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| Division of Occupational Therapy - OT Connect Dysgraphia
Dysgraphia is a term used to describe children who have specific difficulties producing written language (Szklut, & Breath, 2001). This disorder is commonly diagnosed under the title of “disorder of written expression.” In order for this diagnosis to be made, an individual must display “writing skills…substantially below those expected given the person’s chronological age, measured intelligence, and age appropriate education,” which “significantly interferes with academic achievement or activities of daily living that require composition of written texts” (American Psychiatric Association, 1994). A key feature of a disorder of written expression is that the organization and production of information verbally far exceeds the ability to do the same via written language (Kronenberger, 2003). Children with a wide span of developmental achievements, such as the highly intellectually gifted child, may not be learning disabled, but still may have a substantial asynchrony in verbal reasoning, oral communication, and written output. Common Symptoms/Course of disease
According to Szklut, & Breath (2001), dysgraphia can be classified into three groups of symptoms including “penmanship-related aspects of writing (e.g., motor control and execution), linguistic aspects of writing (e.g., spelling and composing), or a combination” (p. 314). Common to all classifications is a difficulty expressing thoughts through writing. Age of Onset: A disorder of written expression is not commonly evident until after the first grade. Although children are required to write in the first grade, the demands are usually simple, not requiring expression of ideas or use of grammar. Parents and teachers typically begin to notice the emergence of a disorder of written expression in the third or fourth grade, when course work increases in complexity (Kronenberger, 2003). Course of Condition: Research indicates that children do not outgrow learning disabilities. However, it is possible for their performance in an area of weakness to improve noticeably with treatment (Szklut, & Breath, 2001; Kronenberger, 2003). Children with developmental asynchronies are expected to gain writing skills to support their oral language abilities. Sex Bias: Learning disabilities occur two to four times as often in boys than girls (Kronenberger, 2003). Cultural Bias: While data on the prevalence of dysgraphia is limited, it is estimated to occur as commonly as reading disorders. Therefore, a disorder of written expression could be found in up to 4% of the population (Szklut, & Breath, 2001). Medication: While many medications treat conditions that may occur in combination with a learning disability (e.g. attention), no medication exists specifically for learning disabilities (Learning disabilities, 2004). Occupational Therapy Involvement Occupational therapy is a profession that enables individuals to reach their highest level of independence in daily functioning activities, also known as, occupations. These occupations are different depending on age, culture, interests, roles, etc. Occupational therapists consider the occupations of childhood to include self-care, work, and play activities. Under the category of work, school-aged children’s occupations include academic skills, such as writing (Amundson, 2001). Handwriting is a skill that most individuals use daily and it is demanded of school-aged children, even though the process is complex. Managing written language involves coordinating the eyes, arms, hands, pencil grip, letter formation, and body posture. When a child experiences difficulty with handwriting, this can interfere with their ability to learn, because teachers depend on written work to measure learning (American Occupational Therapy Association, 2001). It is the role of occupational therapists to view the students’ handwriting performance by concentrating on the interaction between the student, the school environment, and the school occupation. For this to be achieved, the occupational therapists must perform an evaluation to determine which components of handwriting are difficult for the student, how the curriculum or physical layout of the classroom may interfere with performance, and if the students abilities, experiences, and/or cognitive, psychosocial, and sensorimotor skills are interfering with the production of written language. In the instance that handwriting difficulties are noted in preschool or kindergarten, an occupational therapist may also provide evaluation and intervention for children’s prewriting skills and handwriting readiness (Amundson, 2001). Specific treatment strategies: Treatment strategies would vary for each individual who displays difficulty with handwriting. As described above, even within the realm of dysgraphia, many different combinations of symptoms can be present. There are diagnoses involving motor deficiencies that can also cause handwriting problems (Szklut, & Breath, 2001). Therefore, treatment activities for the development of hand skills are often interwoven. Some possible interventions for handwriting include:
Assistive Technologies: A recent research study a concluded that, “Occupational therapy intervention involving word processing with word prediction improves the legibility and spelling of written assignments completed by some children with learning disabilities and handwriting difficulties” (Handley-More, Deitz, Billingsley, & Coggins, 2003). For more information on assistive technologies visit the following sites:
References
How OT Makes a Difference: Evidence-Based Practice Case-Smith, J. (2002). Effectiveness of school-based occupational therapy intervention on handwriting. American Journal of Occupational Therapy, 56, 17-25. For this study, a sample of 29 students 7 to 10 years of age with poor handwriting legibility, but who received direct occupational therapy services, were compared with 9 similar students who did not receive services. In this sample of children, the primary diagnosis was a learning disability, which represents the population that typically receives occupational therapy services for handwriting deficits. Interventions were provided by 12 occupational therapists working in the five school districts that were included in this study. In depth handwriting evaluations were conducted by the author and four occupational therapists at the beginning and end of the school year. Data analysis led to the finding that students who received occupational therapy services demonstrated improved letter legibility, but speed and numeral legibility did not demonstrate positive intervention effects. The findings of this study indicate a need for further research that would measure the outcomes of specific handwriting interventions. Peterson, C.Q., & Nelson, D.L. (2003). Effect of an occupational intervention on printing in children with economic disadvantages. American Journal of Occupational Therapy, 57, 152-160. These researchers used a final sample of 59 first-grade children with economic disadvantages. The sample was randomly divided into an intervention and control group. They provided the intervention group with two 30-minute training sessions every week for 10 weeks, while these children also received regular academic instruction. The only training that the control group received was through regular academic instruction. The occupational interventions were designed and implemented using biomechanical, sensorimotor, and teaching-learning strategies. The Minnesota Handwriting Test was used for pretest and posttest assessments. The results showed that the intervention group gains were markedly greater than those in the control group. Therefore, occupational interventions were effective in improving the printing of children with socioeconomic disadvantages. The following section is based upon an interview of Ashton, an 8-year-old boy diagnosed with a disorder of written expression, and his mother, Jane. According to Jane, there were no signs of delay until her son entered the school system. He was very bright, inquisitive, and had a huge imagination. She first noticed a problem when Ashton was in the second grade and his teacher reported a behavior problem. Upon meeting with the teacher, Jane found that the behavior problem involved Ashton’s continual talking/disrupting of other students instead of doing his work. Jane immediately had a talk with her son about this issue and found that his real reason for not completing assignments was due to a struggle with writing. Ashton’s mother then took him to a pediatrician who diagnosed him and recommended placement in a special education program at school, as well as, occupational therapy services. Ashton was heartbroken and “afraid of being made fun of” if he had to be separated from his peers in a special education classroom. Jane was understanding, but she also had hope in the special education program, which would qualify Ashton for another needed service, occupational therapy. Therefore, a compromise was made, and Ashton’s IEP was written in a way such that only one hour of his day would be spent in a special education classroom, and occupational therapy services would be provided once a week for 45 minutes – 1hour. The first occupational therapy session involved some special assessments that helped identify Ashton’s largest problem area as visual perceptual. With this information, the occupational therapist designed a plan for treatment which involved, kinesthetic writing, Handwriting Without Tears program to teach handwriting, an education plan for Ashton’s teacher and family so that they could understand his condition and help at school and home. Jane was especially impressed that her son’s occupational therapist always encouraged family participation. Ashton reported that he enjoyed occupational therapy and stated “I still had to practice my handwriting in OT, but I was always allowed to choose fun ways to do it.” After the first year of occupational therapy services, Ashton’s grades had improved due to classroom modifications (e.g. taking tests orally), and his handwriting skills had improved, but were still falling far behind his peers who were now moving on to cursive writing. Social problems were beginning to emerge as Ashton was being “made fun of” by his peers. Jane reported that her son was still bringing home most written assignments as homework, because he could not finish them at school. At this point, Ashton’s occupational therapist recommended a word processing and word prediction program that he could use during class for note taking, creative writing, and other assignments that were too demanding of his handwriting skills. Although Jane did not want to give up on Ashton’s handwriting development, she knew that without some type of assistance, her son’s learning in the classroom would be impaired. The occupational therapist then trained Ashton to use a keyboard and operate a program called Co:Writer 4000. This was something that he picked up on very quickly. Jane said that her son brings home much less homework and he enjoys using Co:Writer4000 in his spare time to write stories. To help with Ashton’s self-esteem and social problems, his occupational therapist educated the children in his classroom by inviting one child from the regular classroom into each treatment session. Jane was pleased with this intervention, as well as, others that ultimately helped her son complete the occupations of his daily life.
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