Understanding dysgraphia

Abstract

Nurses at every stage should be aware of dysgraphia, an easily missed neurologic disorder. Use this article to help identify signs and symptoms, and learn about diagnostics and how to support your patient.

In Brief

Nurses at every stage should be aware of dysgraphia, an easily missed neurologic disorder. Use this article to help identify signs and symptoms, to learn about diagnostics, and appreciate how to support your patient.

Figure

A toddler picks up a brightly colored crayon on the table in front of her. She transfers it back and forth a few times, from one hand to the other, then begins to scribble on the sheet of paper before her, making random and uncontrolled marks. Over time, her writing implement becomes more refined, a pencil instead of a crayon. Scribbling evolves into lines, circles, loops, and slanted shapes. With practice, these will become letters and numbers and, eventually, words and sentences. However, 5%-20% of children will have difficulty developing these skills.¹ Eventually, some will be diagnosed with a learning disability known as dysgraphia. This article will focus on the disorder in children and adolescents and will discuss pathology and types of dysgraphia, signs and symptoms of the disorder, diagnostic tests, treatment, and emotional aspects and support for the patient.

Dysgraphia is categorized as both a neurologic disorder and a learning disability. As a neurologic disorder of written expression, it impairs writing ability and fine motor skills. As a learning disability, it interferes with virtually all aspects of writing including spelling, legibility, word spacing and sizing, and letter formation. In the Diagnostic and Statistical Manual of Mental Disorders 5th ed. (DSM-V), dysgraphia is characterized as a learning disability in the category of written expression, when one's writing skills are below those expected given a person's age measure through intelligence and age-appropriate education.² The DSM-V description is unclear about whether writing refers to only the motor skills involved, or if it also includes orthographic skills and spelling that's distorted or difficult to read.²

Although dysgraphia can occur in all age groups, onset in adults is usually the result of head trauma and, therefore, referred to as agraphia. However, because children with dysgraphia may otherwise be skilled readers and speakers, this disorder may be missed or attributed to child sloppiness. Therefore, a child may reach adulthood without receiving the appropriate diagnosis and treatment.

Pathophysiology

Dysgraphia is a neurodevelopmental disorder that appears as a learning disability in early elementary children. The DSM-V doesn't classify dysgraphia as a mental illness but as a specific learning disorder.² Dysgraphia is believed to be a deficiency in the development of brain mechanisms. Several conditions are thought to impact the development of dysgraphia. The neurologic theory supports cerebellum and cortical dysfunction due to organic, functional, and genetic determination.¹ Critical cerebellar functions include movement, motor learning, vision, balance, posture, and mental functioning. Cerebellar involvement supports cognitive processes such as language, executive functioning, and affective regulation.³ Genetic research supports a hereditary factor. A specific gene, chromosome 6, is linked to phonemic awareness; that is, the ability to identify and manipulate individual sounds (phonemes) in spoken words and to understand that spoken words and syllables are made up of sequences of speech sounds. This ability allows the reader to map speech to print, a skill essential for learning to read in an alphabetic reading system.

A second gene, chromosome 15, has been linked to reading and spelling difficulties.⁴ The prenatal, natal, and postnatal periods heavily influence the brain during the critical neurodevelopment process. Alcohol exposure, prematurity, and abusive or neglectful care affect brain development in the uterus. Studies also show that cerebellar dysfunction is linked to other disorders such as dyslexia, autism spectrum disorder, and anxiety disorders.^3,5 Research related to dysgraphia pathophysiology and causes is limited. It's a complex disorder necessitating detailed analysis under current and individualized environmental conditions.⁴

Dysgraphia isn't only a pediatric neurodevelopment problem but also presents in medical illnesses. Adults generally develop dysgraphia due to cerebral dysfunction from trauma, infections, and disease that damage the brain's parietal lobe.⁴ People with neurologic disorders such as cerebrovascular injury, Huntington disease, multiple sclerosis, Alzheimer disease, vascular dementia, and Parkinson disease may exhibit dysgraphia at different times during the disease processes.⁶ The National Institute of Neurological Disorders and Stroke reports that dysgraphia is frequently observed in cerebrovascular events and frontotemporal dementia.^7,8 Alcohol use disorder, brain tumors, and infections are other conditions that may affect cerebellar functioning. Neurobiological-genetics research has found that cerebellar injury can also lead to dysgraphia in adults.⁹

Types of dysgraphia

Up to 10% of children affected with dysgraphia may be able to read but struggle with the ability to think of or use words appropriately to write.¹ These difficulties often impair activities of daily living for both children and adults; therefore, it's important to identify and distinguish between different types of dysgraphia to provide appropriate treatment. Types of dysgraphia include:

• Dyslexic dysgraphia—Children produce illegible written work but may be able to copy. Spelling is usually poor.¹⁰
• Motor dysgraphia—Children exhibit poor dexterity or motor tone and can't write legibly even if copied. Letter formation requires a great deal of effort, but spelling isn't an issue.¹¹
• Spatial dysgraphia—This type of disability is a spatial comprehension defect. Students have a difficult time with writing legibly with irregular spacing between words and difficulty writing on a line.¹
• Phonologic dysgraphia—Children struggle in distinguishing nonwords compared with real words. They have poor verbal working memory to be able to sound out words.¹

Signs and symptoms

The ability to write by hand is a prerequisite for communication. When children can't develop legible writing skills, their success in school can be seriously impaired. Thus, recognizing signs and symptoms of dysgraphia is important to make the correct diagnosis and identify appropriate interventions for rehabilitation.¹² Children with dysgraphia may only have impaired handwriting, only impaired spelling (without reading problems), or both impaired handwriting and impaired spelling.¹³

Typically, handwriting develops in the first few years of school, but dysgraphia may not be recognized during this period of life. Individuals may have strong verbal skills; however, writing skills may be particularly poor, with numerous organizational problems and difficulty knowing where to start in the writing process.¹ Symptoms can depend on many factors including writing habits, motor skills or deficits, potential comorbidity with dyslexia, and/or attention-deficit hyperactivity disorder (ADHD). Problems with letter formation and legibility, spacing of letters and words, writing speed, spelling, grammar, and/or composition may all be present. In younger children, dysgraphia symptoms usually show up first as concrete issues, but issues related to writing are more abstract in older children as academic demands increase and the child's neurologic system develops.¹²

Dysgraphia may affect the entire writing process on several different levels. Preschool children may have an awkward body position when writing, or they may grip the pen or pencil in an awkward manner. As a result, the child may tire easily or become frustrated with the process and will often avoid tasks that require writing or drawing.¹ There may be inconsistencies in the child's writing, with a mixture of print and cursive, upper- and lower-case letters, letters of irregular sizes and shapes, and slanting in different directions. Positioning of lines, margins, and spaces between letters and words may appear “off” or inconsistent. Motor difficulty may lead to a cramped grip, problems holding the pencil or pen, or holding writing utensils too close to the paper.¹ The child may write very slowly due to problems visualizing letters or remembering how to form letters.¹⁴ Older children will often have difficulty understanding rules of spelling, patterns, and structures, and they may struggle to identify and manipulate individual sounds in spoken words. As a result, the child may talk to themselves when writing or carefully watch their writing hand during the process. Handwriting may reveal numerous spelling errors, reversals of letters, syllable omissions, or errors in suffixes.¹⁴ These and other factors contribute to the child's difficulty selecting topics, brainstorming with others, researching topics, and coming up with ideas.¹⁴

Depending on the definitions used, dysgraphia may occur alone, but it's also commonly associated with dyslexia, ADHD, or other disorders of learning. Also, reading problems often occur in 30% to 47% of children with writing problems.¹

Assessment and diagnosis

Although the term “dysgraphia” is commonly used in the literature to describe various types of writing issues, the DSM-V has revised the diagnostic term to describe a “specific learning disability with problems with written expression.”² No medical testing is available or required to make this diagnosis; however, there's a high rate of comorbidity between psychiatric, neurodevelopmental, or learning disorders, so the child should be assessed for symptoms of these conditions.¹ A comprehensive neurologic examination must be performed to rule out “soft” signs such as poor coordination or other abnormal movements. Semistructured interviews can be completed to assess for autism spectrum disorder, ADHD, or mood disorders. If the assessments discover areas of concern, the child should be referred by the provider to a physician or a diagnostic specialist in child neurology, child psychiatry, or another developmental-behavioral child provider.¹⁵

Team assessment is typically performed in an education setting to make the diagnosis of a specific learning disability for an individualized education plan. Generally, the education team, comprised of occupational, speech and physical therapists, educational psychologists, and special education teachers, works together to make the diagnosis. This diagnosis can also be made by a psychologist outside of the educational system. As in the case for other learning disorders, the diagnosis of dysgraphia can often be made through observation of the child. In the case of dysgraphia, the provider should assess the writing impairments and the difficulty these pose to the child's educational process. Reliable indications of dysgraphia include slow writing speed with illegible handwriting; spelling ability and verbal intelligence quotient inconsistencies; and processing delays in naming and awareness.¹ It's most helpful to obtain evidence from other sources, such as parents or teachers, or from other contexts, such as provider reports, review of the child's completed work, and normative data.¹⁴

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 naming, awareness, and planning. Evaluations of pencil grip and writing posture and formalized handwriting evaluations can be used to measure the speed and legibility of the child's writing when copying sentences, letters, and words. Because comorbidity with dyslexia and ADHD is a common problem, the child should also be evaluated for other types of learning problems.¹

Treatment

Because writing is a basic skill needed to function in all aspects of daily living, early recognition and intervention are important. Coping with dysgraphia is a lifelong process of learning how to function throughout daily activities requiring reading and writing. Although, there's no specific treatment, a multisystem cognitive, psychomotor, physical, and environmental approach should be used.¹⁶ Early diagnosis and implementation of a treatment plan is key to helping individuals adapt.

Treatment of dysgraphia is complex and requires a multidisciplinary approach for success. Treatment focuses on both fine and gross motor skills needed for handwriting, and an occupational therapist should be brought in to develop overall motor coordination.¹⁷ Development of gross motor skills of young children with dysgraphia will focus on strengthening arm and shoulder coordination and strengthening core muscles. Activities to improve gross motor skills include pushups, jumping rope, rock wall climbing, monkey bars, and jumping jacks.¹⁸ Fine motor skills development should focus on activities to help with coordination of hands and fingers.¹⁷ Activities for fine motor development may include brushing teeth, proper use of utensils, formation of letters with clay, and Lego building. Occupational therapy should also focus on proper gripping of the pencil and posture, which are both key factors in handwriting.¹⁸ In particular, posture while sitting should entail both feet on the ground with equally weighted distribution to keep hips even, shoulders back and relaxed, and a flexed core.¹⁹ All of these everyday activities need to be incorporated throughout daily living to help individuals cope with dysgraphia.

Individuals with dysgraphia typically have difficulty remembering how to form letters and need more time to learn and practice. A repetitive approach helps individuals with dysgraphia retain information. These individuals need help learning how to visualize and form letters to improve handwriting and psychomotor skills.²⁰ Practicing and learning formation of letters can be achieved through tracing letters with an index finger or pencil eraser, connecting dots to form letters, replicating modeling strokes of letters on paper or in the air, and copying letters from models.²⁰ Once the individual with dysgraphia has learned how to form legible letters, then they must develop automatic letter writing. This can be achieved through several repetitive interventions. One activity for remote memory letter formation can include traceable repetitive numbered arrow cues that provide an outline of each individual letter, helping to store letter formation in their memory.²⁰ They can also practice by writing letters from dictation. Another activity is having the individual cover an index card that contains a specific letter and have them imagine the letter in their mind. Each time the individual completes a handwriting lesson, increase the interval between the lesson and writing the letter from memory.

Educational interventions for individuals with dysgraphia should include educational therapy, accommodations, modifications, and remediation.¹⁷ Implementation of one-on-one educational therapy empowers individuals to develop skills and strategies to manage their learning differences and assist in improving their schoolwork. Educational therapy is typically performed in a private facility outside of the educational classroom and is individualized. This type of therapy evaluates the individual's learning deficits and learned habits, and helps them build new skills to adjust with dysgraphia.²¹

Emotional aspects of dysgraphia and support

Dysgraphia is an emotionally taxing and limiting disorder that can be stressful to an individual living with this condition. The signs and symptoms often first manifest in the academic setting, and children with this condition are often labeled as “lazy” or “not wanting to learn.”²² The negative labels and pressure in a learning setting can cause frustration and anxiety further impeding their ability to learn. In general, being diagnosed and labeled with a learning disability can be very upsetting to the individual. It's important that the child be properly educated on what a learning disability is and that it doesn't mean that they're not intelligent.²³ Failure to properly provide emotional support leads the individuals to develop low self-esteem and communication difficulty with peers, and can result in isolating from others.²² To truly help this individual, the educational team and treatment providers must focus on addressing the emotional challenges presented by this disorder. Accommodations and modifications are important for individuals throughout their daily learning in the classroom setting to improve daily functions. Three primary techniques may be used to emotionally assist the individual: accommodation, modification, and remediation.¹

Accommodation

Accommodations are geared to help the individual cope with the emotional stress of writing. Examples of accommodations are:^1,24

• Extra time allotted for completion of assignments, quizzes/tests, and homework.
• Consideration of alternative forms of completion when presented, such as oral or recorded.
• Implementation of technology, for example, a voice recorder, spellcheck software, talk to text, keyboards, and tablets.
• Reduce the focus on grading for neatness or spelling.

Modifications

These are ways to adjust the individual's program to assist with emotional issues and provide the least restrictive environment possible. Examples of modifications include:^1,24

• Decrease volume of work required for the student to be able to pace with peers.
• Split large assignments or projects into smaller portions.
• Try to keep the student's environment as normalized as possible.

Remediation

Remediation includes methods to help optimize the student's learning curriculum to address specific needs of the individual. Remediation should be ongoing, assessing the individual's response to an intervention. Remediation targets individuals' specific learning problems regarding writing and the formation of letters. Specific curriculum development should be individualized based on the severity of the student's condition. Remediation examples include:¹

• Allot time in the student's curriculum to help build handwriting skills.
• Use occupational therapy to provide individualized attention.
• Provide special education for a supportive environment to allot for challenges.
• Provide educational games and activities to make the learning process more enjoyable and individualized.

Although applying the steps of accommodation, modification, and remediation provides a sound foundation to help support these individuals' psychological well-being, it's also important for parents and educators to employ positive reinforcement to help build the individual's self-esteem.²²

Be ready to identify the signs

Both assessment and treatment of dysgraphia are still in their infancy, and current knowledge and educational interventions to support affected individuals are limited. Education for nurses and to the public about the condition is important to bring light to the difficulties faced by those with dysgraphia. Familiarity with this condition and it's possible manifestations are key to identification and modification to psychologically support these individuals.

On the web

Figure

Centers for Disease Control and Prevention

Developmental Disabilities - Learning Disorders in Children

www.cdc.gov/ncbddd/developmentaldisabilities/learning-disorder.html

International Dyslexia Association

Understanding dysgraphia.

https://dyslexiaida.org/understanding-dysgraphia/

Institutes of Neurological Disorders and Strokes

Dysgraphia – What research is being done?

www.ninds.nih.gov/health-information/disorders/dysgraphia

Cleveland Clinic

Dysgraphia

https://my.clevelandclinic.org/health/diseases/23294-dysgraphia

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