ArticlePDF AvailableLiterature Review

Disorder of written expression and dysgraphia: definition, diagnosis, and management

  • Western Michigan University Homer Stryker MD School of Medicine

Abstract and Figures

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 specific 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.
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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 difculty
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 difculty an individual may have in written
Much controversy exists regarding the precise denition
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. Specic 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 decits
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:
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 specic 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; specic learning disorder; disorder of written expression; accommodation; remediation;
Submitted Oct 22, 2019. Accepted for publication Oct 30, 2019.
doi: 10.21037/tp.2019.11.01
View this article at:
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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
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 specic learning disorder category, but does not dene
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 specic learning disorder, the academic skills
as measured by individually administered standardized tests
must fall signicantly below expectations for the child’s age.
The onset of difculty 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
“Specic 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 scientic, 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 identication of a specic 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 prociency.
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 specic 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. Decient 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 difculty in more complex
writing tasks, as the child’s higher cognitive functions may
be preoccupied by the graphomotor requirements of letter
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 decits 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.
Dysgraphia may occur in isolation but is also commonly
associated with dyslexia as well as other disorders of
learning. Depending on the denitions 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-decit/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.
The diagnosis of specic 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 specic diagnostic criteria. As in
the case for other learning disorders, a key factor should be
the degree of difculty 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
difculties specic to orthographic processes. Children with
suspected dysgraphia should be evaluated for other potential
S50 Chung et al. Dysgraphia
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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 overow movements.
Co-morbid neurodevelopmental disorders (e.g., autism
spectrum disorder, attention-decit/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.
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) modication,
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
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 difculties (39).
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 should be determined by the individual
student’s severity of difculty in written expression. As with
many neurodevelopmental conditions, early intervention
produces the greatest gain (24). A stratied 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 efcacy (45). This
curriculum specically instructs in strategies of writing and
self-regulation with students acting as collaborators during
the course. Students who continue with writing difculties
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.
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 (
What is Dysgraphia? This webpage includes an overview of dysgraphia as well as links to resources for parents
The Importance of Teaching Handwriting This site includes information regarding different accommodations and modifications for
dysgraphia (
Strategies for the Reluctant Writer This page provides instruction on home-based writing intervention administered by parents
TechMatrix A database of assistive technology options (software and hardware) that includes stratification
for grade and educational diagnosis (
Table 5 Handwriting supplemental program
Name Handwriting supplemental programs
Zaner-Bloser Apps, writing games, and other resources covering writing and reading (http://www.zaner-
Handwriting without Tears A popular writing intervention program usable by parents or teachers (
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 (
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://
Eye to Eye A mentoring program that matches children and young adults who have similar learning and
attention issues (
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Funding: None.
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
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:
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Cite this article as: Chung PJ, Patel DR, Nizami I. Disorder
of written expression and dysgraphia: denition, diagnosis, and
management. Transl Pediatr 2020;9(Suppl 1):S46-S54. doi:
... Despite correct learning and practice of handwriting, some children never master this skill to a sufficient level of automation (reviewed in [10][11][12]. These handwriting deficits, referred to as developmental dysgraphia in children, have been defined as a written-language disorder that concerns mechanical writing skills in children of average intelligence and with no distinct neurological or perceptual-motor deficits [13]. ...
... Dygraphia is generally found in association with neurodevelopmental disorders, namely dyslexia (DL), Developmental Coordination Disorder (DCD) and Attention Deficit Disorder/Hyperactivity Disorder (ADHD) [15][16][17][18][19][20]. Dysgraphia preferentially affects boys (3:1 ratio), most likely because of the prevalence of the associated disorders in boys [10,21]. Many studies have shown differences handwriting deficits depending on the associated disorder [22][23][24][25][26][27][28]. ...
... This kind of analysis is performed afterwards. This is the principle of many tests used in different countries (for a review see [10]). The quality of the trace is evaluated based on different features such as letter size and form, spatial organization of handwriting on the paper sheet, margin, etc. ...
... Часто дисграфія залишається, значною мірою, поза увагою через недостатню обізнаність про її прояви серед вчителів, що може викликати непорозуміння, наприклад, можливість cплутати дисграфію з лінощами -це робить дітей вразливими до зниження рівня грамотності, зниження мотивації, негативної самоефективності та/або підвищеного рівня тривожності, коли вони стикаються з письмовими завданнями [8]. Тому з метою попередження виникнення дисграфії у молодших школярів особливого значення набуває її профілактика серед дітей дошкільного віку. ...
... Як зазначили Chung P., Patel D., Nizami I. у «Діагностичному та статистичному посібнику з психічних розладів» (DSM-5) дисграфія включена до категорії «специфічних розладів навчання», але не визначає її як окремий розлад. До симптомів специфічного розладу навчання (APA DSM-5) відносять: неточне або повільне та важке читання слів, труднощі з розумінням змісту прочитаного, труднощі з орфографією, труднощі з письмовим виразом, труднощі з опануванням відчуття чисел, чисел чи обчислень, труднощі з математичними міркуваннями [8]. Відповідно до критеріїв набір симптомів має бути стійким протягом мінімум 6 місяців. ...
... Handwriting is a complex activity involving cognitive, perceptual and motor skills. Because of its prominence at school, handwriting difficulties, or dysgraphia, can lead to many hardships for children, including lower academic success and loss of self-esteem [16]. Several neurodevelopmental disorders are associated with dysgraphia, namely Developmental Coordination Disorder (DCD), dyslexia, and Attention Deficit Hyperactivity Disorder (ADHD) [16]. ...
... Because of its prominence at school, handwriting difficulties, or dysgraphia, can lead to many hardships for children, including lower academic success and loss of self-esteem [16]. Several neurodevelopmental disorders are associated with dysgraphia, namely Developmental Coordination Disorder (DCD), dyslexia, and Attention Deficit Hyperactivity Disorder (ADHD) [16]. ...
... Starting the learning path can be challenging, particularly for children who struggle to acquire basic knowledge. If these difficulties are not addressed, they can lead to frustration, low self-esteem, depression, and school abandonment [1]. Some children simply need more time; others may never reach their peers' level, nonetheless any remediation attempt, thus being affected by specific learning disabilities (SLDs) [2]. ...
... This is particularly true for first graders, that could not train with pre-graphical activities during kindergarten years. However, the situation improved in time, till reaching a percentage of children at risk comparable with literature [1]. ...
Conference Paper
Early screening of handwriting difficulties is key to start remediation activities that help distinguishing between a simple delay and dysgraphia. Technology is fundamental in this process, as also claimed by guidelines for dysgraphia diagnosis: it allows to implement artificial intelligence techniques to help in the discrimination of the difficulty. To this end, a serious game was leveraged to assess handwriting laws altered in dysgraphia starting from symbols drawing. 66 first and second graders were longitudinally tested both with the serious game and with a handwriting proficiency test. Objective features computed from the game were tested to understand if they significantly differed between children at risk and not at risk of dysgraphia, according to a standardized clinical test used to assess handwriting. Then, machine learning models were leveraged to predict the risk and understand the areas of difficulty. On average, 62% of the features significantly differ between risk levels for first graders, whilst only 35% for second graders, thus revealing a better sensitivity in younger children. This is encouraging for an early observation. As for machine learning, a Logistic classifier was able to predict risk with an area under the precision-recall curve of 0.84 for the risk class and 0.98 for the non-risk class. The results of this study could be a valid help for an artificial intelligence-enhanced screening of dysgraphia.
... The neuropsychological profile may vary from individual to individual, but as a group, mild impairments have been found in domain-general cognitive processes, such as those of automatization and executive control, which are fundamental mechanisms for learning (Agostini et al., 2022;Smith-Spark & Gordon, 2022). A large body of literature documents EF impairment in developmental dyslexia, as it is the most representative of all SLDs (Booth et al., 2010;Jerman & Swanson, H, 2005), but there is also evidence of impaired EFs in dyscalculia (Agostini et al., 2022), dysorthography, and dysgraphia (Chung et al., 2020), with no significant differences across SLD subgroups (Brandenburg et al., 2015). It should be noted that EFs can contribute to the activation and use of compensatory strategies and mechanisms that modulate the impact of SLDs on adaptive functioning and probably on the evolution of the disorder over time (Zelazo, 2020). ...
... Dysgraphia is a specifier encompassing difficulties in writing, including spelling, grammar, punctuation, and handwriting (19). Handwriting challenges tend to endure throughout different stages of development and grades for the majority of children grappling with SLDs. ...
Full-text available
Background: Handwriting is one of the most common reasons for referral to occupational therapy among children with specific learning disorders (SLDs). The Persian handwriting assessment tool (PHAT) is a valid assessment instrument. It is important to clarify the reliability of this assessment tool for the accuracy of results and certain clinical uses in Iranian children with SLDs. Objectives: The present study aimed to investigate the internal consistency, test-retest, and inter-rater reliability of the PHAT in children with SLDs aged 10 to 12 years in the Iranian context. Methods: Thirty children (mean ± SD 132.33 ± 53.8 months) with SLDs, studying in grades 4 to 6, were recruited from special education schools and rehabilitation clinics from January to May 2022. Cronbach's alpha and intraclass correlation coefficient (ICC) were calculated to determine internal consistency, test-retest reliability, and inter-rater reliability, respectively. The standard error of measurement (SEM) and minimal detectable change (MDC) were computed to establish absolute reliability. Results: Internal consistency was excellent (α = 0.98 to 0.99), as was inter-rater reliability (ICC = 0.95 to 1.00). Test-retest reliability was good to excellent (0.86 to 1.00). The SEM and MDC values for test-retest reliability were 0 to 0.47 and 0 to 1.29, respectively. Finally, the SEM (0 - 0.21) and MDC (0 - 0.57) values were acceptable for inter-rater reliability. Conclusions: The PHAT is a reliable assessment tool for Iranian children with SLDs aged 10 to 12 years. Further, clinicians can utilize this tool to identify handwriting difficulties in children with SLDs aged 10 to 12 years, which leads to more targeted interventions.
Full-text available
Research regarding dysgraphia, an impairment in writing, is attaining more attention in recent times. The existing studies on dysgraphia draw insights from cognitive, behavioural, neurological, and genetic fields of knowledge. However, these multiple studies on dysgraphia fail to illustrate how these cognitive, behavioural, neurological, and genetic systems interact and intersect in dysgraphia. Therefore, the studies could not offer a comprehensive understanding of dysgraphia. In order to fill this gap, the review attempts to study dysgraphia using the notion of modularity by accommodating insights from cognitive, behavioural, neurological, and genetic aspects of dysgraphia. Such a profound understanding could facilitate an early diagnosis and holistic intervention towards dysgraphia.
Full-text available
Language and characters contain rich information and play an important role in daily communication. Although flexible pressure sensors have aroused extensive attention in information interaction, the application in the special groups who characterized with “voiceless” and/or “dysgraphia” cannot normally speak and/or write is usually ignored. Herein, a high-performance flexible pressure sensor was proposed to learn the expression content from special groups through recognizing the voiceless speaking and abnormal writing. Thanks for the enhanced interfacial interactions and air gaps constructed in device, the as-prepared sensor possesses ultrahigh sensitivity in a small pressure range ( S = 45.95 kPa − 1 , P < 1 kPa) and exhibits an outstanding sensitivity to the slight pressure resulted from voice and writing. In addition, high stability, good flexibility, short response time of 123 ms, and excellent durability over 2000 cycles are also achieved. As the voice and writing detector, it can accurately recognize different voice signals and characters stroke order. Importantly, by comparing with the electrical signals obtained under normal speaking and writing conditions, the real expression content from the special groups can be well acquired. This high-performance pressure sensor, along with its unique structure designing, is expected to be widely used in human − computer interaction, health monitoring, and soft robotics.
Importance: Handwriting legibility and speed assessments have a critical role in identifying and evaluating handwriting problems, which are common among children. Objective: The objective was to evaluate the psychometric properties and clinical utility of handwriting assessments for children ages 3 to 16 yr. Data Sources: A systematic review was conducted in CINAHL, PubMed (MEDLINE), Scopus, and education databases, with no time limits. The search strategy included a combination of the following keywords: handwriting, write, children, assessment, and validity. The exclusion criteria were assessment tools that were electronic, that focused on cognitive components of handwriting, or that only evaluated alphabets other than Latin. Study Selection and Data Collection: The systematic review was carried out on the basis of the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The protocol was registered in the Prospective Register of Systematic Reviews (PROSPERO). Findings: The 14 included instruments had a total sample of 4,987 children. Internal consistency ranged from moderate (.73; Writing Readiness Inventory Tool in Context) to high (.98; Letter Writing). The interexaminer reliability values of the 11 direct assessment instruments ranged from .77 (Systematic Screening for Handwriting Difficulties) to 1.00 (Handwriting Speed Test). Conclusions and Relevance: In this systematic review, existing tools were evaluated by clinical utility and the quality of psychometric properties. Direct assessments showed good psychometric properties. Indirect and self-assessment tools demonstrated poor psychometric properties. Further research on screening tools and tools in other languages is needed. What This Article Adds: Specific learning disorders (e.g., dysgraphia) negatively affect academic learning and, when prolonged in time, self-concept. However, handwriting legibility and speed assessments could be used to identify and evaluate these learning disorders if an early referral to occupational therapy is carried out.
Full-text available
Developmental coordination disorder (DCD) is a common and well-recognized neurodevelopmental disorder affecting approximately 5 in every 100 individuals worldwide. It has long been included in standard national and international classifications of disorders (especially the Diagnostic and Statistical Manual of Mental Disorders). Children and adults with DCD may come to medical or paramedical attention because of poor motor skills, poor motor coordination, and/or impaired procedural learning affecting activities of daily living. Studies show DCD persistence of 30-70% in adulthood for individuals who were diagnosed with DCD as children, with direct consequences in the academic realm and even beyond. In particular, individuals with DCD are at increased risk of impaired handwriting skills. Medium-term and long-term prognosis depends on the timing of the diagnosis, (possible) comorbid disorders (and their diagnosis), the variability of signs and symptoms (number and intensity), and the nature and frequency of the interventions individuals receive. We therefore chose to investigate the signs and symptoms, diagnosis, and rehabilitation of both DCD and developmental dysgraphia, which continues to receive far too little attention in its own right from researchers and clinicians.
Full-text available
Alamargot, D. & Chanquoy, L., (2001). Through the models of writing. Dordrecht-Boston-London : Kluwer Academic Publishers. Denis Alamargot and Lucile Chanquoy’s book offers a vivid and original presenta- tion of main trends in the research field devoted to writing. First, it provides both young and senior scientists with a comparative view of current theoretical models of composition, with different levels of reading made available: each element of these models is clearly situated in its historical context, and scrutinized in its further evo- lution. Second, this well documented theoretical analysis of writing mechanisms is checked against empirical data extracted from a lot of updated experimental studies; and lack of necessary data is thought to be underlined and defined when noted. Following the usual description of writing phases initially proposed by Hayes and Flowers, the first part of this book presents planning, translating and revision processes and compares them to other researchers’ conceptions (from Bereiter and Scardamalia, to Kellogg or Galbraith). Such presentations of isolated models do ex- ist in literature; but the present work really gives a good comparative analysis of components inside each of models, in a clear and cumulative way; a fine-grained ob- servation of differences between similarly-looking models is also performed.
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The mastering of handwriting is so essential in our society that it is important to try to find new methods for facilitating its learning and rehabilitation. The ability to control the graphic movements clearly impacts on the quality of the writing. This control allows both the programming of letter formation before movement execution and the online adjustments during execution, thanks to diverse sensory feedback. New technologies improve existing techniques or enable new methods to supply the writer with real-time computer-assisted feedback. The possibilities are numerous and various. Therefore, two main questions arise: 1-What aspect of the movement is concerned and 2- How can we best inform the writer to help them correct their handwriting? In a first step, we report studies on feedback naturally used by the writer. The purpose is to determine which information is carried by each sensory modality, how it is used in handwriting control and how this control changes with practice and learning. In a second step, we report studies on supplementary feedback provided to the writer to help them to better control and learn how to write. We suggest that, depending on their contents, certain sensory modalities will be more appropriate than others to assist handwriting motor control. We emphasize particularly the relevance of auditory modality as online supplementary feedback on handwriting movements. Using real-time supplementary feedback to assist in the handwriting process is probably destined for a brilliant future with the growing availability and rapid development of tablets.
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In today's environment of high-stakes testing, handwriting is a skill that is often overlooked in order to focus on other areas of the curriculum. However, research indicates that handwriting is tied to academic achievement, especially composition and literacy skills. This article provides strategies that can be used to support students with disabilities in the areas of handwriting, motor skill development, and practice during functional tasks.
Developmental deficits in the acquisition of writing skills (developmental dysgraphias) are common and have significant consequences, yet these deficits have received relatively little attention from researchers. We offer a framework for studying developmental dysgraphias (including both spelling and handwriting deficits), arguing that research should be grounded in theories describing normal cognitive writing mechanisms and the acquisition of these mechanisms. We survey the current state of knowledge concerning developmental dysgraphia, discussing potential proximal and distal causes. One conclusion emerging from this discussion is that developmental writing deficits are diverse in their manifestations and causes. We suggest an agenda for research on developmental dysgraphia, and suggest that pursuing this agenda may contribute not only to a better understanding of developmental writing impairment, but also to a better understanding of normal writing mechanisms and their acquisition. Finally, we provide a brief introduction to the subsequent articles in this special issue on developmental dysgraphia.
Victoria J. Molfese is the Ashland/Nystrand Chair in Early Childhood Education and Professor in the Department of Teaching and Learning at the University of Louisville. She received her Ph.D. in developmental psychology from Pennsylvania State University and has published books, book chapters, and journal articles in cognitive development in infants, children, and adults. She has received grants for research activities, including a National Institutes of Health-funded grant on electrophysiological and behavioral predictors of language and cognitive development in children from infancy through 13 years of age. Her work also has been funded by grants from March of Dimes, the Kellogg Foundation, the U.S. Department of Education, and the National Institutes of Health and Human Services. Her current research focuses on the development of emergent reading and mathematics skills in preschool children and the development of these skills during early school age. Dr. Molfese has been a study section chair and reviewer for National Institutes of Health, a review panel member for the U.S. Department of Education and the National Foundation/March of Dimes, and is a Fellow of the American Psychological Society. She is Associate Editor of Developmental Neuropsychology and on the editorial board of the Journal of Experimental Child Psychology.