Dysgraphia is a condition characterized by an inability to communicate in written language correctly.
What Is Dysgraphia?
Dysgraphia is a serious neurological condition that influences someone’s ability to understand, learn and write. It is a specific learning disorder or disability (SLD 1 ) which makes the sufferer have severe difficulties with the written word which is associated with fine-motor skills impairments, even though the individual may have average abilities and intelligence. This neurodevelopmental disorder tends to develop during childhood but is mostly identified in adulthood. This learning and writing disorder involves impaired handwriting and transcription disability, along with constant movement of fingers. It can impact different aspects of writing such as expression, spelling, word spacing and legibility. The disorder is usually an ongoing condition. However, it can affect both children and adults and can create significant impairments in the sufferer’s life.
According to a recent 2020 study 2 , “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.” People with this condition are unable to gain the right writing abilities for their age and cognitive level even after receiving enough instruction. The disorder may occur when “existing brain pathways are disrupted by an event,” such as brain injury or a neurologic disease, causing issues with skills gained previously.
Dysgraphia is a disability characterized primarily by one’s ability to write neatly and understand the way the fingers should move to write the letters. The word dysgraphia comes from the Greek word “dys” meaning “impaired” and “graphia” meaning “writing by hand”. It often overlaps with other learning disabilities such as speech impairment, attention deficit hyperactivity disorder, or developmental coordination. One 2015 study 3 found that developmental dysgraphia is strongly associated with developmental dyslexia. “It is a disorder characterized by difficulties in the acquisition of writing skills, with writing performance below that expected based on children’s class level,” states the study.
The Diagnostic and Statistical Manual of Mental Disorders characterized this disorder as a “learning disability” in the category of written expression when one’s writing skills are below the expected learning level. A 2020 study 4 pointed out that this disorder is usually associated with multiple cortical and subcortical damage in the functional language regions. It is a transcription disability that means it is a writing disorder associated with impaired handwriting, orthographic coding, syntax errors, odd spellings, and finger sequencing. People with this condition can sometimes write on some level but have difficulties exercising fine motor skills such as tying a shoe. It is important to understand that it does not affect all motor skills. They often have unusual difficulty with handwriting and spelling that can cause writing fatigue. They may lack basic grammar and spelling skills and can get confused with letters p,q, b, and d. They also tend to write the wrong words when they are trying to formulate their thoughts on paper.
This disorder usually occurs when the child first starts writing. Adults, teenagers, and children may also be subjected to this condition.
Dysgraphia At A Glance
- Dysgraphia is an inability to communicate in written language correctly.
- This disorder tends to develop during childhood but is mostly identified in adulthood.
- It involves impaired handwriting and transcription disability, along with constant movement of fingers.
- It can impact different aspects of writing such as expression, spelling, word spacing and legibility.
- They may lack basic grammar and spelling skills and can get confused with letters p,q, b, and d.
- This condition can improve with lifelong therapy.
Effects Of Dysgraphia
This condition can improve with lifelong therapy. When this condition is caused by neurodegenerative disorders it is expected to worsen progressively. People with this condition often find it difficult to concentrate on other things while writing. Due to this, some patients find it difficult to take notes during a class or meeting since most of their attention is primarily focused on writing it down. The inability to write correctly can affect the self-esteem of the student and cause anxiety, a lack of self-confidence, and a negative attitude towards school.
According to a review, 5 )) the prevalence of this disorder is unknown. However, it is likely that it is under-identified. The variance rates in elementary school range from 5 percent to 33 percent. It was also found that writing disorders decreased as the age of the student increased.
Signs And Symptoms
The primary sign of this condition is bad handwriting. However, having bad handwriting doesn’t necessarily mean that they have this disorder. The common signs and symptoms of this condition are as follows:
- Delayed handwriting development
- Confusing upper and lower case letters
- Spelling errors
- Inconsistent writing
- Slow writing speed
- Erasing frequently
- Poor spatial planning
- Unusual wrist, body or paper position while writing
- Unable to copy words
- Saying words aloud while writing
Types Of Dysgraphia
There are usually five types of this disorder. They are as follows:
Dysgraphia characterized by illegible spontaneously written work. Even though the copied work is good, their spelling is usually poor.
This occurs due to deficiency in fine motor skills, poor dexterity, poor muscle tone or unspecified motor clumsiness.
This condition is characterized by a defect in understanding personal space.
This is characterized by poor writing and spelling when encountering unfamiliar and irregular words.
This condition is characterized by an inability to learn new words along with spelling errors.
Read More About Types of Dysgraphia Here
Causes Of Dysgraphia
The exact cause of this condition is still unknown. However, there may be certain factors that are contributing to the development of this condition. They are:
1. Developmental Disorders
If this disorder appears in childhood it usually results in a condition called orthographic coding. This aspect allows the working memory to permanently remember written words and the way the hand or fingers move to write those words. A 2013 study 6 pointed out that a child’s social and intellectual development is affected by the delayed acquisition of language. If treated in time, language learning can be modified to a significant degree, thereby avoiding the complications that affect the child’s development.
2. Neurological Factors
This condition is a more working memory problem. Some individuals fail to develop normal connections among different brain regions needed for writing. People with this condition have difficulty remembering and mastering the automatic response in the sequence of motor movements required to write letters or numbers. A 2009 study pointed out that this disorder is known to be a biologically based disorder with genetic and brain bases.
3. Genetic Factors
Genetic factors may be responsible for the development of this condition. Evidence 7 points to genetic heterogeneity and multiple gene candidates. The number of reported brain imaging studies involving individuals has increased exponentially and findings depend greatly on imaging modality, acquisition parameters including use or nonuse of tasks, specific nature of task requirements when tasks are performed, and data analysis procedures.
4. Brain Injury
When this condition develops in adults, it can develop due to stroke or any other brain injury. Injury to the brain’s parietal lobe can be a cause of this disorder. A 2019 study 8 attempted to understand the effectiveness of a multicomponent intervention for an adolescent with acquired agraphia (complete writing impairment) following severe traumatic brain injury. At program completion, reading speed was 47 words per minute with 7% decoding errors despite increased difficulty of reading material. The participant demonstrated initial mastery of 15 spelling lists containing 15 words each and sustained mastery.
5. Other Factors
Some of the other causes of this condition can include:
- Metabolic 9
- Vascular 10
- Brain tumors 11
- Seizures 12
- Infectious 13
- Inflammatory or autoimmune 14
- Neurodegenerative 15
- Motor neuron disease 16
Diagnosis Of Dysgraphia
The physician will first rule out any other underlying conditions that are causing writing difficulties. There are several tests that are conducted by the doctor to understand the development skills of the child. The symptoms should be present for at least six months in order to be diagnosed with this disorder. These tests can also be used for adults and teenagers. They are:
- Ajuriaguerra Scale
- BHK for children and teenagers
- DASH Scale
- HHE Scale
There may be a team of doctors that include a physician, a licensed psychologist, an occupational therapist, a school psychologist, or a special education teacher who can help to diagnose this condition. For children, there may be an IQ test and assessment to test their writing skills. For adults, examples of written work or written tests may be evaluated by the expert. The patient will be observed by the doctor to look for any deficiency associated with fine motor skills.
Treatment Methods Of Dysgraphia
Here are some of the most effective and widely recommended treatment options available for this condition:
1. Cognitive Rehabilitation
This treatment 17 method consists of training exercises involving pattern association of ocular visual recognition and synchronous movement of hands and fingers in producing written language. The patient is also required to put conscious effort to correct deficiencies.
2. Deep brain stimulation
Deep brain stimulation is a neurological procedure that involves the placement of a neurostimulator that sends electric impulses to specific regions of the brain for treating this disorder. A 2012 study 18 found that this condition is common in patients with Parkinson’s disease. The study found that participants showed improvement in this condition when they underwent deep brain stimulation.
Read More About Brain Science Here
3. Writing Practices
A 2004 study 19 pointed out that one of the best ways to improve this condition is spending more time writing with pen and pencil instead of writing on a computer.
4. Speech/Language Therapy
Speech/language therapy is used to assess and treat communication disorders. The specialist can address concerns related to articulation, fluency, writing, cognitive-communication, aphasia. The specialist interacts with the patient by talking and playing (in the case of children) and using books, pictures, or other graphic methods to help stimulate language development. A 2009 study 20 found that treatment approaches that have been successful in cases of non-progressive dysgraphia can be applied in cases of neurodegenerative disease to either improve written language abilities or prolong skill levels.
5. Occupational Therapy
Occupational therapy is a treatment method used to treat patients who have physical, sensory, or cognitive problems. It also helps kids to improve their academic performance and conduct daily activities. Patients with this disorder are treated with occupational therapy to improve handwriting skills. Some of the therapeutic activities include:
- Developing fine motor skills
- Learning how to hold & use pen or pencil in a new way to make the writing easier
- Working with modeling clay
- Drawing lines within mazes
- Practicing connect the dot puzzles
A 2014 study 21 found it effective in treating patients with occupational therapy. People with Parkinson’s Disease and dysgraphia differ substantially in their various needs, and beginning evidence indicates that baseline differences in performance or needs affect responsiveness to rehabilitation.
Recovery From Dysgraphia
This is a lifelong condition and there is no cure for this disorder. Treatment is focused on interventions and specialized services for patients suffering from this condition. It is possible to train and manage this condition. There are people who are specifically trained to help people with this condition.References:
- McDowell M. Specific learning disability. J Paediatr Child Health. 2018 Oct;54(10):1077-1083. doi: 10.1111/jpc.14168. PMID: 30294983.
- Chung, P. J., Patel, D. R., & Nizami, I. (2020). Disorder of written expression and dysgraphia: definition, diagnosis, and management. Translational pediatrics, 9(Suppl 1), S46–S54. https://doi.org/10.21037/tp.2019.11.01
- Döhla, D., & Heim, S. (2016). Developmental Dyslexia and Dysgraphia: What can We Learn from the One About the Other?. Frontiers in psychology, 6, 2045. https://doi.org/10.3389/fpsyg.2015.02045
- Rocha Cabrero F, De Jesus O. Dysgraphia. [Updated 2020 Jun 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559301/
- High Prevalence of Dysgraphia in Elementary Through High School Students With ADHD and Autism (( Mayes SD, Breaux RP, Calhoun SL, Frye SS. High Prevalence of Dysgraphia in Elementary Through High School Students With ADHD and Autism. J Atten Disord. 2019 Jun;23(8):787-796. doi: 10.1177/1087054717720721. Epub 2017 Jul 25. PMID: 28741400.
- Moreno-Flagge N. Trastornos del lenguaje. Diagnóstico y tratamiento [Language disorders. Diagnosis and treatment]. Rev Neurol. 2013 Sep 6;57 Suppl 1:S85-94. Spanish. PMID: 23897160.
- Berninger, V., & Richards, T. (2010). Inter-relationships among behavioral markers, genes, brain and treatment in dyslexia and dysgraphia. Future neurology, 5(4), 597–617. https://doi.org/10.2217/fnl.10.22
- Hux K, Mahrt T. Alexia and Agraphia Intervention Following Traumatic Brain Injury: A Single Case Study. Am J Speech Lang Pathol. 2019 Aug 9;28(3):1152-1166. doi: 10.1044/2019_AJSLP-18-0245. Epub 2019 Jun 13. PMID: 31194917.
- Miyakawa Y, Fuchigami T, Aoki M, Mine Y, Suzuki J, Urakami T, Takahashi S. Agraphia with reversible splenial corpus callosum lesion caused by hypoglycemia. Brain Dev. 2018 Aug;40(7):592-595. doi: 10.1016/j.braindev.2018.03.003. Epub 2018 Mar 30. PMID: 29606344.
- Vandenborre D, van Dun K, Engelborghs S, Mariën P. Apraxic agraphia following thalamic damage: Three new cases. Brain Lang. 2015 Nov;150:153-65. doi: 10.1016/j.bandl.2015.05.011. Epub 2015 Nov 3. PMID: 26460984.
- Shinoura N, Onodera T, Kurokawa K, Tsukada M, Yamada R, Tabei Y, Koizumi T, Yagi K. Damage to the upper portion of area 19 and the deep white matter in the left inferior parietal lobe, including the superior longitudinal fasciculus, results in alexia with agraphia. Eur Neurol. 2010;64(4):224-9. doi: 10.1159/000318175. Epub 2010 Aug 26. PMID: 20798545.
- Schomer DL, Pegna A, Matton B, Seeck M, Bidaut L, Slossman D, Roth S, Landis T. Ictal agraphia: a patient study. Neurology. 1998 Feb;50(2):542-5. doi: 10.1212/wnl.50.2.542. PMID: 9484395.
- Cirelli A, Ciardi M, Salotti A, Rossi F. An unusual neurological feature of HIV-1 encephalopathy: Gerstmann’s syndrome. Acta Neurol (Napoli). 1994 Jun;16(3):110-3. PMID: 7992659.
- Shimizu H, Yamada M, Matsubara N, Takano H, Umeda Y, Kawase Y, Kitamoto T, Nishizawa M, Takahashi H. Creutzfeldt-Jakob disease with an M232R substitution: report of a patient showing slowly progressive disease with abundant plaque-like PrP deposits in the cerebellum. Neuropathology. 2009 Dec;29(6):735-43. doi: 10.1111/j.1440-1789.2009.01019.x. Epub 2009 Apr 21. PMID: 19422537.
- Evyapan Akkuş D, Güler A. The Ege Agraphia Test Battery for Identifying the Writing Disorders in Cases with Mild Cognitive Impairment and Alzheimer’s Disease. Turk Psikiyatri Derg. 2016 Fall;27(3):185-194. Turkish, English. PMID: 27711939.
- Cui B, Cui LY, Gao J, Liu CY, Liu Q, Liu MS, Shen DC, Liu F. Agraphia in Amyotrophic Lateral Sclerosis with Frontotemporal Lobe Degeneration. Chin Med J (Engl). 2016 Mar 5;129(5):612-4. doi: 10.4103/0366-6999.176999. PMID: 26905000; PMCID: PMC4804447.
- Manzine, P. R., & Pavarini, S. (2009). Cognitive rehabilitation: Literature review based on levels of evidence. Dementia & neuropsychologia, 3(3), 248–255. https://doi.org/10.1590/S1980-57642009DN30300012
- Silbergleit AK, LeWitt P, Junn F, Schultz LR, Collins D, Beardsley T, Hubert M, Trosch R, Schwalb JM. Comparison of dysphagia before and after deep brain stimulation in Parkinson’s disease. Mov Disord. 2012 Dec;27(14):1763-8. doi: 10.1002/mds.25259. Epub 2012 Oct 31. PMID: 23115021.
- Beeson PM. Remediation of written language. Top Stroke Rehabil. 2004 Winter;11(1):37-48. doi: 10.1310/D4AM-XY9Y-QDFT-YUR0. PMID: 14872398.
- Rapp, B., & Glucroft, B. (2009). The benefits and protective effects of behavioural treatment for dysgraphia in a case of primary progressive aphasia. Aphasiology, 23(2), 236–265. https://doi.org/10.1080/02687030801943054
- Foster, E. R., Bedekar, M., & Tickle-Degnen, L. (2014). Systematic review of the effectiveness of occupational therapy-related interventions for people with Parkinson’s disease. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 68(1), 39–49. https://doi.org/10.5014/ajot.2014.008706