input of these stimuli. Stimulation of the right thalamus may open the perceptual and processing gate for number reading and computations of numbers. On the basis of this research, Ojemann (1974) concluded that abstract reasoning skills draw on the whole brain and specific subcortical mechanisms so that dysfunction anywhere is likely to increase mental rigidity and to reduce adaptivity. Luria (1980) also emphasized the relation between arithmetic operations and spatial imagery and concepts. He suggested that spatial acalculia results from right hemisphere lesions and that acalculia itself implies bilateral dysfunction. Furthermore, Gaddes (1985), in an overview of arithmetic difficulties, suggested that a medial posterior right hemisphere dysfunction contributes to difficulty in spatial perception and imagery and

Nonverbal Perceptual-Organization-Output Disabled Classification

Research on Subtypes of Nonverbal Learning Disabilities Studies by Badian (1983), Denckla (1978), Nagy and Szatmari (1986), Rourke and associates (Strang & Rourke, 1983; Rourke & Finlayson, 1978), Weinberg and MacLean (1986), Weiner (1980), and Wing (1981) have all examined the relations among visual-perceptual skills, social skills, motor development, and arithmetic. Because there is considerable variability in how these learning disabled children are conceptualized, a discussion of each of the classification schemes listed in Table 1 is needed.

Rourke has advanced the idea that central processing deficiencies can lead to both social-emotional disturbances and learning disabilities (Rourke & Fisk, 1981). Studies by Petrauskas and Rourke (1979), Weiner (1980), and Porter and Rourke (1985) have reported the finding of four separate subtypes of learning disabled children based on social-emotional characteristics. Rourke and Finlayson (1978) identified what were termed as nonverbal perceptual-organization-output disabled (NPOOD) children whose reading and spelling performances were average or above and whose arithmetic skills were relatively weaker, with impairments found in visuospatial skills. This group evidenced strong auditory perceptual skills. Rourke and Finlayson concluded that NPOOD children have a dysfunctional right hemisphere, and children with reading and spelling difficulties have a relatively dysfunctional left hemisphere. Strang and Rourke (1983, 1985) found that the arithmetic errors evidenced by NPOOD children on the Wide Range Achieve-

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Received July 28, 1988 Revision received February 13, 1989 Accepted April 20, 1989