Dysgraphia

Original Editor - Maram Salem Top Contributors - Maram Salem

Introduction

Dysgraphia is a developmental disorder that affects the acquisition of writing skills. It manifests itself in various aspects of writing, including spelling, handwriting (legibility), spacing between letters, and expression. Dysgraphia is not a reflection of a child's intellectual capabilities and is one of the more common learning disorders. Despite the prevalence of this disorder, it is under-researched and under-diagnosed. It has a high co-morbidity rate with other learning disorders.

Definition

Developmental dysgraphia is a disorder of writing ability at any stage. Writing ability includes not just components of spelling, but includes grammar, letter spacing, difficulty holding a pencil/poor grip, writing fatigue, poor punctuation, inconsistent sentence structure, and difficulty with writing out concepts.

There are two subtypes of dysgraphia:

• motor dysgraphia: this refers to the difficulty with the actual process of holding a pencil and the production of written text. People with the motor component may fatigue due to lack of motor strength or coordination.
• dysorthography or dyslexic dysgraphia: this subtype focuses on the language processing aspect of dysgraphia. Word spelling is highly deficient, usually as a direct result of dyslexia.

Prevalence

It is estimated that between 10% to 30% of children have difficulty with writing. The exact prevalence of dysgraphia depends on which definition (motor or dysorthography) is used. It is more common in boys than girls. Students are usually screened and referred for occupational therapy services in schools to address any writing deficits.

Co-morbidities

Dysgraphia can occur alone but is more commonly found as a co-morbidity with other learning disorders such as dyslexia, ADHD, developmental coordination disorder, and autism. It is estimated that 30% to 47% of children that demonstrate problems with writing will demonstrate problems with reading.

Etiology

The current research about developmental dysgraphia is based on research of patients diagnosed with acquired dysgraphia, or the inability to produce written language due to neurological damage (e.g., post-CVA). Since writing is a multi-component function of the brain that involves working memory, organisation, and comprehension, and motor planning, people with dysgraphia can have a deficit in one of more of these brain functions.

Acquired dysgraphia, which can occur in adults as described above, manifests itself with language impairment or deficits visual-spatial abilities. Depending on the location of the neurological damage in the brain, impairments related to dysgraphia can vary. For example, patients can present phonological deficits in which a patient has difficulty writing unfamiliar words. Patients can also present with lexical dysgraphia that hinders their ability to write unfamiliar or ambiguous words.

Current research aims to determine how the cerebellum plays possible a role. Another area of research focuses on genetics and the impact it has on writing and spelling. MRI studies on family members with similar learning disabilities suggest possible genetic components to writing difficulties.

Characteristics/Clinical Presentation

Because handwriting, spelling, and reading are developing during the primary years, dysgraphia is not easily discerned by educators or parents. Signs and symptoms can vary, but generally include the following:

• poor grip/body position when writing
• tire quickly when writing
• avoidance of writing and drawing tasks
• inconsistency with written letters: inconsistent spacing between letters, reversing letters, or inversing (rotating) letters
• cannot write within the margins
• illegible handwriting
• writing a mixture of cursive and print
• difficulty with word finding, sentence completion, and comprehension
• found with young adults: difficulty with written organisation of thought and written syntax and written grammar

Medical Management

If dysgraphia is suspected, it is usually screened in a school setting by a child study team (social workers, educators, child psychologists, speech therapists, physiotherapists, and occupational therapists). If a formal diagnosis is warranted, a student is referred for an evaluation outside of the school system. In the United States, dysgraphia is not listed as a separate disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5, but it is included under the specific learning disorder category.

Multiple areas are observed and tested prior to making a diagnosis of dysgraphia:

• slow writing speed
• illegible handwriting
• poor spelling despite age appropriate verbal IQ
• processing delays in graphomotor planning (skills needed to recognise letters and words, memorise them, decide what to write, plan the movements to write, and execute the writing)
• processing delays in orthographic awareness (letter positioning, sequencing, and recognising patterns in words)
• processing delays in rapid automatic naming (how quickly a person can name words, objects, letters, or pictures)

In addition to the list above, an assessment regarding a child's grasp of the pencil and writing posture is made.

Because of dysgraphia's high co-morbidity rate with other diagnoses, children should be evaluated for other co-morbidities as well (e.g., dyslexia or developmental coordination disorder). Parent and teacher report are taken into consideration when attempting to make a diagnosis. Interventions are administered in school settings and outside the school (outpatient services). Providing resources within the classroom and modifying the student's educational environment to allow for full participation to keep up with age-level peers is key to a student's success and growth. Educators implement strategies such as use of larger pencils for grip, modified papers with larger margins or lines, additional time for exams and homework assignments, and oral testing (rather than strictly written exams) can be provided.

Physiotherapy Intervention

Although occupational therapy is one of the frontline interventions administered for people with dysgraphia, physiotherapy may be warranted due to the high co-morbidity rate of dysgraphia with other developmental disorders. Therapeutic exercises that incorporate bilateral upper extremity use and coordination, such as jumping jacks, alternating toe touches, and mountain climbers may be beneficial. Poor posture and lack of core strength can be addressed with core stabilisation training. This can assist with improving legibility of writing and sitting endurance to complete a writing assignment.