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Introduction: definitions and disagreement
At its broadest definition, dysgraphia is a disorder of
writing ability at any stage, including problems with letter
formation/legibility, letter spacing, spelling, fine motor
coordination, rate of writing, grammar, and composition.
Acquired dysgraphia occurs when existing brain pathways
are disrupted by an event (e.g., brain injury, neurologic
disease, or degenerative conditions), resulting in the loss
of previously acquired skills. In contrast, this review will
concentrate on developmental dysgraphia, i.e., the difculty
in acquiring writing skills despite sufficient learning
opportunity and cognitive potential. This article will use
the terms dysgraphia and specific learning disorder with
impairment of written expression in their broadest terms, to
encompass any difculty an individual may have in written
communication.
Much controversy exists regarding the precise denition
of and deficits seen in dysgraphia, depending on the
theoretical mechanisms attributed to the disorder (1).
Historically, dysgraphia was most often defined as an
impairment in the production of written text, usually due
to a lack of muscle coordination. Specic testing in affected
children highlighted minor differences in performance of
ne motor tasks (e.g., repeated nger tapping) or abnormal
measures of hand strength and endurance (2). These decits
stemmed from hindrance in ne motor coordination, visual
perception, and proprioception and manifested an illegible
or slowly formed written product. Oral spelling was usually
preserved. This conceptualization of dysgraphia has been
categorized as “motor” or “peripheral” dysgraphia (3).
Secondly, Deuel (4) proposed a second subtype of
dysgraphia termed “spatial dysgraphia”. The primary
impairment in this sub-type of dysgraphia was thought to
Review Article
Disorder of written expression and dysgraphia: definition,
diagnosis, and management
Peter J. Chung1, Dilip R. Patel2, Iman Nizami2
1Department of Pediatrics, University of California Irvine, Irvine, CA, USA; 2Department of Pediatric and Adolescent Medicine, Western Michigan
University Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
Contributions: (I) Conception and design: All authors; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV)
Collection and assembly of data: None; (V) Data analysis and interpretation: None; (VI) Manuscript writing: All authors; (VII) Final approval of
manuscript: All authors.
Correspondence to: Peter J. Chung. Department of Pediatrics, University of California Irvine, Irvine, CA, USA. Email: peterjchung@gmail.com.
Abstract: Writing is a complex task that is vital to learning and is usually acquired in the early years of
life. ‘Dysgraphia’ and ‘specific learning disorder in written expression’ are terms used to describe those
individuals who, despite exposure to adequate instruction, demonstrate writing ability discordant with their
cognitive level and age. Dysgraphia can present with different symptoms at different ages. Different theories
have been proposed regarding the mechanisms of dysgraphia. Dysgraphia is poorly understood and is often
undiagnosed. It has a high rate of co-morbidity with other learning and psychiatric disorders. The diagnosis
and treatment of dysgraphia and specic learning disorders typically centers around the educational system;
however, the pediatrician can play an important role in surveillance and evaluation of co-morbidity as well as
provision of guidance and support.
Keywords: Dysgraphia; specic learning disorder; disorder of written expression; accommodation; remediation;
modication
Submitted Oct 22, 2019. Accepted for publication Oct 30, 2019.
doi: 10.21037/tp.2019.11.01
View this article at: http://dx.doi.org/10.21037/tp.2019.11.01
54
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be related to problems of spatial perception, which impaired
spacing of letters and greatly impacted drawing ability. In
such cases, oral spelling and nger tapping were preserved
but drawing, spontaneous writing, and copying text were
impaired.
However, others have placed much more focus on the
language processing deficits related to written expression,
with less emphasis on any motor issues. Qualifying terms for
this type of dysgraphia include “dysorthography”, “linguistic
dysgraphia”, or “dyslexic dysgraphia” (5). The primary
mechanism of this dysgraphia is related to inefficiency of
the “graphomotor loop”, in which the phonologic memory
(regarding sounds associated to phonemes) communicates
with the orthographic memory (regarding written letters).
Impaired verbal executive functioning, including storage
and working memory, have also been related to this
disorder (5). Oral spelling, drawing, copying, and finger
tapping are usually preserved in this type of dysgraphia. In
contrast but related to dysgraphia, dyslexia is theorized to
result from two-way dysfunction of the “phonologic loop”,
which is the communication between orthographic and
phonologic processes.
The Diagnostic and Statistical Manual of Mental
Disorders 5th edition (DSM-5) (6) includes dysgraphia under
the specic learning disorder category, but does not dene
it as a separate disorder. According to the criteria, a set of
symptoms (Table 1) should be persistent for a period of at
least 6 months in the context of appropriate interventions in
place. For any specic learning disorder, the academic skills
as measured by individually administered standardized tests
must fall signicantly below expectations for the child’s age.
The onset of difculty in learning is generally during early
school years; however, it is more apparent as the complexity
of work increases with progression to higher grades. Other
causes of learning difficulty include intellectual disability,
vision impairment, hearing impairment, underlying mental
or neurological disorder, and lack of adequate learning
support or academic instructions.
In the United States, the Individuals with Disabilities
Education Act (IDEA) revised in 2004 broadly defines
“Specic Learning Disability” in the following manner (7):
The child does not achieve adequately for the
child’s age or to meet State-approved grade-level
standards in one or more of the following areas,
when provided with learning experiences and
instruction appropriate for the child’s age or State-
approved grade–level standards: Oral expression,
listening comprehension, written expression,
basic reading skills, reading uency skills, reading
comprehension, mathematics calculation, or
mathematics problem solving.
The child does not make sufficient progress to
meet age or State-approved grade-level standards
in one or more of the areas when using a process
based on the child’s response to scientic, research-
based intervention; or the child exhibits a pattern
of strengths and weaknesses in performance,
achievement, or both, relative to age, State-
approved grade-level standards, or intellectual
development, that is determined by the group to be
relevant to the identication of a specic learning
disability, using appropriate assessments; and the
group determines that its ndings are not primarily
the result of a visual, hearing, or motor disability;
mental retardation; emotional disturbance; cultural
factors; environmental or economic disadvantage;
or limited English prociency.
Between 10% and 30% of children experience
difficulty in writing, although the exact prevalence
depends on the definition of dysgraphia (8). As with
many neurodevelopmental conditions, dysgraphia is more
common in boys than in girls (9). Handwriting problems
are a frequent reason for occupational therapy consultation.
Dysgraphia and disorders of written expression can have
lifelong impacts, as adults with difficulty writing may
continue to experience impairment in vocational progress
and activities of daily living (10).
Writing development
As noted above, the concept of “writing” encompasses a
broad spectrum of tasks, ranging from the transcription of
a single letter to the intricate process of conceptualizing,
drafting, revising, and editing a doctoral dissertation.
Writing is an important academic skill that has been
Table 1 Symptoms of specic learning disorder: APA DSM-5
Inaccurate or slow and effortful word reading
Difficulty understanding the meaning of what is read
Difficulty with spelling
Difficulty with written expression
Difficulties mastering number sense, number facts, or calculation
Difficulties with mathematical reasoning
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associated with overall academic achievement (11). On
average, writing tasks occupy up to half of the school
day (12), and students with difficulty writing are often
mislabeled as sloppy or lazy rather than being recognized as
having a learning disorder. Decient handwriting has been
associated with lower self-perception, lower self-esteem,
and poorer social functioning (13,14).
The acquisition of writing follows a step-wise
progression in early childhood; individuals who struggle
with foundational writing skills are likely to exhibit greater
delays as they fail to match their peers’ growth in writing
ability. In preschool, children are taught to copy symbols
and shapes to develop the basic visual-motor coordination
skills for transcription. Letter awareness typically begins
in kindergarten and progresses through second grade,
during which time the child becomes familiarized with
the relationship between sounds and phonemes while
continuing to grow in motor skills (15). Automaticity, in
which individual letter writing has become a rote response,
is usually developed by third grade (16). As many American
school curricula no longer include specific instruction on
the steps of letter formation, children who struggle to
develop automaticity may fail to acquire this skill (5,17).
Automaticity and handwriting should continue to improve
through the elementary school years (18) with implications
for long-term outcomes; notably, the skill of automaticity is
associated with higher quality and longer length of writing
products in high school and college (19,20).
Beyond the early school years, writing projects require
the additional ability to organize, plan, and implement
a complete written product. Such tasks require the
recruitment of executive functioning and higher-order
language processing. For example, writing a sentence
requires several steps: (I) internally creating the desired
statement; (II) segmenting the desired statements into
sections for transcription; (III) retaining the sections in
verbal working memory while executing the task of writing;
and (IV) checking that the completed written product
matches the original thought. Writing more complex
products such as paragraphs or essays requires additional
planning, organization, and revision to stitch together
multiple statements and thoughts into a coherent whole.
Failure to develop writing automaticity by third grade
greatly increases the likelihood of difculty in more complex
writing tasks, as the child’s higher cognitive functions may
be preoccupied by the graphomotor requirements of letter
formation.
Mechanisms and etiology
Many of the theories regarding mechanisms of dysgraphia
have been derived from studies of individuals with acquired
dysgraphia (21,22). Writing has been shown to be a complex
process that requires the higher order cognition (language,
verbal working memory and organization) coordinated with
motor planning and execution to constitute the functional
writing system (23). Different writing tasks require different
cognitive processes, and individuals with dysgraphia may
have disorders in one or more areas. For example, when
asked to spell a dictated word, the listener must utilize
phonological awareness to access phonological long-term
memory and the associated lexical-semantic representations.
This in turn activates the orthographic long-term memory
to create abstract letter representations that require motor
planning and coordination to execute the task of writing, all
maintained in the working memory. Spelling a pseudoword
or novel word requires the function of sublexical spelling
process that applies known phoneme-graphene conventions
to predict the correct spelling. Generating a new word
spontaneously would rst require the usage of orthographic
skills, which would then access the lexical representation.
Writing rapidly and fluidly requires motor planning and
coordination mediated by the cerebellum. Throughout the
writing task, visual and auditory processing and attention is
crucial to the production of legible writing.
Impairment in even one facet of the writing process
can impair an individual’s ability to generate an age-
appropriate product (24). Although researchers have
theorized that different subtypes of dysgraphia may be
correlated to different mechanisms (25), newer studies have
demonstrated interrelations between brain areas responsible
for automaticity, language, and motor coordination. The
perceived divergence between theories of dysgraphia may
not be as great as once thought. For example, children with
dyslexia have also been noted to be at increased risk for
other mild motor decits in tasks like nger tapping, riding
a bike, and tying shoelaces.
Increased attention has also been placed on the
cerebellum as playing a role in dysgraphia. Case studies
have shown that cerebellar injury can cause symptoms of
acquired dysgraphia, indicating that it plays some role in
the coordination of writing (21). Functional imaging studies
have also demonstrated that this region of the brain plays
a vital role in language and automaticity (26). Possible
mechanisms of involvement include the hypothesis that
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the cerebellum is required in the development of a neural
system or framework, which can be disrupted in different
ways and result in different functional impairments (1).
Genes and their role in the possible etiology or
mechanisms of learning disorders is an emerging field.
Genetic aggregation studies suggest that verbal executive
function tasks, orthographic skills, and spelling ability may
have a genetic basis. For example, genes on chromosome
15 have been linked to poor reading and spelling (27) and
genes on chromosome 6 have been linked to phonemic
awareness (28). Individuals with learning disabilities and
their family members have been noted to have differential
brain activation patterns on functional magnetic resonance
imaging, suggesting a genetic contribution, but not
causation (29). As the eld of genetics continues to evolve,
more information regarding the genetics of learning
disorders like dysgraphia is likely to emerge.
Co-morbidities
Dysgraphia may occur in isolation but is also commonly
associated with dyslexia as well as other disorders of
learning. Depending on the denitions utilized, anywhere
from 30% to 47% of children with writing problems also
have reading problems. In addition, difficulty in writing
can be seen in many other neurodevelopmental disorders,
including attention-deficit/hyperactivity disorder, cerebral
palsy, and autism spectrum disorder. Research demonstrates
that 90–98% of children with these disorders struggle with
writing (29-32). Developmental coordination disorder
(DCD), in which individuals have deficiencies in motor
development and motor skill acquisition, often also affects
writing development; around half of those with DCD also
exhibit impaired writing abilities (33). With regards to the
association between learning disorders and mental health
disorders, co-morbidity is the rule, not the exception (34,35).
Given this high risk of co-morbidity, clinicians should be
surveilling patients for possible related conditions; e.g., the
patient with autism spectrum disorder should be monitored
for problems with reading, writing, and math while the
patient with dysgraphia may warrant an investigation of co-
morbid attention-decit/hyperactivity disorder.
Red flags
As academic demands increase and neurodevelopment
progresses, dysgraphia may manifest in a variety of signs and
symptoms. It can affect one or more levels of the writing
process. As noted above, handwriting is typically developing
in the early school years, and thus, dysgraphia is usually
not recognized during this period. However, dysgraphia
(especially isolated dysgraphia) may not be recognized,
even into the young adult years. Co-morbid dyslexia and
dysgraphia is more readily recognized, although impairments
in reading ability are usually prioritized and addressed over
impairments in writing. The National Center for Learning
Disabilities has published a summary of warning signs for
dysgraphia based on the age and stage of development
(Table 2) (36). As in seen in the table, dysgraphia symptoms
manifest first as concrete impairments at younger ages and
later as abstract impairments at older ages.
Diagnosis
The diagnosis of specic learning disability is typically made
in an educational setting by a team assessment, which often
includes occupational therapists, speech therapists, physical
therapists, special education teachers, and educational
psychologists. In the United States, most often, the
diagnosis is made following an assessment towards eligibility
for an individualized educational plan (36). The diagnosis of
a learning disability or dysgraphia can also be given through
a psychoeducational evaluation outside of the educational
system. As the term “dysgraphia” is not recognized by
the American Psychological Association, there is no
professional consensus on specic diagnostic criteria. As in
the case for other learning disorders, a key factor should be
the degree of difculty that the writing impairment imposes
on the child’s access to the general education curriculum.
Evidence should be drawn from multiple sources and
contexts, including observation, anecdotal report, review of
completed work, and normative data.
One expert recommendation for the diagnosis of
dysgraphia is the following: slow writing speed; illegible
handwriting; inconsistency between spelling ability and
verbal intelligence quotient; and processing delays in
graphomotor planning, orthographic awareness, and/or
rapid automatic naming. Secondary tests to consider are
evaluations of pencil grip and writing posture. Formalized
handwriting assessments (Table 3) can be used to measure
the speed and legibility of students when copying letters,
words, sentences, and/or pseudowords. Visual-motor
integration assessment may include evaluations such as
the Beery Developmental Test of Visuomotor Integration
(VMI) (37); however, these tests typically do not analyze
difculties specic to orthographic processes. Children with
suspected dysgraphia should be evaluated for other potential
S50 Chung et al. Dysgraphia
© Translational Pediatrics. All rights reserved. Transl Pediatr 2020;9(Suppl 1):S46-S54 | http://dx.doi.org/10.21037/tp.2019.11.01
learning problems given the high rates of co-morbidity with
dyslexia and other learning disorders.
There is no medical testing required or available for
diagnosing dysgraphia. However, given the high rate of co-
morbidity between psychiatric, neurodevelopmental, and
learning disorders, the physician should investigate for
symptoms of possible related conditions. The physician
should conduct a thorough neurologic examination,
including “soft” neurologic signs like poor coordination,
dysrhythmias, mirror movements, and overow movements.
Co-morbid neurodevelopmental disorders (e.g., autism
spectrum disorder, attention-decit/hyperactivity disorder)
and mood disorders (e.g., anxiety, depression) can be
evaluated through the use of semi-structured interviews
and/or validated parent and teacher report forms. Should
screening procedures indicate any areas of concerns, the
general medical practitioner should consider referring
for specialist consultation for additional diagnostic
conceptualization and treatment recommendations,
including child neurology, child psychiatry, developmental-
behavioral pediatrics, or other mental health providers.
Management
The primary intervention for dysgraphia and other learning
disorders occurs in the educational setting. Interventions
can generally be stratified into the following levels: (I)
accommodation, where the student accesses the mainstream
education curriculum with supportive or assistive resources
without changing the educational content; (II) modication,
where the school adapts the student’s goals and objectives
as well as provides services to reduce the effect of the
disability; and (III) remediation, where the school provides
specific intervention to decrease the severity of the
student’s disability. As the manifestations of dysgraphia and
other learning disorders change with shifting academic
demands and cognitive development, management of these
conditions is a uid and life-course process that must adapt
with the most current level of impairment. As outlined by
IDEA, the school system should assess and provide the
necessary supports for the student’s needs in the educational
setting.
Accommodations
Accommodations should be directed to decrease to the
stress associated with writing. Specific devices may be
utilized, such as larger pencils with special grips and paper
with raised lines to provide tactile feedback. Extra time
can be permitted for homework, class assignments, and
quizzes/tests. Depending on the student’s comfort level,
alternative ways of demonstrating knowledge (e.g., oral
or recorded responses rather than written examination)
Table 2 Signs of dysgraphia: United States National Center for Learning Disabilities
Age group Signs or symptoms
Pre-school children An awkward grip or body position when writing
Tire easily with writing
Avoidance of writing and drawing tasks
Written letters are poorly formed, inversed, reversed, or inconsistently spaced
Difficulty staying within margins
The school-aged child Illegible handwriting
Switching between cursive and print
Difficulty with word-finding, sentence completion, and written comprehension
The teenager and young adult Difficulty with written organization of thought
Difficulty with written syntax and written grammar that is not duplicated with oral tasks
Table 3 Examples of standardized writing assessment tools
Minnesota Handwriting Assessment
Evaluation Tool of Children’s Handwriting
Scale of Children’s Readiness in Printing
Detailed Assessment of Speed of Handwriting
Beery Developmental Test of Visuomotor Integration (VMI)
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can be considered. Technologic accommodations include
automated spellcheck, voice-to-text recognition software,
tablets, and computer keyboards; as devices become
increasingly more advanced, new devices should be
considered for their application in the classroom. However,
handwriting practice should continue at school as written
language is still needed for many daily tasks (e.g., lling out
forms). Research has also demonstrated that the process
of writing words by hand may provide a unique impetus to
learning (38). It is important to note that accommodations
may not directly address impairment of executive
functioning tasks related to writing, including planning and
organization. Computers and voice-to-text supports can
decrease writing stress in those with continued automaticity
challenges, but these accommodations do not address
higher-level writing difculties (39).
Modications
Dysgraphia may require modifications to the student’s
academic program, especially with regards to written
products. Teachers can opt to scale down large written
assignments, break up large projects into smaller ones, or
grade students based on a single dimension of their work
(e.g., content or spelling, not both). In general, following
the “least restrictive environment” for learning, the school
should strive to keep the student within the mainstream
education environment as much as possible.
Remediation
Remediation should be determined by the individual
student’s severity of difculty in written expression. As with
many neurodevelopmental conditions, early intervention
produces the greatest gain (24). A stratied approach may be
utilized following a response-to-intervention model (RTI).
This model consists of three tiers of intervention; students
who continue to struggle to lower tiers “step up” to higher
tiers. Tier 1 consists of preventative screening on all students
for learning differences. Expert recommendations have been
written for general education teachers regarding ways to
encourage sound writing habits (9). Tier 2 consists of targeted
intervention towards students with specific learning issues.
Tier 3 focuses the most intensive treatment on students who
have continued to struggle and require the most support.
In most intervention studies, students usually demonstrate
improvement after 20 lessons over several weeks.
Most often, intervention for dysgraphia in the early
elementary years focuses on developing fine motor skills.
Motor activities for increasing hand coordination and
strength include tracing, drawing in mazes, and playing
with clay as well as exercises like finger tapping and
rubbing/shaking the hands. Intervention can also include
teaching grip control and good writing posture. However,
research has demonstrated that teaching motor skills in
conjunction with orthographic skills is the most effective
approach (40). One example method of teaching
orthographic tasks is described by Berninger (19): the
student learns to write each letter by rst visually learning
the steps to write the letter (based on a sample with
numbered arrow cues), then visualizing the act of writing
the letter, using the cues to transcribe the letter, and
checking the written product with the initial sample (41).
Other techniques focus the learners’ attention on the
movements associated with writing rather than the written
product itself [e.g., reviewing video models instead of static
guides (42) and using placeholder pens without ink (43)].
The family should provide enjoyable writing activities
outside of the educational setting so that the individual
can learn that writing can be a pleasant and enjoyable
experience. Research has demonstrated that educational
games and activities can be used to help students practice
retrieving letters from long-term memory (44).
Students with dysgraphia may also need help in more
complex parts of writing, including planning, drafting,
and revising, especially as they enter the middle and high
school years. Randomized-control trials have shown that
interventions like “writing clubs” can improve performance
in students struggling with these skills. Another validated
approach is the self-regulated strategy development program
that has shown generalized and sustained efcacy (45). This
curriculum specically instructs in strategies of writing and
self-regulation with students acting as collaborators during
the course. Students who continue with writing difculties
in middle and high school may require additional specific
instruction in composition (46,47). Some psychoeducational
programs (Table 4) , handwriting programs (Table 5) and
support groups (Table 6) are useful resources for children
with dysgraphia and their families and other professionals.
Conclusions
Writing is a skill that is central to learning and activities
of daily living; it begins to develop in early childhood but
continues through the school age. Though common in
children, dysgraphia and disorders of written expression
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are often overlooked by the school and family as a
character aw rather than a genuine disorder. A variety
of cognitive mechanisms have been proposed regarding
the mechanism of dysgraphia and continued research
is needed in the field to clarify the definition and
etiology of the disorder. Regardless of the presenting
symptoms, early diagnosis and intervention has been
linked to improved results. Because of typical delay in
the diagnosis of dysgraphia, the primary care provider
can play an important role in recognizing the condition
and initiating the proper work-up and intervention.
Screening for co-morbid medical, neurodevelopmental,
psychiatric and learning disorders is also an important
function of the provider. Education and support for the
family, coordination of care with the educational system,
additional referrals to subspecialists, and follow-up
screening for co-morbidities are important tasks for the
primary care provider to adopt.
Table 4 Psychoeducational resources for parents
Name Psychoeducation for parents
Understanding Dysgraphia: Fact Sheet This brief document is an easy-to-read summary about dysgraphia and is published
by the international dyslexia foundation (http://www.interdys.org/ewebeditpro5/upload/
Understanding_Dysgraphia_Fact_Sheet_12-01-08.pdf)
What is Dysgraphia? This webpage includes an overview of dysgraphia as well as links to resources for parents
(http://www.ncld.org/types-learning-disabilities/dysgraphia/what-is-dysgraphia)
The Importance of Teaching Handwriting This site includes information regarding different accommodations and modifications for
dysgraphia (http://www.readingrockets.org/article/27888/)
Strategies for the Reluctant Writer This page provides instruction on home-based writing intervention administered by parents
(http://www.ldonline.org/article/Strategies_for_the_Reluctant_Writer/6215)
TechMatrix A database of assistive technology options (software and hardware) that includes stratification
for grade and educational diagnosis (http://techmatrix.org/)
Table 5 Handwriting supplemental program
Name Handwriting supplemental programs
Zaner-Bloser Apps, writing games, and other resources covering writing and reading (http://www.zaner-
bloser.com/)
Handwriting without Tears A popular writing intervention program usable by parents or teachers (www.hwtears.com/)
Big Strokes for Little Folks Suitable for students who have problems writing letters but can recognize them. Published by
Psychological Corp.
Sensible Pencil A program to teach letter writing, applicable in the home and school. Published by ATC
Learning Company
Loops and Other Groups A kinesthetic approach to teach writing in cursive (http://www.pearsonassessments.com/
HAIWEB/Cultures/en-us/Productdetail.htm?Pid=076-1641-890)
Table 6 Support groups
Name Support groups
Parent Center Network A hub for providing support to parents of children with disabilities on a regional level (http://
www.parentcenternetwork.org)
Eye to Eye A mentoring program that matches children and young adults who have similar learning and
attention issues (http://eyetoeyenational.org/)
S53Translational Pediatrics, Vol 9, Suppl 1 February 2020
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Acknowledgments
Funding: None.
Footnote
Conflicts of Interest: DRP serves as the unpaid Deputy
Editor-in-Chief of TP and the unpaid Guest Editor of the
focused issue “Neurodevelopmental and Neurobehavioral
Disorders in Children”. TP. Vol 9, Supplement 1 (February
2020). The other authors have no conflicts of interest to
declare.
Ethical Statement: The authors are accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.
Open Access Statement: This is an Open Access article
distributed in accordance with the Creative Commons
Attribution-NonCommercial-NoDerivs 4.0 International
License (CC BY-NC-ND 4.0), which permits the non-
commercial replication and distribution of the article with
the strict proviso that no changes or edits are made and
the original work is properly cited (including links to both
the formal publication through the relevant DOI and the
license). See: https://creativecommons.org/licenses/by-nc-
nd/4.0/.
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Cite this article as: Chung PJ, Patel DR, Nizami I. Disorder
of written expression and dysgraphia: denition, diagnosis, and
management. Transl Pediatr 2020;9(Suppl 1):S46-S54. doi:
10.21037/tp.2019.11.01
