DIS-GRAF-EEA: What is it and how do I know?

What is Dysgraphia 

I am sure many of you have heard of the term Dysgraphia (dis-graf-eea). We have already touched on Dyspraxia, which has links to Dysgraphia, however Dysgraphia is a seperate entity and  a common difficulty experienced by children and observed by OTs.

Dysgraphia is defined as ‘the delayed development in, or acquired loss of the skill of writing’. Dysgraphia may affect one child in twenty, and whilst having links with Dyspraxia, is a seperate disorder – given the writing challenges that exist have a greater relation to poor sequential information processing and poor motor/kinaesthetic skills. It is considered a learning difficulty that impacts on a person’s ability to write. It can manifest itself as difficulties with spelling, poor handwriting and trouble putting thoughts on paper as well as speed and quality of handwriting. Because writing requires a complex set of motor and information processing skills, just saying someone has ‘Dysgraphia’ is not always sufficient or even correct!

Handwriting is one of the most complex skills that is learnt and taught. It requires motor, sensory, perceptual, praxis (motor planning) and cognitive functions and the integration of these functions. When you identify all the individual components required in writing, it is not surprising that many children have great difficulty undertaking and being confident in the skill of writing.

What could Dysgraphia look like…on paper?

Though this can vary, for many children the below is a brief summary of some of the signs of Dysgraphia. It is also important to understand that handwriting and drawing can often take time to develop and just because your child may have difficulty with this skill in kindergarten or Reception, it doesn’t necessarily mean they have Dysgraphia or significant writing difficulties. As mentioned, it is a tricky skill!

Kindergarten and Reception Age children

  • Tight pencil grip, with reduced web space
  • Awkward or hunched body position
  • Avoiding writing or drawing tasks
  • Difficulty with number and shape formation
  • Inconsistent spacing between letters or words
  • Difficulty distinguishing uppercase and lowercase letters
  • Difficulty with spatial awareness
  • Fatiguing quickly while writing

Junior and Primary School-Age Children

Many of the above still persist with Primary school aged children, but can also be accompanied by:

  • Handwriting is quite illegible
  • Often a mixture of cursive and print writing (especially at an age wen cursive has been introduced).
  • Having to say words out loud while writing them
  • Concentrating so hard on writing that comprehension of what’s written is missed
  • Difficulty with remembering words, thinking of what to write or spelling
  • Omitting or not finishing words in sentences
  • Distractible during writing tasks and increased avoidance

Handwriting detective work

Despite these mentioned challenges, a child that has signs of one of the above difficulties does not suggest that a child has Dysgraphia. Rather, a combination of these challenges can signify difficulty in fine motor tasks, such as handwriting, or potential Dyspraxia.

There are a number of ways to evaluate handwriting difficulties, and can include:

  1. Assessing Foundational skills and Neuromuscular mechanisms
    • Often a large focus for most OTs addressing handwriting difficulties, including Dysgraphia. This include looking a the important ‘big body’ skills that contribute to effective handwriting. These include:  Postural control, Upper limb stability, shoulder stability, hand strength and overall muscle tone (which impacts on endurance). These can be observed in standardised OT Assessments such as the SIPT.
  2. Sensory integrative functioning
    • Given our heavy focus on Sensory Integration at OTFC, we will also assess a child’s difficulties in touch perception and discrimination. These can influence pencil grip (i.e. being able to feel where the fingers should go of if they move), visual perceptual deficits and poor motor planning skills can influence quality and speed of writing. These can be observed in standardised OT Assessments such as the Miller Preschool Assessment, Beery VMI and SIPT.
  3. Motor control 
    • Difficulties with fine motor control, finger dexterity, finger isolation and intrinsic finger/hand strength strength and endurance . Avoidance of these tasks during preschool can further impact on the foundation skills of the hands required for handwriting. These can be observed in standardised OT Assessments such as the Miller Preschool Assessment, Beery VMI and SIPT.
    • In addition to these, the Handwriting Speed Test will provide insight into a child’s handwriting, compared to age norms of their peers.
  4. Cognitive and psychosocial behaviours
    • Often a by product of difficulties in writing (e.g. confidence and avoidance), however a number of children have difficulties with attention span, memory, general behaviour, overall motivation and self-concept, which can further impact on handwriting skills and success in this area.

From such assessments it is important to establish what therapeutic approach is going to be most effective as well as appropriate. For many older primary children, changing pencil grips, spending hours on letter formation and correction may not produce the desired outcomes. This is largely due to the difficulties in the foundation skills in writing, by a later age. Importantly, we have a number of advances in technology that can provide alternate options that can be cost effective and more likely adopted by the child.

Moreover, from assessments and information given from a number of people that spend time or work with a child, one can gain a picture of whether or not the child does present with Dysgraphia.

So…am I able to help my child?! 

Okay, so you’ve had the assessment process, now what? Often after the assessment process, there is discussion around the best course of action to address writing difficulties. This often includes discussion with health professionals, teachers and parents. For the most part, there are three primary areas of addressing problems due to Dysgraphia. The best course of action is often dependant on the level of difficulty experienced with handwriting. Addressing possible Dysgraphia takes the below approaches:

Remedial approaches

  • This is an area we spend time working on considerably at OTFC. Here, we aim to address underlying inefficiencies in sensory processing, motor coordination and perceptual skills that influence handwriting skills, in order to improve the foundations of good writing. The below ‘Pyramid of Learning’ from Williams and Shellenberger outlines the development of learning and how sensory and sensory motor skills are important in developing skills further up the pyramid (e.g. Academic Learning). As such, we will struggle to make progress in handwriting if there are difficulties in tactile perception, visual perceptual challenges or motor planning – hence the links with Dyspraxia.

Functional approaches

  • Once the above areas are somewhat more consolidated, then we we would place further emphasis on mastering the skills through practice and repetition. Similar to other skills (particularly fine motor skills of cutting, threading, twisting) handwriting can be improved through support addressing specific motor plans and sequences. These are often achieved through tracing, repetition and practice and modelling.

For most children, if they have significant difficulties and clear signs of Dysgraphia, these difficulties will often continue and support will be required. Importantly, to ensure that handwriting is not a task ‘avoided at all costs’, but rather can be made more functional, support should be given in both compensatory approaches and some functional approaches.

Compensatory approaches

  • Pencil grips, slant boards, Dictaphones, use of computers, scribes, voice activated software and even oral assessment can be very effective in providing options for those that want to get their ideas across, but struggle to do so. With  advances in technology, iPads and computers are becoming more commonplace, and specific appropriate apps can make getting ideas across more accessible and ensure children are included in ‘writing’ tasks.

So, now that we know a little bit more about Dysgraphia, we will next week look at some specific ideas to help those with handwriting difficulties, such as Dysgraphia, addressing remedial, functional and compensatory approaches for home and school.

*Information sourced from: OTFC Clinical Director and staff, Education and Individual Services (2015) <www.somerset.gov.uk>, Australian Journal of Learning Disabilities (2006) Volume 11, Number 4 and Regina G. Richards (2015), Strategies for Dealing with Dysgraphia, Learning Disabilities Online <http://www.ldonline.org/article/5890/>


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