Practice Essentials
Writing is a complex task requiring the mastery and integration of a number of subskills. The process of writing connects cognition, language, and motor skills. Some children have difficulties in one aspect of the process, such as producing legible handwriting or spelling, whereas other children have difficulty organizing and sequencing their ideas. Difficulties in one area can delay skill development in the other areas, as practice of all writing skills may be impeded. Children often experience this disorder as thoughts that move faster than their hand can translate them into written ideas on the page. In real-world situations, children with primary impairment in handwriting often have associated spelling problems without reading problems. In addition, for some people, impairment in attention due to Attention Deficit Hyperactivity Disorder may be associated with dysgraphia. [1]
Students with Specific Learning Disabilities that impair writing skills (handwriting, spelling, and/or composing) may not only need accommodations (e.g., allowing more time to complete written work or using a laptop) but also continuing explicit instruction in alphabet letter access, retrieval, and production and copying words in sentence context and using multiple modes of letter production in spelling and composition instruction. The use of different approaches to handwriting (writing by hand, typing) may be helpful to strengthen the orthographic loop of working memory that supports written language learning by connecting the mind's eye with the serial movements of hands and fingers in producing the sequential component strokes of letter forms. [2]
Recent research looked at DTI and fMRI to elucidate the brain regions involved and found that connections from the supramarginal gyrus to the anterior cingulate and from the inferior frontal gryus to the frontal gyrus may be involved and are affected in word-specific spelling impairment in children with dysgraphia. [3]
Background
Proficiency in written expression skills can be viewed as the culmination of a child's education. Along with reading, expressing oneself in writing is an essential accomplishment of childhood that facilitates the necessary and rewarding tasks of adult life. The ability to write at an age-appropriate level is required for all academic progress. For some children, the acquisition of written expression skills is a difficult and enduring problem.
Disorders of written expression often accompany reading or other learning difficulties; less research has been performed in isolated written expression problems than in other learning areas. In fact, whether written expression exists is an isolated disorder is uncertain. Not infrequently, writing is the most significant stumbling block for a child. The diagnosis of written language disorder can help point the way toward necessary treatment and support. Although individualized teaching strategies may change epigenetic gene expression and improve reading and writing during earlier stages of education, the underlying gene sequences may continue to play an etiological role for individuals with expressive writing disorder, especially as curriculum requirements increase in nature, complexity, and volume with increasing academic complexity. [4]
Vision problems can interfere with the process of reading, but children with dyslexia or related learning disabilities have the same visual function and ocular health as children without such conditions; however, there is no valid evidence at this point that children who participate in vision therapy are more responsive to educational instruction than children who do not participate. [5]
Dysgraphia can also be associated with other medical conditions such as absence seizures. [6]
Children with written expression difficulties can find essential activities at school, such as note taking, to be insurmountable tasks. Note taking requires listening, comprehending, retaining information while continuing to process new information, and summarizing the important points into a useful format. The physical acts involved in writing notes must occur simultaneously with these cognitive processes. All of this must be accomplished with sufficient speed, automaticity, and with a quality of production leading to writing legibly enough for the notes to be useful later.
Diagnostic Criteria (DSM5)
In 2013, the American Psychiatric Association released the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM5). In this latest edition, specific learning disorder (SLD) is the umbrella term for mathematics, reading, and written expression disorders. It is now a single, overall diagnosis, incorporating deficits that impact academic achievement. Rather than limiting learning disorders to diagnoses particular to reading, mathematics, and written expression, the criteria describe shortcomings in general academic skills and provide detailed specifiers for the areas of reading, mathematics, and written expression. The diagnosis requires persistent difficulties in reading, writing, arithmetic, or mathematical reasoning skills during formal years of schooling. [7]
Specific learning disorder with impairment in written expression includes possible deficits in:
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Spelling accuracy
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Grammar and punctuation accuracy
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Clarity or organization of written expression
Epidemiology
Frequency
A lack of agreement on definitions of learning disorders, as well as variation in the procedures that lead to school determinations among states and among individual school districts, lead to widely varying estimates of incidence. Most information available about the prevalence of the disorder of written expression is based on studies of reading disorders or learning disorders in general. Disorder of written expression is assumed to occur with a similar frequency to other learning disorders. The prevalence of specific learning disoder across the academic domains of reading, writing, and mathematics is 5%-15% among school-age children across different languages and cultures. [7]
In neuropsychological research with adults with acquired deficits, reading and writing appear to be independent skills areas, with dysgraphia occurring without dyslexia. This has not been well studied in children. Disorder of written expression, without preoccurring or concurrent learning disorders of reading and/or mathematics, is considered rare.
Mortality/Morbidity
Evidence suggests that disorder of written expression is accompanied by language and perceptual-motor deficits and often occurs in combination with reading disorder, mathematics disorder, or both. Some research points to preschool-aged and early school-aged difficulties with language and phonological skills in children who later are diagnosed with learning disorders, which may include written expression. Difficulties with phonological awareness appear to underlie spelling difficulties and may be related to, or concurrent with, other aspects of a disorder of written expression.
To allow for sufficient formal instruction, a disorder of written expression is not usually diagnosed until after the end of a child's first grade year in school. The poor progress with writing and, often, reading is usually apparent in the first grade; a diagnosis can often be made by second grade. Written expression problems often persist throughout school and can continue into postsecondary and adult years. College students with learning problems have difficulty with speed and automaticity of writing.
The writing skills of children with other learning disorders often are similar to the writing skills of children of a younger age group, as much as 3-6 years younger. That is to say, a 12-year-old child with learning disorders may write similar to a 6-year-old or 9-year-old child who does not have learning disorders rather than to a 12-year-old child without learning disorders. Children with other learning problems perform at levels below their peers without learning disorders in written expression at every age. The gap between the writing of children with learning disorders and their peers without learning disorders widens with age.
Frequently, learning disorders are comorbid with behavior disorders, most frequently ADHD and oppositional defiant disorder. Clinical experience with children with ADHD often reveals that they have poor written expression skills. Writing is a task that requires planning, organizational skills, and persistence of attention and effort. The nature and direction of the relationship of learning disorders, behavior disorders, and disorders of attention is unclear and may differ in gender specific ways.
Learning disorders of all types are associated with other mental health problems. The DSM-IV mentions low self-esteem, demoralization, and social skill deficits as associated with learning disorders. The school dropout rate is significantly higher for children with learning disorders than for children without learning disorders. Some research points to an increased incidence of subsequent substance abuse problems and lower levels of employment. Viewing these as factors that can occur with the disorder of written expression but also as factors that can be positively impacted by appropriate treatment of the academic and associated issues is important.
Pathophysiology
Genetic studies have focused attention on the area of DYX2 on chromosome 6p21.3 as several genes in this locus have been associated with reading disabilities as well as the gene areas DCDC2 and KIAA0319 appear to both contribute to reading and writing disabilities. Another important factor in reading and writing disabilities, READ1, a polymorphic compound with a short tandem repeat within intron 2 of risk gene DCDC2 may have a non-additive genetic interaction with KIAHap, a risk haplotype in risk gene KIAA0319 may be a transcriptional regulator of ETV and so also a transcriptional regulator of KIAA0319. [8]
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Prognosis
Prognosis is guarded. Disorders of written expression can remain as a lifelong barrier to fluent writing for persons unable to access assistive technologies such as computer-assisted dictation systems or spellcheck computer programs.
Patient Education
Use of assistive technologies is critical to a person being able to accommodate and function despite the disability. The use of assistive technology such as computer-assisted dictation systems and the use of spellcheck not just in computer documents but also in email communication can be extremely helpful. The use of a human being to proofread written documents can be extremely helpful as computer-assisted technology is not yet sophisticated enough to ensure that the words chosen by spellcheck reflect the true meaning that the person wishes to communicate. [9]
