Dysgraphia: SLD in Written Expression

So what exactly is a Specific Learning Disability (SLD) in Math or Writing? The Office of Special Education for the U.S. Department of Education is encouraging schools to use the words Dyscalculia and Dysgraphia in Individual Education Plans (IEPs) and 504s. The excerpt from the letter below contains the link to the whole document.

The Office of Special Education and Rehabilitation Services (OSERS) has received communications from stakeholders, including parents, advocacy groups, and national disability organizations, who believe that State and local educational agencies (SEAs and LEAs) are reluctant to reference or use dyslexia, dyscalculia, and dysgraphia in evaluations, eligibility determinations, or in developing the individualized education program (IEP) under the IDEA. The purpose of this letter is to clarify that there is nothing in the IDEA that would prohibit the use of the terms dyslexia, dyscalculia, and dysgraphia in IDEA evaluation, eligibility determinations, or IEP documents.

So now that the term Dysgraphia have been sanctioned for use let’s take a look at this little-known disability.

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Dysgraphia is a specific learning disability that affects how easily children acquire written language and how well they use written language to express their thoughts. Dysgraphia is a Greek word. The base word graph refers both to the hand’s function in writing and to the letters formed by the hand. The prefix dys- indicates that there is impairment. Graph refers to producing letter forms by hand. The suffix -ia refers to having a condition. Thus, dysgraphia is the condition of impaired letter writing by hand, that is, disabled handwriting and sometimes spelling. Impaired handwriting can interfere with learning to spell words in writing.

Dysgraphia as defined in the latest edition of the Diagnostic and Statistical Manual (DSM-5) is a “specific learning disorder” with impairment in written expression. Writing problems can result from one or more of the following components:

• Fine motor difficulties
• Visual-spatial difficulties
• Handwriting issues

In addition, spelling problems, difficulty with word retrieval and verbal fluency, and language processing problems can all contribute to difficulty producing a written product.

There are several different kinds of dysgraphia. Some people with dysgraphia have handwriting that is often illegible and shows irregular and inconsistent letter formations. Others write legibly, but very slowly and/or very small. When these individuals revert to printing, as they often do, their writing is often a random mixture of upper- and lowercase letters. In all cases of dysgraphia, writing requires inordinate amounts of energy, stamina, and time. Dysgraphia can interfere with a student’s ability to express ideas. Expressive writing requires a student to synchronize many mental functions at once: organization, memory, attention, motor-skill, and various aspects of language ability. Automatic accurate handwriting is the foundation for this juggling act. In the complexity of remembering where to put the pencil and how to form each letter, a dysgraphic student forgets what he or she meant to express. Dysgraphia can cause low classroom productivity, incomplete homework assignments, and difficulty in focusing attention. Emotional factors arising from dysgraphia often exacerbate matters. At an early age, these students are asked to forego recess to finish copying material from the board, and are likely to be sent home at the end of the day with a sheaf of unfinished papers to be completed. They are asked to recopy their work but the second attempt is often no better than the first. Because they are often bright and good at reading, their failure to produce acceptable work is blamed on laziness or carelessness. The resulting anger and frustration can prevent them ever reaching their true potential.

Common symptoms of dysgraphia include:
The symptoms of dysgraphia fall into six categories: visual-spatial, fine motor, language processing, spelling/handwriting, grammar, and organization of language. A child may have dysgraphia if his writing skills lag behind those of his peers and he has at least some of these symptoms:

Visual-Spatial Difficulties
Has trouble with shape-discrimination and letter spacing
Has trouble organizing words on the page from left to right
Writes letters that go in all directions, and letters and words that run together on the page
Has a hard time writing on a line and inside margins
Has trouble reading maps, drawing or reproducing a shape
Copies text slowly

Fine Motor Difficulties
Has trouble holding a pencil correctly, tracing, cutting food, tying shoes, doing puzzles, texting and keyboarding
Is unable to use scissors well or to color inside the lines
Holds his wrist, arm, body or paper in an awkward position when writing

Language Processing Issues
Has trouble getting ideas down on paper quickly
Has trouble understanding the rules of games
Has a hard time following directions
Loses his train of thought

Spelling Issues/Handwriting Issues
Has a hard time understanding spelling rules
Has trouble telling if a word is misspelled
Can spell correctly orally but makes spelling errors in writing
Spells words incorrectly and in many different ways
Has trouble using spell-check—and when he does, he doesn’t recognize the correct word
Mixes upper- and lowercase letters
Blends printing and cursive
Has trouble reading his own writing
Avoids writing
Gets a tired or cramped handed when he writes
Erases a lot

Grammar and Usage Problems
Doesn’t know how to use punctuation
Overuses commas and mixes up verb tenses
Doesn’t start sentences with a capital letter
Doesn’t write in complete sentences but writes in a list format
Writes sentences that “run on forever”

Organization of Written Language
Has trouble telling a story and may start in the middle
Leaves out important facts and details, or provides too much information
Assumes others know what he’s talking about
Uses vague descriptions
Writes jumbled sentences
Never gets to the point, or makes the same point over and over
Is better at conveying ideas when speaking

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Does Dysgraphia occur with other learning disabilities?

Children with impaired handwriting may also have attention-deficit disorder (ADHD)—inattentive, hyperactive, or combined inattentive and hyperactive subtypes. Children with this kind of dysgraphia may respond to a combination of explicit handwriting instruction plus stimulant medication, but appropriate diagnosis of ADHD by a qualified professional and monitoring of response to both instruction and medication are needed

In a medical journal article by Richards et al (12/2016), they say the relationship between presence or absence of Attention Deficit Hyperactivity Disorder (ADHD) in persisting developmental dysgraphia (impaired handwriting) and brain connectivity during writing tasks was investigated. Thirteen participants (6 males, 1 female with ADHD; 4 males, 2 females without ADHD) in upper elementary or middle school grades performed four fMRI writing tasks-two cognitive (mind wandering and planning to compose) and two transcription (handwriting and spelling). Presence or absence of ADHD was correlated with brain connectivity on all four fMRI writing tasks during scanning, rather than just on the fMRI handwriting task as predicted based on prior research. However, the nature of the fMRI functional connectivity (from which of four seeds with which of eight brain regions) for the four fMRI writing tasks varied as a function of presence or absence of ADHD. The significance of these findings is discussed for both understanding the invisible biological bases of co-occurring ADHD and persisting developmental dysgraphia and teaching students with developmental dysgraphia and co-occurring ADHD.

Dysgraphia may occur alone or with dyslexia (impaired reading disability) or with oral and written language learning disability (OWL LD, also referred to as speech language impairment, SLI).

Dyslexia is a disorder that includes poor word reading, word decoding, oral reading fluency, and spelling. Children with dyslexia may have impaired orthographic and phonological coding and rapid automatic naming and switching. Phonological coding refers to coding sounds in spoken words in working memory. Phonological coding is necessary for developing phonological awareness—analyzing the sounds in spoken words that correspond to alphabet letters. If children have both dysgraphia and dyslexia, they may also have difficulty in planning sequential finger movements.

OWL LD (SLI) are disorders of language (morphology—word parts that mark meaning and grammar; syntax—structures for ordering words and understanding word functions; finding words in memory, and/or making inferences that go beyond what is stated in text). These disorders affect spoken as well as written language. Children with these language disorders may also exhibit the same writing and reading and related disorders as children with dysgraphia or dyslexia.

In an article by Mayes el al they examined the importance of diagnostic, demographic, and neurocognitive correlates of dysgraphia in 1006 students 6–16 years was determined. Children with ADHD or autism (n = 831) and neurotypical children (n = 175) were administered the Developmental Test of Visual-Motor Integration (VMI), Wechsler subscales, and reading and math tests. IQ was the strongest correlate of dysgraphia (VMI scores), followed by diagnosis (ADHD/autism vs. neurotypical). Visual-fine motor ability was the only other significant correlate. Verbal and visual reasoning ability, processing speed, working memory, attention, reading, and math did not contribute significantly more to concurrently predicting dysgraphia, nor did age, sex, race, and parent occupation. Dysgraphia was common in children with ADHD (56%) and autism (56%), especially those with a learning disability in reading (71%) or math (72%). The study demonstrates the importance of controlling for both IQ and diagnosis when examining factors related to dysgraphia, which previous studies have not done. Students with ADHD, autism, learning disability, or fine motor problems should be evaluated for dysgraphia because the majority of students with any one of these problems will have impaired handwriting, which needs to be identified and addressed in school. Effective accommodations to compensate for dysgraphia are available to help avoid its negative repercussions.

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So what can be done to help a child with Dysgraphia?

There are many things that can be done for remediation with dysgraphia in both the public school and homeschool environment.  Here is a list of possible accommodations and modifications:

Accommodations

• When considering accommodating or modifying expectations to deal with dysgraphia, consider changes in
• The rate of producing written work
• The volume of the work to be produced
• The complexity of the writing task
• The tools used to produce the written product
• The format of the product
• Change the demands of writing rate
• Allow more time for written tasks including note-taking, copying, and tests
• Allow students to begin projects or assignments early
• Include time in the student’s schedule for being a ‘library assistant’ or ‘office assistant’ that could also be used for catching up or getting ahead on written work, or doing alternative activities related to the material being learned.
• Encourage learning keyboarding skills to increase the speed and legibility of written work.
• Have the student prepare assignment papers in advance with required headings (Name, Date, etc.), possibly using the template described below under “changes in complexity.”
• Adjust the volume
• Instead of having the student write a complete set of notes, provide a partially completed outline so the student can fill in the details under major headings (or provide the details and have the student provide the headings).
• Allow the student to dictate some assignments or tests (or parts of tests) a ‘scribe’. Train the ‘scribe’ to write what the student says verbatim (“I’m going to be your secretary”) and then allow the student to make changes, without assistance from the scribe.
• Remove ‘neatness’ or ‘spelling’ (or both) as grading criteria for some assignments, or design assignments to be evaluated on specific parts of the writing process.
• Allow abbreviations in some writing (such as b/c for because). Have the student develop a repertoire of abbreviations in a notebook. These will come in handy in future note-taking situations.
• Reduce copying aspects of work; for example, in Math, provide a worksheet with the problems already on it instead of having the student copy the problems.
• Change the complexity
• Have a ‘writing binder’ option. This 3-ring binder could include:
• A model of cursive or print letters on the inside cover (this is easier to refer to than one on the wall or blackboard).
• A laminated template of the required format for written work. Make a cut-out where the name, date, and assignment would go and model it next to the cutout. Three-hole punch it and put it into the binder on top of the student’s writing paper. Then the student can set up his paper and copy the heading information in the holes, then flip the template out of the way to finish the assignment. He can do this with worksheets, too.
• Break writing into stages and teach students to do the same. Teach the stages of the writing process (brainstorming, drafting, editing, and proofreading, etc.). Consider grading these stages even on some ‘one-sitting’ written exercises, so that points are awarded on a short essay for brainstorming and a rough draft, as well as the final product. If writing is laborious, allow the student to make some editing marks rather than recopying the whole thing. On a computer, a student can make a rough draft, copy it, and then revise the copy, so that both the rough draft and final product can be evaluated without extra typing.
• Do not count spelling on rough drafts or one-sitting assignments.
• Encourage the student to use a spellchecker and to have someone else proofread his work, too. Speaking spellcheckers are recommended, especially if the student may not be able to recognize the correct word (headphones are usually included).
• Change the tools
• Allow the student to use cursive or manuscript, whichever is most legible
• Consider teaching cursive earlier than would be expected, as some students find cursive easier to manage, and this will allow the student more time to learn it.
• Encourage primary students to use paper with the raised lines to keep writing on the line.
• Allow older students to use the line width of their choice. Keep in mind that some students use small writing to disguise its messiness or spelling, though.
• Allow students to use paper or writing instruments of different colors.
• Allow student to use graph paper for math, or to turn lined paper sideways, to help with lining up columns of numbers.
• Allow the student to use the writing instrument that is most comfortable. Many students have difficulty writing with ballpoint pens, preferring pencils or pens which have more friction in contact with the paper. Mechanical pencils are very popular. Let the student find a ‘favorite pen’ or pencil (and then get more than one like that).
• Have some fun grips available for everybody, no matter what the grade. Sometimes high school kids will enjoy the novelty of pencil grips or even big “primary pencils.”
• Word Processing should be an option for many reasons. Bear in mind that for many of these students, learning to use a word processor will be difficult for the same reasons that handwriting is difficult. There are some keyboarding instructional programs which address the needs of learning disabled students. Features may include teaching the keys alphabetically (instead of the “home row” sequence), or sensors to change the ‘feel’ of the D and K keys so that the student can find the right position kinesthetically.
• Consider whether use of speech recognition software will be helpful. As with word processing, the same issues which make writing difficult can make learning to use speech recognition software difficult, especially if the student has reading or speech challenges. However, if the student and teacher are willing to invest time and effort in ‘training’ the software to the student’s voice and learning to use it, the student can be freed from the motor processes of writing or keyboarding.

Modifications

• For some students and situations, accommodations will be inadequate to remove the barriers that their writing problems pose. Here are some ways assignments can be modified without sacrificing learning.
• Adjust the volume
• Reduce the copying elements of assignments and tests. For example, if students are expected to ‘answer in complete sentences that reflect the question,’ have the student do this for three questions that you select, then answer the rest in phrases or words (or drawings). If students are expected to copy definitions, allow the student to shorten them or give him the definitions and have him highlight the important phrases and words or write an example or drawing of the word instead of copying the definition.
• Reduce the length requirements on written assignments — stress quality over quantity.
• Change the complexity
• Grade different assignments on individual parts of the writing process, so that for some assignments “spelling doesn’t count,” for others, grammar.
• Develop cooperative writing projects where different students can take on roles such as the ‘brainstormer,’ ‘organizer of information,’ ‘writer,’ ‘proofreader,’ and ‘illustrator.’
• Provide extra structure and intermittent deadlines for long-term assignments. Help the student arrange for someone to coach him through the stages so that he doesn’t get behind. Discuss with the student and parents the possibility of enforcing the due dates by working after school with the teacher in the event a deadline arrives and the work is not up-to-date.
• Change the format
• Offer the student an alternative project such as an oral report or visual project. Establish a rubric to define what you want the student to include. For instance, if the original assignment was a 3-page description of one aspect of the Roaring Twenties (record-breaking feats, the Harlem Renaissance, Prohibition, etc) you may want the written assignment to include:
  • A general description of that ‘aspect’ (with at least two details)
  • Four important people and their accomplishments
  • Four important events – when, where, who and what
  • Three good things and three bad things about the Roaring Twenties

What would be a goal for the IEP when you have Dysgraphia?

Back to that goal question again.  Sometimes, they are hard to come up, so I thought I would include some ideas.

IEP Goals for Writing , Keyboarding, and Copying

Did you know these were the only goal examples I could readily find?  If you find any others please let me know!

A little off topic but important to know…How to get the school OT to treat handwriting issues.
OT Services in the IEP: Handwriting

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Apps to help those with Dysgraphia

• SnapType
• ScanWritr
• DragonDictation
• LetterSchoolPhorm

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Information on Assistive Technology

General information on AT

Your Child’s Key to Great Writing: Assistive Technology for Dysgraphia and Writing Disabilities
Journal Article on Assistive Technology for Dysgraphia – June 2015

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Evaluating Dysgraphia via Psychometric Testing

An Occupational Therapist can evaluate the fine motor problems, but for the purposes of identification for school services and accommodations, an evaluation by a licensed psychologist or a certified school psychologist is needed.

Following is a list of categories, along with possible assessments, that a psychologist may use for evaluating dysgraphia. Usually one measure is used per category. And while this list includes many commonly used measures, it does not include all options.

Intelligence Measures

• The Wechsler Intelligence Scale for Children (WISC-V)
• The Wechsler Adult Intelligence Scale (WAIS-IV)
• Differential Ability Scales (DAS)

Constructional Ability

• Beery Visual-Motor Integration Test-6th edition (VMI)
• Bender Gestalt II
• NEPSY-II (Design Copying)

Working Memory

• Working memory on intelligence tests (listed above)
• Test of Memory and Learning-2 (TOMAL-2)
• Visual working memory (Finger Windows) on Wide Range Assessment of Memory and Learning-2 (WRAML-2)

Executive Functions

• Rey Complex Figure Test
• Behavior Rating Inventory of Executive Function (BRIEF)
• NEPSY or Woodcock Johnson subtests

Writing and Spelling Skills

• Wechsler Individual Achievement Test (WIAT-III, a preferred test of organizing written language and usage for older children)
• Woodcock Johnson-III Tests of Achievement (WJ-III)
• Test of Written Language-4 (TOWL-4)

Phonological Awareness

• Comprehensive Test of Phonological Processing (C-TOPP)
• Word Decoding, Pseudoword Decoding on WIAT-III and Word Attack on the WJ-III
• NEPSYII phonological processing

Retrieval fluency

• WJ-III Written Fluency, Rapid Naming
• NEPSY Verbal Fluency, Speeded Coding

I also like the Process Assessment of the Learner-II (PAL-II), normed up to grade 4, which also looks at the ability to listen and take notes. Obviously, children with dysgraphia of all ages will have trouble taking notes; unfortunately there is not a note-taking test for older students.

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Wrap up

I hope you found this blog post on Dysgraphia helpful. All links to the original source material are embedded into the article.  Please join us for more discussion on Dysgraphia at one of our Facebook groups: IEP Assistance and Special Needs Parenting Advice or Homeschooling Special (Needs) Kids.