case study disorder of written expression

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Transl Pediatr
v.9(Suppl 1); 2020 Feb

Disorder of written expression and dysgraphia: definition, diagnosis, and management

Peter j. chung.

1 Department of Pediatrics, University of California Irvine, Irvine, CA, USA;

Dilip R. Patel

2 Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, USA

Iman Nizami

Writing is a complex task that is vital to learning and is usually acquired in the early years of life. ‘Dysgraphia’ and ‘specific learning disorder in written expression’ are terms used to describe those individuals who, despite exposure to adequate instruction, demonstrate writing ability discordant with their cognitive level and age. Dysgraphia can present with different symptoms at different ages. Different theories have been proposed regarding the mechanisms of dysgraphia. Dysgraphia is poorly understood and is often undiagnosed. It has a high rate of co-morbidity with other learning and psychiatric disorders. The diagnosis and treatment of dysgraphia and specific learning disorders typically centers around the educational system; however, the pediatrician can play an important role in surveillance and evaluation of co-morbidity as well as provision of guidance and support.

Introduction: definitions and disagreement

At its broadest definition, 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. Acquired dysgraphia occurs when existing brain pathways are disrupted by an event (e.g., brain injury, neurologic disease, or degenerative conditions), resulting in the loss of previously acquired skills. In contrast, this review will concentrate on developmental dysgraphia, i.e., the difficulty in acquiring writing skills despite sufficient learning opportunity and cognitive potential. This article will use the terms dysgraphia and specific learning disorder with impairment of written expression in their broadest terms, to encompass any difficulty an individual may have in written communication.

Much controversy exists regarding the precise definition of and deficits seen in dysgraphia, depending on the theoretical mechanisms attributed to the disorder ( 1 ). Historically, dysgraphia was most often defined as an impairment in the production of written text, usually due to a lack of muscle coordination. Specific testing in affected children highlighted minor differences in performance of fine motor tasks (e.g., repeated finger tapping) or abnormal measures of hand strength and endurance ( 2 ). These deficits stemmed from hindrance in fine motor coordination, visual perception, and proprioception and manifested an illegible or slowly formed written product. Oral spelling was usually preserved. This conceptualization of dysgraphia has been categorized as “motor” or “peripheral” dysgraphia ( 3 ).

Secondly, Deuel ( 4 ) proposed a second subtype of dysgraphia termed “spatial dysgraphia”. The primary impairment in this sub-type of dysgraphia was thought to be related to problems of spatial perception, which impaired spacing of letters and greatly impacted drawing ability. In such cases, oral spelling and finger tapping were preserved but drawing, spontaneous writing, and copying text were impaired.

However, others have placed much more focus on the language processing deficits related to written expression, with less emphasis on any motor issues. Qualifying terms for this type of dysgraphia include “dysorthography”, “linguistic dysgraphia”, or “dyslexic dysgraphia” ( 5 ). The primary mechanism of this dysgraphia is related to inefficiency of the “graphomotor loop”, in which the phonologic memory (regarding sounds associated to phonemes) communicates with the orthographic memory (regarding written letters). Impaired verbal executive functioning, including storage and working memory, have also been related to this disorder ( 5 ). Oral spelling, drawing, copying, and finger tapping are usually preserved in this type of dysgraphia. In contrast but related to dysgraphia, dyslexia is theorized to result from two-way dysfunction of the “phonologic loop”, which is the communication between orthographic and phonologic processes.

The Diagnostic and Statistical Manual of Mental Disorders 5 th edition (DSM-5) ( 6 ) includes dysgraphia under the specific learning disorder category, but does not define it as a separate disorder. According to the criteria, a set of symptoms ( Table 1 ) should be persistent for a period of at least 6 months in the context of appropriate interventions in place. For any specific learning disorder, the academic skills as measured by individually administered standardized tests must fall significantly below expectations for the child’s age. The onset of difficulty in learning is generally during early school years; however, it is more apparent as the complexity of work increases with progression to higher grades. Other causes of learning difficulty include intellectual disability, vision impairment, hearing impairment, underlying mental or neurological disorder, and lack of adequate learning support or academic instructions.

Inaccurate or slow and effortful word reading

Difficulty understanding the meaning of what is read

Difficulty with spelling

Difficulty with written expression

Difficulties mastering number sense, number facts, or calculation

Difficulties with mathematical reasoning

In the United States, the Individuals with Disabilities Education Act (IDEA) revised in 2004 broadly defines “Specific Learning Disability” in the following manner ( 7 ):

❖ The child does not achieve adequately for the child’s age or to meet State-approved grade-level standards in one or more of the following areas, when provided with learning experiences and instruction appropriate for the child’s age or State-approved grade–level standards: Oral expression, listening comprehension, written expression, basic reading skills, reading fluency skills, reading comprehension, mathematics calculation, or mathematics problem solving.
❖ The child does not make sufficient progress to meet age or State-approved grade-level standards in one or more of the areas when using a process based on the child’s response to scientific, research-based intervention; or the child exhibits a pattern of strengths and weaknesses in performance, achievement, or both, relative to age, State-approved grade-level standards, or intellectual development, that is determined by the group to be relevant to the identification of a specific learning disability, using appropriate assessments; and the group determines that its findings are not primarily the result of a visual, hearing, or motor disability; mental retardation; emotional disturbance; cultural factors; environmental or economic disadvantage; or limited English proficiency.

Between 10% and 30% of children experience difficulty in writing, although the exact prevalence depends on the definition of dysgraphia ( 8 ). As with many neurodevelopmental conditions, dysgraphia is more common in boys than in girls ( 9 ). Handwriting problems are a frequent reason for occupational therapy consultation. Dysgraphia and disorders of written expression can have lifelong impacts, as adults with difficulty writing may continue to experience impairment in vocational progress and activities of daily living ( 10 ).

Writing development

As noted above, the concept of “writing” encompasses a broad spectrum of tasks, ranging from the transcription of a single letter to the intricate process of conceptualizing, drafting, revising, and editing a doctoral dissertation. Writing is an important academic skill that has been associated with overall academic achievement ( 11 ). On average, writing tasks occupy up to half of the school day ( 12 ), and students with difficulty writing are often mislabeled as sloppy or lazy rather than being recognized as having a learning disorder. Deficient handwriting has been associated with lower self-perception, lower self-esteem, and poorer social functioning ( 13 , 14 ).

The acquisition of writing follows a step-wise progression in early childhood; individuals who struggle with foundational writing skills are likely to exhibit greater delays as they fail to match their peers’ growth in writing ability. In preschool, children are taught to copy symbols and shapes to develop the basic visual-motor coordination skills for transcription. Letter awareness typically begins in kindergarten and progresses through second grade, during which time the child becomes familiarized with the relationship between sounds and phonemes while continuing to grow in motor skills ( 15 ). Automaticity, in which individual letter writing has become a rote response, is usually developed by third grade ( 16 ). As many American school curricula no longer include specific instruction on the steps of letter formation, children who struggle to develop automaticity may fail to acquire this skill ( 5 , 17 ). Automaticity and handwriting should continue to improve through the elementary school years ( 18 ) with implications for long-term outcomes; notably, the skill of automaticity is associated with higher quality and longer length of writing products in high school and college ( 19 , 20 ).

Beyond the early school years, writing projects require the additional ability to organize, plan, and implement a complete written product. Such tasks require the recruitment of executive functioning and higher-order language processing. For example, writing a sentence requires several steps: (I) internally creating the desired statement; (II) segmenting the desired statements into sections for transcription; (III) retaining the sections in verbal working memory while executing the task of writing; and (IV) checking that the completed written product matches the original thought. Writing more complex products such as paragraphs or essays requires additional planning, organization, and revision to stitch together multiple statements and thoughts into a coherent whole. Failure to develop writing automaticity by third grade greatly increases the likelihood of difficulty in more complex writing tasks, as the child’s higher cognitive functions may be preoccupied by the graphomotor requirements of letter formation.

Mechanisms and etiology

Many of the theories regarding mechanisms of dysgraphia have been derived from studies of individuals with acquired dysgraphia ( 21 , 22 ). Writing has been shown to be a complex process that requires the higher order cognition (language, verbal working memory and organization) coordinated with motor planning and execution to constitute the functional writing system ( 23 ). Different writing tasks require different cognitive processes, and individuals with dysgraphia may have disorders in one or more areas. For example, when asked to spell a dictated word, the listener must utilize phonological awareness to access phonological long-term memory and the associated lexical-semantic representations. This in turn activates the orthographic long-term memory to create abstract letter representations that require motor planning and coordination to execute the task of writing, all maintained in the working memory. Spelling a pseudoword or novel word requires the function of sublexical spelling process that applies known phoneme-graphene conventions to predict the correct spelling. Generating a new word spontaneously would first require the usage of orthographic skills, which would then access the lexical representation. Writing rapidly and fluidly requires motor planning and coordination mediated by the cerebellum. Throughout the writing task, visual and auditory processing and attention is crucial to the production of legible writing.

Impairment in even one facet of the writing process can impair an individual’s ability to generate an age-appropriate product ( 24 ). Although researchers have theorized that different subtypes of dysgraphia may be correlated to different mechanisms ( 25 ), newer studies have demonstrated interrelations between brain areas responsible for automaticity, language, and motor coordination. The perceived divergence between theories of dysgraphia may not be as great as once thought. For example, children with dyslexia have also been noted to be at increased risk for other mild motor deficits in tasks like finger tapping, riding a bike, and tying shoelaces.

Increased attention has also been placed on the cerebellum as playing a role in dysgraphia. Case studies have shown that cerebellar injury can cause symptoms of acquired dysgraphia, indicating that it plays some role in the coordination of writing ( 21 ). Functional imaging studies have also demonstrated that this region of the brain plays a vital role in language and automaticity ( 26 ). Possible mechanisms of involvement include the hypothesis that the cerebellum is required in the development of a neural system or framework, which can be disrupted in different ways and result in different functional impairments ( 1 ).

Genes and their role in the possible etiology or mechanisms of learning disorders is an emerging field. Genetic aggregation studies suggest that verbal executive function tasks, orthographic skills, and spelling ability may have a genetic basis. For example, genes on chromosome 15 have been linked to poor reading and spelling ( 27 ) and genes on chromosome 6 have been linked to phonemic awareness ( 28 ). Individuals with learning disabilities and their family members have been noted to have differential brain activation patterns on functional magnetic resonance imaging, suggesting a genetic contribution, but not causation ( 29 ). As the field of genetics continues to evolve, more information regarding the genetics of learning disorders like dysgraphia is likely to emerge.

Co-morbidities

Dysgraphia may occur in isolation but is also commonly associated with dyslexia as well as other disorders of learning. Depending on the definitions utilized, anywhere from 30% to 47% of children with writing problems also have reading problems. In addition, difficulty in writing can be seen in many other neurodevelopmental disorders, including attention-deficit/hyperactivity disorder, cerebral palsy, and autism spectrum disorder. Research demonstrates that 90–98% of children with these disorders struggle with writing ( 29 - 32 ). Developmental coordination disorder (DCD), in which individuals have deficiencies in motor development and motor skill acquisition, often also affects writing development; around half of those with DCD also exhibit impaired writing abilities ( 33 ). With regards to the association between learning disorders and mental health disorders, co-morbidity is the rule, not the exception ( 34 , 35 ). Given this high risk of co-morbidity, clinicians should be surveilling patients for possible related conditions; e.g., the patient with autism spectrum disorder should be monitored for problems with reading, writing, and math while the patient with dysgraphia may warrant an investigation of co-morbid attention-deficit/hyperactivity disorder.

As academic demands increase and neurodevelopment progresses, dysgraphia may manifest in a variety of signs and symptoms. It can affect one or more levels of the writing process. As noted above, handwriting is typically developing in the early school years, and thus, dysgraphia is usually not recognized during this period. However, dysgraphia (especially isolated dysgraphia) may not be recognized, even into the young adult years. Co-morbid dyslexia and dysgraphia is more readily recognized, although impairments in reading ability are usually prioritized and addressed over impairments in writing. The National Center for Learning Disabilities has published a summary of warning signs for dysgraphia based on the age and stage of development ( Table 2 ) ( 36 ). As in seen in the table, dysgraphia symptoms manifest first as concrete impairments at younger ages and later as abstract impairments at older ages.

Age group	Signs or symptoms
Pre-school children	An awkward grip or body position when writing
	Tire easily with writing
	Avoidance of writing and drawing tasks
	Written letters are poorly formed, inversed, reversed, or inconsistently spaced
	Difficulty staying within margins
The school-aged child	Illegible handwriting
	Switching between cursive and print
	Difficulty with word-finding, sentence completion, and written comprehension
The teenager and young adult	Difficulty with written organization of thought
The teenager and young adult	Difficulty with written syntax and written grammar that is not duplicated with oral tasks

The diagnosis of specific learning disability is typically made in an educational setting by a team assessment, which often includes occupational therapists, speech therapists, physical therapists, special education teachers, and educational psychologists. In the United States, most often, the diagnosis is made following an assessment towards eligibility for an individualized educational plan ( 36 ). The diagnosis of a learning disability or dysgraphia can also be given through a psychoeducational evaluation outside of the educational system. As the term “dysgraphia” is not recognized by the American Psychological Association, there is no professional consensus on specific diagnostic criteria. As in the case for other learning disorders, a key factor should be the degree of difficulty that the writing impairment imposes on the child’s access to the general education curriculum. Evidence should be drawn from multiple sources and contexts, including observation, anecdotal report, review of completed work, and normative data.

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 graphomotor planning, orthographic awareness, and/or rapid automatic naming. Secondary tests to consider are evaluations of pencil grip and writing posture. Formalized handwriting assessments ( Table 3 ) can be used to measure the speed and legibility of students when copying letters, words, sentences, and/or pseudowords. Visual-motor integration assessment may include evaluations such as the Beery Developmental Test of Visuomotor Integration (VMI) ( 37 ); however, these tests typically do not analyze difficulties specific to orthographic processes. Children with suspected dysgraphia should be evaluated for other potential learning problems given the high rates of co-morbidity with dyslexia and other learning disorders.

Minnesota Handwriting Assessment

Evaluation Tool of Children’s Handwriting

Scale of Children’s Readiness in Printing

Detailed Assessment of Speed of Handwriting

Beery Developmental Test of Visuomotor Integration (VMI)

There is no medical testing required or available for diagnosing dysgraphia. However, given the high rate of co-morbidity between psychiatric, neurodevelopmental, and learning disorders, the physician should investigate for symptoms of possible related conditions. The physician should conduct a thorough neurologic examination, including “soft” neurologic signs like poor coordination, dysrhythmias, mirror movements, and overflow movements. Co-morbid neurodevelopmental disorders (e.g., autism spectrum disorder, attention-deficit/hyperactivity disorder) and mood disorders (e.g., anxiety, depression) can be evaluated through the use of semi-structured interviews and/or validated parent and teacher report forms. Should screening procedures indicate any areas of concerns, the general medical practitioner should consider referring for specialist consultation for additional diagnostic conceptualization and treatment recommendations, including child neurology, child psychiatry, developmental-behavioral pediatrics, or other mental health providers.

The primary intervention for dysgraphia and other learning disorders occurs in the educational setting. Interventions can generally be stratified into the following levels: (I) accommodation, where the student accesses the mainstream education curriculum with supportive or assistive resources without changing the educational content; (II) modification, where the school adapts the student’s goals and objectives as well as provides services to reduce the effect of the disability; and (III) remediation, where the school provides specific intervention to decrease the severity of the student’s disability. As the manifestations of dysgraphia and other learning disorders change with shifting academic demands and cognitive development, management of these conditions is a fluid and life-course process that must adapt with the most current level of impairment. As outlined by IDEA, the school system should assess and provide the necessary supports for the student’s needs in the educational setting.

Accommodations

Accommodations should be directed to decrease to the stress associated with writing. Specific devices may be utilized, such as larger pencils with special grips and paper with raised lines to provide tactile feedback. Extra time can be permitted for homework, class assignments, and quizzes/tests. Depending on the student’s comfort level, alternative ways of demonstrating knowledge (e.g., oral or recorded responses rather than written examination) can be considered. Technologic accommodations include automated spellcheck, voice-to-text recognition software, tablets, and computer keyboards; as devices become increasingly more advanced, new devices should be considered for their application in the classroom. However, handwriting practice should continue at school as written language is still needed for many daily tasks (e.g., filling out forms). Research has also demonstrated that the process of writing words by hand may provide a unique impetus to learning ( 38 ). It is important to note that accommodations may not directly address impairment of executive functioning tasks related to writing, including planning and organization. Computers and voice-to-text supports can decrease writing stress in those with continued automaticity challenges, but these accommodations do not address higher-level writing difficulties ( 39 ).

Modifications

Dysgraphia may require modifications to the student’s academic program, especially with regards to written products. Teachers can opt to scale down large written assignments, break up large projects into smaller ones, or grade students based on a single dimension of their work (e.g., content or spelling, not both). In general, following the “least restrictive environment” for learning, the school should strive to keep the student within the mainstream education environment as much as possible.

Remediation

Remediation should be determined by the individual student’s severity of difficulty in written expression. As with many neurodevelopmental conditions, early intervention produces the greatest gain ( 24 ). A stratified approach may be utilized following a response-to-intervention model (RTI). This model consists of three tiers of intervention; students who continue to struggle to lower tiers “step up” to higher tiers. Tier 1 consists of preventative screening on all students for learning differences. Expert recommendations have been written for general education teachers regarding ways to encourage sound writing habits ( 9 ). Tier 2 consists of targeted intervention towards students with specific learning issues. Tier 3 focuses the most intensive treatment on students who have continued to struggle and require the most support. In most intervention studies, students usually demonstrate improvement after 20 lessons over several weeks.

Most often, intervention for dysgraphia in the early elementary years focuses on developing fine motor skills. Motor activities for increasing hand coordination and strength include tracing, drawing in mazes, and playing with clay as well as exercises like finger tapping and rubbing/shaking the hands. Intervention can also include teaching grip control and good writing posture. However, research has demonstrated that teaching motor skills in conjunction with orthographic skills is the most effective approach ( 40 ). One example method of teaching orthographic tasks is described by Berninger ( 19 ): the student learns to write each letter by first visually learning the steps to write the letter (based on a sample with numbered arrow cues), then visualizing the act of writing the letter, using the cues to transcribe the letter, and checking the written product with the initial sample ( 41 ). Other techniques focus the learners’ attention on the movements associated with writing rather than the written product itself [e.g., reviewing video models instead of static guides ( 42 ) and using placeholder pens without ink ( 43 )].

The family should provide enjoyable writing activities outside of the educational setting so that the individual can learn that writing can be a pleasant and enjoyable experience. Research has demonstrated that educational games and activities can be used to help students practice retrieving letters from long-term memory ( 44 ).

Students with dysgraphia may also need help in more complex parts of writing, including planning, drafting, and revising, especially as they enter the middle and high school years. Randomized-control trials have shown that interventions like “writing clubs” can improve performance in students struggling with these skills. Another validated approach is the self-regulated strategy development program that has shown generalized and sustained efficacy ( 45 ). This curriculum specifically instructs in strategies of writing and self-regulation with students acting as collaborators during the course. Students who continue with writing difficulties in middle and high school may require additional specific instruction in composition ( 46 , 47 ). Some psychoeducational programs ( Table 4 ), handwriting programs ( Table 5 ) and support groups ( Table 6 ) are useful resources for children with dysgraphia and their families and other professionals.

Name	Psychoeducation for parents
Understanding Dysgraphia: Fact Sheet	This brief document is an easy-to-read summary about dysgraphia and is published by the international dyslexia foundation ( )
What is Dysgraphia?	This webpage includes an overview of dysgraphia as well as links to resources for parents ( )
The Importance of Teaching Handwriting	This site includes information regarding different accommodations and modifications for dysgraphia ( )
Strategies for the Reluctant Writer	This page provides instruction on home-based writing intervention administered by parents ( )
TechMatrix	A database of assistive technology options (software and hardware) that includes stratification for grade and educational diagnosis ( )

Name	Handwriting supplemental programs
Zaner-Bloser	Apps, writing games, and other resources covering writing and reading ( )
Handwriting without Tears	A popular writing intervention program usable by parents or teachers ( )
Big Strokes for Little Folks	Suitable for students who have problems writing letters but can recognize them. Published by Psychological Corp.
Sensible Pencil	A program to teach letter writing, applicable in the home and school. Published by ATC Learning Company
Loops and Other Groups	A kinesthetic approach to teach writing in cursive ( )

Name	Support groups
Parent Center Network	A hub for providing support to parents of children with disabilities on a regional level ( )
Eye to Eye	A mentoring program that matches children and young adults who have similar learning and attention issues ( )

Conclusions

Writing is a skill that is central to learning and activities of daily living; it begins to develop in early childhood but continues through the school age. Though common in children, dysgraphia and disorders of written expression are often overlooked by the school and family as a character flaw rather than a genuine disorder. A variety of cognitive mechanisms have been proposed regarding the mechanism of dysgraphia and continued research is needed in the field to clarify the definition and etiology of the disorder. Regardless of the presenting symptoms, early diagnosis and intervention has been linked to improved results. Because of typical delay in the diagnosis of dysgraphia, the primary care provider can play an important role in recognizing the condition and initiating the proper work-up and intervention. Screening for co-morbid medical, neurodevelopmental, psychiatric and learning disorders is also an important function of the provider. Education and support for the family, coordination of care with the educational system, additional referrals to subspecialists, and follow-up screening for co-morbidities are important tasks for the primary care provider to adopt.

Acknowledgments

Funding: None.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Conflicts of Interest : DRP serves as the unpaid Deputy Editor-in-Chief of TP and the unpaid Guest Editor of the focused issue “Neurodevelopmental and Neurobehavioral Disorders in Children”. TP . Vol 9, Supplement 1 (February 2020). The other authors have no conflicts of interest to declare.

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99 Disorder of Written Expression (315.2)

Dsm-iv-tr criteria.

A. Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given the person’s chronological age, measured intelligence, and age-appropriate education.
B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g., writing grammatically correct sentences and organized paragraphs).
C. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.
Coding note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.

Associated features

This disorder was previously called developmental expressive writing disorder. This disabilitiy affects both the physical reproduction of letters and the organization of thoughts and ideas in written compositions. Disorder of written expression is one of the more poorly understood learning disorders. Learning disabilities that only manifested themselves in written work were first described in the late 1960’s. These early studies described three types of written disorders: 1.) Inability to form letters and numbers correctly, also called dysgraphia 2.) inability to form words spontaneously or form dictation 3.) inability to organize words into meaningful thoughts.
There are several in studying disorder of written expression and in implementing a remedial program. Disorder of written expression usually appears in conjunction with other reading and learning disorders, making it difficult to seperate manifestations of the disability related to only to written expression. Delays are noted in attention, visual-motor integration, visual processing, and expressive language.
Children with Disorder of Written Expression experience great difficulty with the use of their writing skills. The writing skills of these students are significantly lower than their peers according to a typical child’s age, acumen, and schooling. Writing complete sentences and forming adequate paragraphs are challenges for those with disorder of written expression. Also, the individuals with the disorder tend to make excessive errors and appear to have poor understanding in the areas of punctuation, grammar, and spelling. Some common symptoms of people with disorder of written expression include: poor or illegible handwriting, poorly formed letters or numbers, excessive spelling errors, excessive punctuation errors, excessive grammar errors, sentences that lack logical cohesion, paragraphs and stories that are missing elements and that do not make sense or lack logical conclusions, and dificient writing skills that significantly impact academic achievement or daily life.
Disorder of written expression is almost always associated with other learning disorders like a reading or mathematics disorder, and it is frequently accompanied by low self-esteem, social problems, increased rates of school dropout, conduct disorder, attention deficit disorder, and possibly depression. Often times, people assume because a person is diagnosed with a learning disability, such as disorder of written expression, the individual must also have lower intelligence. However, people diagnosed with disorder of written expression often have average or above average intelligence.

Child vs. adult presentation

Typically, an individual is diagnosed with disorder of written expression around the age of eight, which is usually around the time that children begin to read and write. Due to the fact that a child’s motor skills are still developing, the diagnosis is not usually made prior to age eight. Parents tend to recognize signs and symptoms of disorder of written expression in their children around grades four and five when writing skills become a big part in the classroom exercises. Ddsorder of written expression has no cure. Therefore, while the disorder is typically diagnosed in young children, it continues to be present throughout adulthood as well.

Gender and cultural differences in presentation

Most researchers say males are more commonly diagnosed with the disorder of written expression than females. In these cases, studies pertaining with learning disabilities, no significant gender difference has been found. On the other hand, general or special education teachers identify twice as many males than females. For the purpose of identifying cultural differences, a random sample of the population is tested, as well as the individualized testing that is performed to diagnose the disorder. Equally vital, is the inclusion of a similar socioeconomic and educational status for the participants that are being researched.

Epidemiology

Three to ten percent of school aged children in the United States are estimated to have disorder of written expression. Fifteen percent of the United States population are said to have a type of Learning Disability. When it is not comorbid with other learning disorders, a solitary experience with the disorder of written expression is extremely rare.
Deficits in written work may be attributed to a reading, language, or attention disorder, limited educational background, or lack of fluency in the language of the institution.
The cause of disorder of written expression is unknown because of lack of research surrounding the disorder. Certain facts support the idea that biological and environmental factors can contribute to learning disorders. Research has shown that high levels of testosterone in the fetus may cause language delays. Which could contribute to the idea that disorder of written expression is more prevalent in boys. Also, the particular conditions to which the fetus is exposed to while in utero may be linked to learning disorders, but not just specifically disorder of written expression. Environmental factors can also cause learning disorders, however, there is no certain cause of disorder of written expression.
There are different factors that could contribute to written expression disorder. Some of these factors include: prenatal, environmental, and intrinsic factors. Prenatal factors refer to potential toxins, infections, and/or nutritional deficits to a fetus. Intrinsic factors refers to neurobiology, biochemical, genetic, and other medical conditions.

Empirically supported treatments

There are no standard tests specifically designed to evaluate disorder of written expression.
Some tests that might be helpful in diagnosing disorder of written expression include the Diagnostic Evaluation of Writing Skills (DEWS), the Test of Early Written Language (TEWL), and the Test of Adolescent Language (TAL).
Intense writing remediation may help, but no specific method or approach has proved particularly successful. The person being evaluated should also perform tasks such as writing from dictation or copying written material as part of diagnostic testing.
The most effective treatment approach for disorder of written expression is remedial education. Because little is known about disorder of written expression, treatment is often aimed toward learning disorders that are more common or familiar. Noticeable improvement is frequently seen after treatment, but the degree to which one recovers depends on the severity of the disorder.
A qualified evaluator should compare multiple samples of the student’s written work with the written work normally expected from students of comparable backgrounds. The symptoms should be evaluated in light of a person’s age, intelligence, educational experience, and culture or life experience. Written expression must be substantially below the samples of produced by other’s of the same age, intelligence, and background.

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Disorder of written expression and dysgraphia: definition, diagnosis, and management

Affiliations.

1 Department of Pediatrics, University of California Irvine, Irvine, CA, USA.
2 Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, USA.
PMID: 32206583
PMCID: PMC7082241
DOI: 10.21037/tp.2019.11.01

Writing is a complex task that is vital to learning and is usually acquired in the early years of life. 'Dysgraphia' and 'specific learning disorder in written expression' are terms used to describe those individuals who, despite exposure to adequate instruction, demonstrate writing ability discordant with their cognitive level and age. Dysgraphia can present with different symptoms at different ages. Different theories have been proposed regarding the mechanisms of dysgraphia. Dysgraphia is poorly understood and is often undiagnosed. It has a high rate of co-morbidity with other learning and psychiatric disorders. The diagnosis and treatment of dysgraphia and specific learning disorders typically centers around the educational system; however, the pediatrician can play an important role in surveillance and evaluation of co-morbidity as well as provision of guidance and support.

Keywords: Dysgraphia; accommodation; disorder of written expression; modification; remediation; specific learning disorder.

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Conflict of interest statement

Conflicts of Interest: DRP serves as the unpaid Deputy Editor-in-Chief of TP and the unpaid Guest Editor of the focused issue “Neurodevelopmental and Neurobehavioral Disorders in Children”. TP. Vol 9, Supplement 1 (February 2020). The other authors have no conflicts of interest to declare.

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Case Studies of Fictional Characters

Disorder of written expression (315.2), dsm-iv-tr criteria.

A. Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given the person’s chronological age, measured intelligence, and age-appropriate education.
B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g., writing grammatically correct sentences and organized paragraphs).
C. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.
Coding note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.

Associated features

This disorder was previously called developmental expressive writing disorder. This disabilitiy affects both the physical reproduction of letters and the organization of thoughts and ideas in written compositions. Disorder of written expression is one of the more poorly understood learning disorders. Learning disabilities that only manifested themselves in written work were first described in the late 1960’s. These early studies described three types of written disorders: 1.) Inability to form letters and numbers correctly, also called dysgraphia 2.) inability to form words spontaneously or form dictation 3.) inability to organize words into meaningful thoughts.
There are several in studying disorder of written expression and in implementing a remedial program. Disorder of written expression usually appears in conjunction with other reading and learning disorders, making it difficult to seperate manifestations of the disability related to only to written expression. Delays are noted in attention, visual-motor integration, visual processing, and expressive language.
Children with Disorder of Written Expression experience great difficulty with the use of their writing skills. The writing skills of these students are significantly lower than their peers according to a typical child’s age, acumen, and schooling. Writing complete sentences and forming adequate paragraphs are challenges for those with disorder of written expression. Also, the individuals with the disorder tend to make excessive errors and appear to have poor understanding in the areas of punctuation, grammar, and spelling. Some common symptoms of people with disorder of written expression include: poor or illegible handwriting, poorly formed letters or numbers, excessive spelling errors, excessive punctuation errors, excessive grammar errors, sentences that lack logical cohesion, paragraphs and stories that are missing elements and that do not make sense or lack logical conclusions, and dificient writing skills that significantly impact academic achievement or daily life.
Disorder of written expression is almost always associated with other learning disorders like a reading or mathematics disorder, and it is frequently accompanied by low self-esteem, social problems, increased rates of school dropout, conduct disorder, attention deficit disorder, and possibly depression. Often times, people assume because a person is diagnosed with a learning disability, such as disorder of written expression, the individual must also have lower intelligence. However, people diagnosed with disorder of written expression often have average or above average intelligence.

Child vs. adult presentation

Gender and cultural differences in presentation

Epidemiology

Three to ten percent of school aged children in the United States are estimated to have disorder of written expression. Fifteen percent of the United States population are said to have a type of Learning Disability. When it is not comorbid with other learning disorders, a solitary experience with the disorder of written expression is extremely rare.
Deficits in written work may be attributed to a reading, language, or attention disorder, limited educational background, or lack of fluency in the language of the institution.
The cause of disorder of written expression is unknown because of lack of research surrounding the disorder. Certain facts support the idea that biological and environmental factors can contribute to learning disorders. Research has shown that high levels of testosterone in the fetus may cause language delays. Which could contribute to the idea that disorder of written expression is more prevalent in boys. Also, the particular conditions to which the fetus is exposed to while in utero may be linked to learning disorders, but not just specifically disorder of written expression. Environmental factors can also cause learning disorders, however, there is no certain cause of disorder of written expression.
There are different factors that could contribute to written expression disorder. Some of these factors include: prenatal, environmental, and intrinsic factors. Prenatal factors refer to potential toxins, infections, and/or nutritional deficits to a fetus. Intrinsic factors refers to neurobiology, biochemical, genetic, and other medical conditions.

Empirically supported treatments

There are no standard tests specifically designed to evaluate disorder of written expression.
Some tests that might be helpful in diagnosing disorder of written expression include the Diagnostic Evaluation of Writing Skills (DEWS), the Test of Early Written Language (TEWL), and the Test of Adolescent Language (TAL).
Intense writing remediation may help, but no specific method or approach has proved particularly successful. The person being evaluated should also perform tasks such as writing from dictation or copying written material as part of diagnostic testing.
The most effective treatment approach for disorder of written expression is remedial education. Because little is known about disorder of written expression, treatment is often aimed toward learning disorders that are more common or familiar. Noticeable improvement is frequently seen after treatment, but the degree to which one recovers depends on the severity of the disorder.
A qualified evaluator should compare multiple samples of the student’s written work with the written work normally expected from students of comparable backgrounds. The symptoms should be evaluated in light of a person’s age, intelligence, educational experience, and culture or life experience. Written expression must be substantially below the samples of produced by other’s of the same age, intelligence, and background.
Abnormal Psychology: An e-text!. Authored by : Dr. Caleb Lack. Located at : http://abnormalpsych.wikispaces.com/ . License : CC BY-NC-SA: Attribution-NonCommercial-ShareAlike

case study disorder of written expression

Vol 9, Supplement 1 (February 22, 2020): Translational Pediatrics (Neurodevelopmental and Neurobehavioral Disorders in Children) /

Disorder of written expression and dysgraphia: definition, diagnosis, and management

Peter J. Chung 1 , Dilip R. Patel 2 , Iman Nizami 2

1 Department of Pediatrics, University of California Irvine , Irvine, CA , USA ; 2 Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker MD School of Medicine , Kalamazoo, MI , USA

Contributions: (I) Conception and design: All authors; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: None; (V) Data analysis and interpretation: None; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Abstract: Writing is a complex task that is vital to learning and is usually acquired in the early years of life. ‘Dysgraphia’ and ‘specific learning disorder in written expression’ are terms used to describe those individuals who, despite exposure to adequate instruction, demonstrate writing ability discordant with their cognitive level and age. Dysgraphia can present with different symptoms at different ages. Different theories have been proposed regarding the mechanisms of dysgraphia. Dysgraphia is poorly understood and is often undiagnosed. It has a high rate of co-morbidity with other learning and psychiatric disorders. The diagnosis and treatment of dysgraphia and specific learning disorders typically centers around the educational system; however, the pediatrician can play an important role in surveillance and evaluation of co-morbidity as well as provision of guidance and support.

Keywords: Dysgraphia; specific learning disorder; disorder of written expression; accommodation; remediation; modification

Submitted Oct 22, 2019. Accepted for publication Oct 30, 2019.

doi: 10.21037/tp.2019.11.01

Introduction: definitions and disagreement

In the United States, the Individuals with Disabilities Education Act (IDEA) revised in 2004 broadly defines “Specific Learning Disability” in the following manner ( 7 ):

The child does not achieve adequately for the child’s age or to meet State-approved grade-level standards in one or more of the following areas, when provided with learning experiences and instruction appropriate for the child’s age or State-approved grade–level standards: Oral expression, listening comprehension, written expression, basic reading skills, reading fluency skills, reading comprehension, mathematics calculation, or mathematics problem solving.
The child does not make sufficient progress to meet age or State-approved grade-level standards in one or more of the areas when using a process based on the child’s response to scientific, research-based intervention; or the child exhibits a pattern of strengths and weaknesses in performance, achievement, or both, relative to age, State-approved grade-level standards, or intellectual development, that is determined by the group to be relevant to the identification of a specific learning disability, using appropriate assessments; and the group determines that its findings are not primarily the result of a visual, hearing, or motor disability; mental retardation; emotional disturbance; cultural factors; environmental or economic disadvantage; or limited English proficiency.

Writing development

Mechanisms and etiology

Co-morbidities

Accommodations

Modifications

Remediation

Conclusions

Acknowledgments

Funding: None.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Written Language Disorders

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See the Written Language Disorders (School-Age) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

The scope of this Practice Portal page is limited to written language disorders (i.e., disorders of reading and writing) in preschool and school-age children (3–21 years old). It can be understood best in relation to the companion Practice Portal on Spoken Language Disorders .

A disorder of written language involves a significant impairment in fluent word reading (i.e., reading decoding and sight word recognition), reading comprehension , written spelling , and/or written expression (Ehri, 2000; Gough & Tunmer, 1986; Kamhi & Catts, 2012; Tunmer & Chapman, 2007, 2012). A word reading disorder is also known as dyslexia .

An appropriate assessment and treatment of written language disorders often incorporates interprofessional education/interprofessional practice (IPE/IPP) . Members of the interprofessional practice team may include, but are not limited to, the following:

reading specialist
occupational therapist
special educator
learning specialist
physical therapist
speech-language pathologist
“English as a second language” teacher

Written language disorders, as with spoken language disorders, can involve any or a combination of the five language domains (i.e., phonology, morphology, syntax, semantics, and pragmatics) as well as the spelling system of a language, or orthography . Problems can occur in the awareness, comprehension, and production of language at the phonemic, syllable, word, sentence, and discourse levels, as indicated below (Nelson, 2014; Nelson et al., 2015). In cases of dyslexia, phonological processing problems are a core deficit (Hogan et al., 2005; Seidenberg, 2017). See ASHA's resources on Disorders of Reading and Writing and Language In Brief for further information.

Sound-, Syllable-, and Word-Level Difficulties

Difficulty with phonological and morphological structures of words
Difficulty forming stable associations with the orthographic representations of words and letters in print
Impaired reading decoding and written spelling skills

Sentence- and Discourse-Level Difficulties

Difficulty recognizing discourse components
Difficulty using syntax and cohesive devices to represent relationships among ideas
Impaired reading comprehension and formulation of academic discourse (narrative and expository) and social communication

A relationship may exist between language disorders and learning disabilities, as indicated in the following definition of specific learning disability :

The term “specific learning disability” means a disorder in one or more of the psychological processes involved in understanding or in using language, spoken or written, which may manifest itself in an imperfect ability to listen, speak, read, write, spell, or do mathematical calculations. (Individuals with Disabilities Education Improvement Act of 2004)

A learning disability label may be used once academic struggles with reading and writing are identified, even though the underlying issue is a language disorder (Sun & Wallach, 2014).

A written language disorder may occur in the presence of other conditions, such as the following:

spoken language disorder
attention-deficit/hyperactivity disorder
emotional disability
intellectual disability
deaf or hard of hearing
autism spectrum disorder

Relationship Between Spoken and Written Language in Alphabetic Systems

There are strong relationships between spoken and written language, such as the role of phonological awareness in decoding as well as the roles of vocabulary and syntax in reading (e.g., Hulme & Snowling, 2013; Kamhi & Catts, 2012). These relationships are underscored in the simple (or narrow) view of reading , which includes decoding and linguistic comprehension as the primary components (Gough & Tunmer, 1986). Understanding the relationships of spoken and written language is key to developing reading comprehension skills (Tunmer & Chapman, 2012) as well as developing automatic retrieval (for spelling) and automatic identification (for reading; Ehri, 2014; Richards et al., 2006).

Children need strong knowledge of both spoken and written language in order to be successful readers and writers. Children with spoken language problems frequently have difficulty learning to read and write, and conversely, children with reading and writing problems often have difficulty with spoken language (Kamhi & Catts, 2012). For more details, see the Practice Portal page on Spoken Language Disorders ; see also Language In Brief and Disorders of Reading and Writing .

Reading is the process by which an individual constructs meaning by transforming printed symbols in the form of letters or visual characters into recognizable words. Components of reading are outlined in the following definitions:

Word recognition —the ability to identify words when reading, either through word decoding or sight word identification
Phonological decoding —the ability to transform letter strings into the phonological components of a corresponding spoken word
Sight word identification —automatic visual recognition of a word and its meaning
Reading fluency —the ability to recognize and read words within a text with accuracy, using appropriate intonation, rhythm, and speed
Reading fluency is affected by reading automaticity , which is the ability to read a list of words serially and accurately within a specified time.
Reading fluency combines rapid decoding and sight word identification.
Reading comprehension —the ability to understand the meaning of written text
Comprehension includes vocabulary knowledge, using morphological structures of written words to extract word meaning, using cues to “unpack” complex syntax, and understanding different discourse structures (e.g., fiction or expository text).
Comprehension requires executive function skills (e.g., the ability to use prior knowledge and make inferences and predictions, the ability to monitor one’s reading comprehension).

For information about research supporting the five key components of reading instruction (i.e., phonemic awareness, phonics, fluency, vocabulary, and text comprehension), see the National Reading Panel report (National Institute of Child Health and Human Development, 2000).

Writing is the process of communicating ideas using printed symbols in the form of letters or visual characters, which make up words. Words are formulated into sentences; these sentences are organized into larger paragraphs and often into different discourse genres (narrative, expository, persuasive, poetic, etc.).

Writing includes the following:

Writing process —the ability to plan, organize, draft, reflect on, revise, and edit written text; the ability to address specific audience needs and convey the purpose of the text (e.g., persuasion)
Written product —the end product of the writing process

The written product may be described in terms of the following components:

Word level —word choice, spelling, morphology
Sentence level —syntax and complexity, content and punctuation
Text level —organizational structure, coherence and cohesiveness
Writing conventions —capitalization and punctuation of a written product
Communication functions —to inform, to persuade
Organizational structure —chronological, sequential, compare and contrast
Effectiveness in meeting the information needs of the audience

Handwriting difficulties can have an impact on a child’s ability to spell words in writing, express thoughts adequately in writing, and complete writing tasks in a timely manner. Developmental handwriting difficulties are associated with deficits in orthographic coding, which involves mapping the abstract representation of letters to the motor movements used to write words (McCloskey & Rapp, 2017). It is important to provide accommodations during assessment and for instruction if the child or adolescent has been diagnosed as or is suspected of having a handwriting disorder. Occupational therapists can be consulted on a case-by-case basis to recommend appropriate accommodations (e.g., permitting use of a keyboard or providing a scribe). However, handwriting is not only a motor skill; it is also a written language skill, and handwriting instruction may be integrated with reading and writing instruction when appropriate.

Spelling , or phonological encoding , is the process of mapping from phoneme to grapheme to spell the spoken word in written form. Spelling requires the ability to segment words into phonemes (units of sound that distinguish one word from another, e.g., /k/ as in / k ʌp /) and the ability to map those phonemes onto graphemes (units of letters that represent sounds, e.g., “c” as in “cup”) in the correct order in written form. Words may be spelled regularly (i.e., follow traditional spelling conventions) or irregularly (i.e., do not follow traditional spelling conventions). In addition, children learn spelling or graphotactic rules often taught through phonics instruction (Treiman, 2018). Only about 4% English words are irregular, and English spelling is more predictable when considering language of origin and history, meaning and part(s) of speech, speech sound spelling patterns, and word position constraints (Moats, 2005/2006).

Difficulty or progress in either spelling or the foundational language knowledge areas that support it can influence word-level reading, reading comprehension, and writing composition (Apel, 2009). Given the interconnectedness of spelling and the language areas above, spelling ability affects other areas of literacy. This interconnectedness also helps explain why individuals could be adept at reading and still have challenges with spelling and/or writing.

Foundational language knowledge areas that support spelling include the following:

Phonological knowledge —the conscious and active recognition and manipulation of individual sounds (phonemes) in words. It supports spelling when phonological knowledge is used to segment words into individual phonemes to spell unknown words (Kamhi & Catts, 2012).
Orthographic pattern knowledge includes the set of patterns or conventions that govern the translation of speech into print. This may include knowledge of letter sounds (e.g., “j,” “g,” “gde” for /ʤ/), permissible letter combinations (e.g., “qu,” not “qw”), rules for spelling roots and base words (e.g., “strike” and “made” have a long vowel and a silent “e”), and positional constraints for letters across word positions (e.g., “pr” is typically found only in initial and medial positions).
Mental graphemic representations ( MGRs) or mental orthographic images refer to mental images of written words or word parts stored in the mental orthographic lexicon. When MGRs or mental orthographic images are strong, spellers (and readers) perform fluently and accurately without expending cognitive energy for composition or decoding.
Semantic knowledge relates to the recognition of how meaning impacts spelling. Writers use semantic knowledge to explicitly consider how spelling is influenced by meaning, and vice versa (“there”/“their”/“they’re”). With this knowledge, writers can choose accurate spellings of words to convey their intended meaning (Kamhi & Catts, 2012).
Morphological knowledge helps spellers direct explicit attention to the morphemic structure of words. This includes changes that occur when morphemes are added to base words (“hop” to “hopped,” doubling the “p”), the relationship between morphological word families (“read”: “reread,” “reader,” “nonreader,” “reading,” “reads,” “unreadable”), and recognition of the fixed spelling of affixes ( anti– , sub– , –ed , –ness ; Kamhi & Catts, 2012).

Spelling depends on phonological awareness, orthographic pattern awareness, and semantic/morphological awareness; conscious (explicitly taught) and subconscious (statistically learned) knowledge of phonological, orthographic, and morphological representations of words and their parts; the development of orthographic representations (also called “MGRs” and “mental images”) of specific words and word parts in long-term memory (called the orthographic lexicon ); and the ability to create mental models of their interrelationships (e.g., Apel & Masterson, 2001; Berninger et al., 2008; Bourassa & Treiman, 2001; Ehri, 2000; Masterson & Apel, 2007).

Reading and Writing Across Languages and in Dual Language Learners (DLLs)

Writing systems across languages vary in their spelling-to-sound relations or grapheme–phoneme consistency. Extensive research indicates that readers in consistent or shallow orthographies (e.g., Spanish, Finnish, Greek) have an advantage during the early stages of reading for the establishment of spelling-to-sound relations or decoding (Caravolas et al., 2019; Seymour et al., 2003; Spencer & Hanley, 2004). DLLs can effectively learn to read and write across languages following a biliteracy approach (August & Shanahan, 2006; Butvilofsky et al., 2016). For DLLs with reading difficulties, biliteracy can afford the benefits of a shallow orthography during the early stages of reading. That is, the consistency in spelling-to-sound relations can facilitate decoding and phonological awareness in struggling DLL readers.

Incidence and Prevalence

Incidence of written language disorders refers to the number of new cases identified in a specified time period. Prevalence of written language disorders refers to the number of people who are living with the condition in a given time period.

Incidence and prevalence of written language disorders vary across research studies due to differences in participant characteristics, study designs, methodology (e.g., different outcomes measured), and diagnostic classification criteria within and across subtypes of written language disorder.

Reading and Writing Disorders

Based on a population-based birth cohort in Rochester, Minnesota, between 5.3% and 11.8% of children and adolescents were estimated to have a reading disorder (Katusic et al., 2001), and between 6.9% and 14.7% were estimated to have a writing disorder by 19 years of age (Katusic et al., 2009). In an epidemiological study that involved 493 participants, Catts, Compton, et al. (2012) estimated that approximately 32% of the participants in the study experienced reading difficulties that could be considered a reading disability at one or more grades. Of the 32% of participants with reading difficulties, 6% had early reading problems, 52% were persistent poor readers (i.e., poor readers throughout all grades), and 42% were late poor readers (i.e., reading problems were evident after the fourth grade). Many poor readers, however, do not always qualify as having reading disorders.

Co-Occurring Speech and Language Impairments

Higher rates of all forms of written language disorders have been documented in children with speech and/or language impairments. By the end of kindergarten, more than 25% of children with language impairment were reported to also be poor readers (Murphy et al., 2016). Additionally, Stoeckel et al. (2013) compared the cumulative incidence of written language disorder by the age of 19 years in children with and without speech and/or language impairments. The findings revealed higher incidences of writing disorders with accompanying reading disorders as well as writing disorders alone among children with communication impairments (see Table 1).

	Individuals speech and/or language impairments	Individuals speech and/or language impairments
	9.1%	4.1%
reading disorder	50.1%	9.9%

Table 1. Rates of written language disorder in children with and without speech and/or language impairments.

Additional Considerations

Studies reported results based on gender; however, there were no indications on whether the data collected were based on sex assigned at birth, gender identity, or both. Males were estimated to be 1.83 times more likely than females to be identified with reading problems. Findings also indicated that the gender differences between males and females increased with more severe reading problems (Quinn, 2018). Based on Stoeckel et al. (2013), the cumulative incidence of written language disorder was also higher in males compared to females, including those with (61.4% vs. 55.1%) and those without (18.5% vs. 9.4%) speech and/or language impairments.

Attention-Deficit/Hyperactivity Disorder (ADHD)

Children with ADHD have demonstrated a greater risk for written language disorder and/or reading disability. By 19 years of age, the cumulative incidences of written language disorder with an accompanying reading disability and written language disorder alone were estimated to be 45.9% and 16.6%, respectively, in children with ADHD (Yoshimasu et al., 2011). Similarly, the cumulative incidence of reading disability was revealed to be significantly higher in children with ADHD (51% in boys, 46.7% in girls; Yoshimasu et al., 2010).

Autism Spectrum Disorder

Mayes and Calhoun (2006) revealed that 60% of children with autism without intellectual disability had a learning disability in written expression. Learning disabilities in reading and spelling among children with autism were indicated to be lower, with 6% and 9%, respectively. Although children with autism without intellectual disability were found to have similar rates of reading disability as the general population, findings from Baixauli et al. (2021) indicated that adolescents with autism who do not have an intellectual disability performed significantly poorer on reading comprehension tasks requiring cognitive flexibility (e.g., perception, conflict monitoring).

Youth in the Juvenile Justice System

Youth with reading disabilities were found to be prevalent in the juvenile justice system. According to a British study, approximately 43%–57% of participating juvenile offenders could be classified with a reading disability. Almost 39% of juvenile offenders demonstrated phonological difficulties, a skill associated with reading development (Snowling et al., 2000).

Signs and Symptoms

Signs and symptoms of written language disorders vary across individuals, depending on the language domain(s) affected, severity and level of disruption to communication, age of the individual, and stage of linguistic development.

In preschool and kindergarten, children who are at risk for reading disorders are likely to have difficulty with phonological awareness and phonics (Torgesen, 2002, 2004). This problem may continue as they work to develop the skills they need for accurate and fluent word recognition.

Some children are identified as having reading difficulties only when they reach higher elementary grades (fourth grade and above), when the focus of reading changes from “learning to read” to “reading to learn” (Chall, 1983) and the emphasis shifts from word recognition and spelling to reading comprehension and use of reading comprehension strategies (Leach et al., 2003).

Poor reading comprehension test scores in these post-primary grades can be the first indicators of reading problems. These difficulties are likely to be accompanied by weak higher order comprehension skills in areas such as metacognitive awareness (e.g., Anderson, 1980; Wong & Wong, 1986) and use of strategies to aid comprehension (e.g., Hare & Pulliam, 1980; Kletzein, 1991). Comprehension difficulties also may reflect mild or well-disguised reading acquisition problems (e.g., word-level reading skills) that become more severe with increasing word-level decoding demands (e.g., Juel, 1991; LaBerge & Samuels, 1974; Perfetti, 1985; Salceda et al., 2013).

See Signs and Symptoms of Written Language Disorders . Be mindful that some signs and symptoms may be influenced by cultural and linguistic variations and are not indicative of a disorder.

Language-Based Causes

Reading is a language-based skill that relies heavily on an individual’s phonological, semantic, syntactic, and pragmatic knowledge; thus, weaknesses in one or more of these aspects of language could negatively impact the ability to read (Kamhi & Catts, 2012). Children with reading disorders may have difficulty with the following:

Phonological awareness —attending to the sound structure of speech for analysis and manipulation. The term phonemic awareness is used when the units being manipulated are phonemes.
Phonological retrieval —recalling phonological information (phonemes associated with specific graphemes). Difficulties may include substitutions, circumlocutions, or overuse of nonspecific words.
Phonological memory —encoding and storage of phonological information in memory, also known as phonological coding.
Phonological production —speech production abilities, including producing complex speech sound sequences.
Receptive and expressive vocabulary (Wise et al., 2007)
Use and comprehension of morphology and syntax (Rispens et al., 2004)
Production and comprehension of text-level language (Hagtvet, 2003)

The primary cause of word-level reading difficulties is phonological processing deficits (e.g., Kamhi & Catts, 2012; Torgesen et al., 1997; Wagner & Torgesen, 1987). Comprehension difficulties can result from word-level reading problems, language deficits, knowledge deficiencies, and many other factors (e.g., engagement, interest, motivation, and attention; Kamhi & Catts, 2012; Snow, 2010). Children with a history of oral language difficulty are at high risk for difficulty learning to read and write (Kamhi & Catts, 2012). Most children learn to read without much difficulty; their early literacy experiences support the development of skills needed for learning to read and write. Other children have more limited literacy experiences but go on to develop written language skills given appropriate high-quality instruction (e.g., Justice et al., 2003, 2008; Scanlon & Vellutino, 1996, 1997).

Successful reading skills depend on adequate language development; therefore, language weaknesses can result in reading difficulties (e.g., weak sound–symbol correspondence, decreased reading comprehension, difficulty planning and organizing written products). However, the relationship between reading skills and language skills is reciprocal—reading weaknesses can also result in language difficulties (e.g., weak phonological awareness skills, restricted vocabulary development, reduced ability to use text to demonstrate comprehension).

External Factors

External factors are environmental variables that can have a negative impact on the child’s reading acquisition. They include the following:

Limited early literacy experience, such as shared picture book reading, can adversely affect language development by reducing children’s exposure to vocabulary, advanced grammar, and narrative discourse (Stothard et al., 1998). In addition, early literacy experiences expose children to increased awareness of print with positive effects on later reading.
Insufficient and/or inadequate reading and writing instruction (Vellutino et al., 1996).
Insufficient early oral language experience that is too constrained to support the acquisition of literacy (Hoff, 2013).
Low socioeconomic status is associated with late reading difficulties (Kieffer, 2010). In the National Assessment of Educational Progress (2019) report, the lowest reading scores across the nation were among students living in poverty.
Matthew effects (Duff et al., 2015; Stanovich, 1986; Wood et al., 2020)—negative consequences associated with low performance in reading and writing (e.g., child is in a low-ability group) that can lead to low expectations, poor motivation, and limited practice, which affect written language development.

Internal Factors

Internal factors are those particular to a child. They include genetic and neurological factors as well as spoken language deficits (see the relationship between spoken and written language in the Overview section of this page).

Studies comparing identical and fraternal twins report a higher co-occurrence of reading disabilities in identical twins than in fraternal twins (DeFries & Alarcón, 1996; J. G. Light & DeFries, 1995). Genetic influences are reflected in early reading performance, but environmental factors (e.g., family and school) can influence subsequent growth in early reading skills (Petrill et al., 2010).

Neurological basis —Differences in brain structure and function have been found in individuals with reading disabilities as compared with typical readers, although the relationship is not clear. It may be that some differences are the result—rather than the cause—of reading problems (Catts, Kamhi, & Adlof, 2012).
Structural differences include the following:
Atypical patterns of symmetry in the temporal lobe (e.g., Galaburda, 1988)
Presence of focal dysplasias in the cortex (Galaburda, 1991)
Differences in the corpus callosum (e.g., Duara et al., 1991), inferior parietal lobe (e.g., W. E. Brown et al., 2001), and cerebellum (e.g., Eckert et al., 2003)
Atypical structure and/or function in the inferior frontal cortex, superior temporal cortex, temporoparietal cortex, and occipitotemporal cortex (Ozernov-Palchik et al., 2016)
Functional differences include the following:
Less left-hemisphere dominance than typical readers (see Bryden, 1982; Gerber, 1993)
Differences in activation (overactivation or underactivation) in various brain regions (e.g., Hoeft et al., 2011; Meyler et al., 2008; Richlan et al., 2009; Shaywitz et al., 1998; Temple et al., 2001)

Visually based deficits, auditory processing deficits, and attention-based deficits have often been proposed as core causes for reading disabilities, but they can also be part of comorbid disorders (see Catts et al., 2012; Hendren et al., 2018).

Visually based deficits include reversal errors (e.g., reading or writing “b” for “d”), erratic eye movements (e.g., more or longer fixations than typical readers), and transient processing deficits (i.e., problems processing global visual features). There is no general support that visually based deficits cause reading disabilities (Handler & Fierson, 2017). In fact, these “deficits” may reflect typical development (reversal error) or cognitive processing difficulties (erratic eye movements) during reading—or may be linked to phonological processing deficits (transient processing deficits).
Auditory processing deficits include deficits in auditory perception (e.g., problems perceiving rapid sound changes) and lack of sensitivity to syllable-level prosodic information. Research findings are inconsistent regarding the presence of auditory processing deficits in poor readers and whether these deficits are sufficient to cause reading problems.
Attention-based deficits (particularly inattention) are thought to be associated with reading difficulties because reading demands significant attention. However, research does not support a causal relationship. Although attention deficits and reading difficulties can co-occur, they appear to be distinct developmental disorders with different causes. When they co-occur, inattention may contribute to reading comprehension difficulties. Attention deficits related to reading difficulty have been found in auditory and visual domains and may contribute to phonological deficits (Hendren et al., 2018).

Roles and Responsibilities

Speech-language pathologists (SLPs) play a critical and direct role in the development of literacy in children and adolescents and in the diagnosis, assessment, and treatment of written language disorders, including dyslexia, given that

SLPs have unique knowledge about the subsystems of language as they relate to spoken and written language and knowledge of the metalinguistic skills required for reading and writing (e.g., phonological, semantic, orthographic, and morphological awareness);
spoken language provides the foundation for the development of reading and writing abilities;
spoken and written language are interconnected at every level;
children with spoken language problems and with language impairment often have difficulty learning to read and write; and
instruction in one modality (spoken or written) can influence growth in the other modality.

The following roles and activities for SLPs include clinical services (assessment, diagnosis, planning, and treatment); prevention and advocacy; and education, administration, and research (ASHA, 2016):

Providing prevention information to individuals and groups known to be at risk for written language disorders as well as to individuals working with those at risk
Helping to prevent written language problems by fostering language acquisition and emergent literacy
Being involved in initiatives (e.g., response to intervention [ RTI ]) to prevent academic failure as a result of reading and writing difficulties
Establishing collaborative partnerships with teachers, administrators, reading specialists, and others to foster literacy acquisition among students at risk for or experiencing reading and writing disorders
Educating other professionals on the needs of persons with written language disorders and the role of SLPs in diagnosing and managing these disorders
Participating in activities that will result in early identification of language-based difficulties that put young children (preschool through kindergarten) at risk for literacy problems
Screening individuals at risk for reading and writing difficulties, including determining the need for further assessment and/or referral for other services
Considering whether students who are already being treated for spoken language difficulties might require assessment related to reading and writing
Conducting a comprehensive, culturally and linguistically appropriate assessment of written language skills, including performance in additional language(s) as applicable (reading and writing)
Understanding the influences of additional languages or dialects on reading and writing
Understanding potential situational bias and test-item bias in assessment
Diagnosing disorders of reading and writing—including dyslexia—and describing the relationship between these disorders and the student’s spoken language difficulties
Referring to other professionals to rule out other conditions, determine etiology, and facilitate access to comprehensive services
Making decisions about the management of written language disorders
Making recommendations for a multitiered system of supports (e.g., RTI ) in the schools to support speech and language development
Developing culturally and linguistically appropriate treatment plans, providing treatment, documenting progress, and determining appropriate dismissal criteria
Using appropriate materials to promote biliteracy and strengthen oral language skills in additional language(s)
Counseling persons with written language disorders and their families regarding communication-related issues and providing education aimed at preventing further complications relating to written language disorders
Consulting and collaborating with other professionals, family members, caregivers, and others to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate
Serving as a member of the interprofessional team within the schools and providing a focus on the language underpinnings of the curriculum to help students meet state curriculum standards (see Interprofessional Education/Interprofessional Practice [IPE/IPP] )
Remaining informed of research in the area of written language disorders and helping advance the knowledge base related to the nature and treatment of these disorders
Advocating for individuals with written language disorders and their families at the local, state, and national levels
Providing quality control and risk management

As indicated in the Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so.

The role of the SLP in literacy intervention may vary by setting and availability of other professionals (e.g., reading teacher and resource personnel) who also provide written language intervention. Regardless of the SLP’s specific role, it is important that intervention be collaborative. For example, the SLP can be part of the team helping to implement Common Core State Standards in English Language Arts (Common Core State Standards Initiative, 2010).

See the Assessment section of the Written Language Disorders (School-Age) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Screening of written language skills is conducted if a reading or writing disorder is suspected. It may be triggered by parent and/or teacher concerns about the child’s reading and writing performance or the child’s failure to meet response to intervention (RTI) criteria.

Screening indicates the potential need for further assessment but does not result in a diagnosis. It typically includes

administering formal screening measures with demonstrated evidence of adequate sensitivity and specificity;
using informal measures such as those designed by the clinician or published and tailored to the population being screened (for a discussion of nonstandardized methods to help quantify specific reading and writing skills, see Paul & Norbury, 2012);
using elicitation and analysis of language samples, writing samples, and dynamic assessment across languages in dual language learners (DLLs) and in students who use additional varieties of English (e.g., African American English [AAE]);
observing literacy activities in the classroom and obtaining information from the classroom teacher and parents;
collecting progress-monitoring data from RTI services and examining RTI criteria that have not been met;
screening articulation and phonology, if indicated; and
screening spoken language.

A hearing screening should be conducted to rule in or rule out hearing loss so that it can be considered during the assessment. If the child wears glasses, then they should wear the glasses during testing, and any necessary visual accommodations should be made (e.g., large-print stimuli or other magnifications, lighting modifications).

Screening may result in

collaboration with classroom teachers to provide facilitative instruction in phonological awareness, spelling, or vocabulary (i.e., pre-referral intervention);
recommendation for comprehensive language assessment (including both spoken and written language);
recommendation for comprehensive speech sound assessment, if the child’s speech sound system is not appropriate for their age;
referral for a complete audiologic assessment;
referral for a vision exam if observations during screening suggest possible visual acuity problems;
referral for assessments by a physical therapist and/or an occupational therapist if observations of handwriting during screening suggest possible motor or motor programming problems; and
referral to a language-matched bilingual service provider or securing an interpreter to assist in bilingual assessment, as warranted.

Comprehensive Assessment

Assessment of reading and writing skills should be linguistically appropriate, culturally relevant, and functional. It involves the collaborative efforts of families/caregivers, classroom teachers, SLPs, special educators, and other professionals as needed. A cross-disciplinary/interdisciplinary framework for assessment (and treatment) is encouraged (Berninger, 2015; Silliman & Berninger, 2011). See Collaboration and Teaming and Assessment and Evaluation of Speech-Language Disorders in Schools . Also, please see ASHA’s Practice Portal pages on Cultural Responsiveness , Multilingual Service Delivery in Audiology and Speech-Language Pathology , and Collaborating With Interpreters, Transliterators, and Translators .

For information about specific reading and writing disorders, including differential diagnosis considerations, see Disorders of Reading and Writing .

Both formal and informal assessment activities are used, discussed as follows:

Formal tests of written language may be administered by the SLP or another member of the special education team (e.g., special education teacher or reading specialist). When another member of the team administers the tests, the SLP works collaboratively to coordinate assessments and interpret the results. When possible, the SLP uses measures of oral and written language that have been co-normed on the same standardization samples so that their results may be compared directly. This allows for a more integrated approach to the assessment of language and literacy skills (Nelson, 2014; Nelson et al., 2015).
Informal activities can include observations of students engaged in literacy activities and assessment of writing samples from curriculum-based activities. One advantage of informal curriculum-based assessment is that the SLP then can introduce and develop instructional techniques to see how the student responds. These dynamic assessment techniques can lead directly into intervention.

See Assessment Tools, Techniques, and Data Sources for procedures and data sources that may be used in assessment.

Assessment of reading and writing skills takes into consideration the child’s developmental stage, language(s) used, and expected literacy skills, based on age or grade. Typical components of a comprehensive assessment for disorders of reading and writing include the following.

Case History

History of speech, language, and/or literacy difficulties in the family
History of hearing or vision problems
Language(s) used in home, including spoken language(s) and preferred written language(s)
Developmental milestones
Child’s interest in reading and writing activities
Beliefs about the importance of literacy and literacy-building activities
Family’s and teacher’s concerns about the child’s reading and writing skills

See the ASHA Practice Portal page on Cultural Responsiveness for guidance on taking a case history with all clients.

Hearing Screening

This is conducted if not completed during screening. See ASHA’s Practice Portal page on Childhood Hearing Screening .

Spoken Language Assessment

See the Assessment section of the ASHA Practice Portal page on Spoken Language Disorders .

Speech Sound Assessment (If Indicated)

See the Assessment section of the ASHA Practice Portal page on Speech Sound Disorders: Articulation and Phonology .

Phonological Processing

This includes the following:

Assessment tasks include speech sound segmentation and blending at the word, onset–rime, syllable, and phonemic levels.
Assessment tasks include phonological retrieval, which can be assessed by rapid naming tasks (e.g., rapid naming of letters and numbers).
Assessment tasks include nonword repetition (e.g., repeat /pæg/).
Assessment tasks may include producing complex speech sound sequences (Kamhi & Catts, 2012).

Social Communication (If Indicated)

See the Assessment section of the ASHA Practice Portal page on Social Communication Disorder .

Curriculum-Based Assessment

Analyze the language demands of curricular activities.
Observe the student as they attempt curricular activities without assistance.
Identify gaps between the demands of the task and the abilities of the student.

Literacy Assessment

This includes basic and higher-level reading, writing, and spelling skills, listed roughly in developmental order.

The purpose of reading assessment across languages is to identify reading processes that are difficult for the child, such as decoding, identifying words, accessing word meanings, and the automaticity of these processes. The interconnections between oral and reading fluency, language use, and language of instruction must be considered when planning assessment.

One of the challenges of identifying reading disorders in DLLs is that they cannot be compared to monolingual readers (Caravolas et al., 2019). Most formal reading assessments are normed on monolingual readers, and caution must be exercised. A reading assessment for DLLs should take place in the language of reading instruction and include oral reading discrepancies across modalities (e.g., decoding, word recognition, fluency, reading comprehension; Ijalba et al., 2020). The following are components of reading evaluation:

Print awareness —recognizing that books have a front and a back and that the direction of words is from left to right; recognizing where words on the page start and stop; recognizing word boundaries; recognizing environmental signs or logos.
Phonological awareness —including phonemic awareness; rhyming, blending, and segmenting; manipulating syllables and sounds.
Alphabet knowledge —including naming alphabetic letters from A to Z.
Alphabetic principle —understanding that written letters represent spoken sounds.
Sound–symbol correspondence —knowing the sounds for corresponding letters and letter combinations.
Phonemic decoding —using sound–symbol knowledge to segment and blend sounds in grade-level words. Reading decoding may be assessed with tasks that involve nonword or pseudoword reading.
Set for variability —the ability to derive an approximate pronunciation for a printed word and then use semantic knowledge and phonological ability to correct an imperfect pronunciation.
Word recognition —the ability to identify words when reading, either through word decoding or sight word identification. Word recognition must be assessed with tasks that involve real words.
Reading automaticity —reading isolated words rapidly and accurately.
Reading fluency —reading connected text smoothly and accurately with appropriate intonation and without frequent or significant pausing.
Knowledge of derivational morphology —prefixes and suffixes that change the part of speech or meaning of a word
Knowledge of inflectional morphology —changes in word form that mark tense, number, possession, or comparison
Knowledge of orthographic patterns of irregularly spelled words (e.g., “right,” “might,” “tight”; “could,” “should,” “would”)
Knowledge of variations in text structures and genres (e.g., narratives vs. expository text) and different purposes of text (to persuade, inform, or entertain)
Reading comprehension
Retelling or summarizing a passage while maintaining meaning
Answering questions about a passage to demonstrate the following:
Knowledge of multiple-meaning words
Knowledge of age-appropriate vocabulary
Knowledge of synonyms and antonyms
Knowledge of figurative language (e.g., idioms, metaphors, proverbs)
Ability to understand complex sentences
Ability to make inferences and integrate meaning within text
Using strategies to facilitate comprehension (e.g., skimming, using end-of-chapter questions to guide reading, rereading, and taking notes)
Using strategies to demonstrate comprehension of a reading passage
Using strategies for managing different styles of reading (e.g., reading for overview, critical reading for complete meaning and interpretation, using background knowledge to aid comprehension)

It is important to consider the following items to accurately assess a child’s spelling ability:

Phonological awareness —including phonemic awareness; segmenting syllables, onset–rimes, phonemes; discriminating and identifying phonemes; identifying syllable stress.
Orthographic pattern awareness —knowledge about sublexical units of a written word. This includes letter–sound relationships, orthographic patterns and rules, and orthotactic constraints and probabilities.
Orthographic lexicon —stored representations of specific written words and word parts (including affixes).
Semantic awareness and knowledge —awareness of the effect of word meaning on spelling and use of word meaning to spell words including the spelling of homophones (words that have identical phonological representations but different spellings and meanings, e.g., “bear”–“bare”) and words that share a common letter pattern and meaning (e.g., “magic,” “magician,” “magical,” “magically”).
Knowledge and awareness of inflectional morphology (changes in word form that mark tense, number, possession, or comparison) and the letter–meaning relationships for inflectional morphemes represented in written form.
Knowledge and awareness of derivational morphology (prefixes and suffixes that change the part of speech or meaning of a word) and the letter–meaning relationships for derivational morphemes represented in written form.
Application of all the above to spell an unfamiliar word instead of avoiding the use of the word when uncertain of the word’s spelling or to correct the spelling of a misspelled word.
Spelling automaticity —spelling words rapidly and accurately. This requires a well-established orthographic lexicon.
Demonstrating understanding of the phonemic, morphological, and orthographic components of spelling in context.

Please note that several of the items listed above may be duplicates of definitions under the Reading section. The repeated terminology is intentional, as those items pertain to skills necessary for both successful reading and spelling.

For further information regarding assessing a child’s spelling ability, obtaining information about foundational linguistic skills, developing goals for intervention, and strengthening written language skills through spelling intervention, see the works of Brimo (2013), Masterson and Apel (2010, 2013), and Moxam (2020).

It is important to consider the following abilities to accurately assess a child’s writing ability:

Making marks on paper
Showing intent to communicate meaning in writing
Printing all letters of the alphabet
Printing first and last name
Labeling pictures
Producing conventional text via copying dictation
Demonstrating fluency with text production via handwriting and/or keyboarding
Writing process
Planning and organizing, composing, reflection
Revising and editing content, spelling, and writing conventions
Writing product
Fluency (number of words produced in a specified time period)
Vocabulary and lexical diversity
Word choice
Word inflection in sentence contexts
Use of multisyllabic words
Evidence of morphemic awareness in word choice and spelling
Sentence formulation (e.g., diversity of sentence types, using end punctuation)
Appropriate grammar of sentences (coding for correct vs. incorrect sentences)
Sentence complexity
Code for simple versus complex sentences
Calculate clause density ratios
Calculate mean length of T-unit
Ability to write within an assigned genre
Ability to ensure completeness, organization, and cohesiveness
Writing conventions (capitalization, punctuation, and paragraph formations)

Assessment may result in one or more of the following:

Diagnosis of a written language disorder (affecting reading and/or writing, with patterns of strengths and weaknesses described in relation to the key components of reading decoding, written spelling, reading comprehension, and written expression)
Description of the characteristics and severity of the disorder
Diagnosis of a spoken language, speech sound, or social communication disorder
Referral for further assessment of possible hearing or vision problems
Recommendations for intervention and support, including multitiered systems of support such as RTI services to support literacy development
Referral to and consultation or collaboration with other professionals as needed, including the following:
audiologist
neuropsychologist
ophthalmologist
pediatrician

For more information, see ASHA’s webpage on Interprofessional Education/Interprofessional Practice (IPE/IPP) .

Cultural and Environmental Factors

Cultural norms and values influence many aspects of language development. For example, although people in all cultures tell stories, narrative discourse and how children tell and receive stories vary widely across cultures. Background experiences shape how children infer messages within a story and how they predict next steps. This results in variations in features of discourse, such as topic maintenance and event sequencing (McCabe & Bliss, 2003; Roseberry-McKibbin, 2014). Given the bidirectional relationship between spoken and written language, it is expected that children’s oral narrative discourse style will influence written narrative discourse. Therefore, acceptable oral variations should be considered appropriate for written narrative discourse as well (Gorman et al., 2011) and should never be used as symptoms for diagnosing a disorder.

Story features that might vary with cultural diversity include the following:

Topic maintenance —how much the story focuses on a single topic with little deviation or extraneous detail
Organizational structure —may be
linear —a story with a clear beginning, middle, and end or
cyclical —a story that ends in the same place it began
Character —including the nature of the relationship as well as how the character behaves and if the character is named
Creative elements —embellishment, fantasy, suspense, and conflict (may vary by culture)

When a clinically significant reading problem is suspected, it is important to rule out environmental variables and other variables that could be having a negative impact on the child’s literacy skills (Roseberry-McKibbin, 2013, 2014). When circumstances are complex, dynamic assessment procedures might help identify a written language disorder, if present.

For more information, see the ASHA Practice Portal page on Cultural Responsiveness .

Children Who Are Linguistically Diverse

Simultaneous and sequential dlls.

Written language dominance may not match spoken language dominance in children who are simultaneous or sequential DLLs. For example, children who use additional languages in the home have oral language skills in their first language (L1) but may not have learned how to read or write in that language (Roseberry-McKibbin, 2014).

The age of exposure to English is directly related to bilingual reading development. Bilingual children who are exposed to English prior to the age of 3 years develop reading skills similar to those of monolingual English speakers (Kovelman et al., 2008).

Phonological awareness skills tend to be better in bilingual children than in monolingual speakers (Kovelman et al., 2008; Páez et al., 2007), and these skills may facilitate development of decoding and word-level literacy skills. The development of text-level skills (reading comprehension and writing) relies more heavily on oral English proficiency, including vocabulary knowledge, listening comprehension, and syntactic skills (August & Shanahan, 2006).

Characteristics of the writing system in an individual’s first language may influence their reading and writing abilities in English. Orthography, phonology, and semantic units of the child’s home language will influence written English, particularly when languages share similarities. For example, English and Spanish share many cognate words (e.g., “club,” “mango,” “animal,” and “chocolate”), providing biliterate children with a cognate advantage (Lubliner & Hiebert, 2011). Additionally, transparent writing systems, such as Spanish, have more regular sound-to-letter correspondences than English and can facilitate reading and writing. In contrast, the writing system in Mandarin is made up of characters, and each character may represent a word or morpheme. Words consist of one or more morphemes and in spoken language, tones may differentiate morphemes (Comrie, 2009, pp. 703-723). Such differences between English and Mandarin reduce the opportunities to transfer skills across languages in early biliterate readers.

Variations in vocabulary and syntax across languages can influence reading comprehension in English. For example, some words may not have translation equivalents across languages. Differences in morphological and syntactic structures across languages can add to problems in reading comprehension.

For more information, see the ASHA Practice Portal page on Multilingual Service Delivery in Audiology and Speech-Language Pathology .

Children Who Use Nonstandard American English Dialects

In contrast to bilingual children, children who use nonstandard American English dialects may have more difficulty with decoding and word-level literacy skills (e.g., spelling; M. C. Brown et al., 2015). In a study comparing grammar and early spelling skills, children who spoke AAE did not differ from children who spoke Standard American English in their recognition of inflectional grammatical morphemes. However, the children who spoke AAE tended to omit these inflections in spoken production and in spelling. The differences between groups in oral production and spelling patterns were consistent with linguistic differences between AAE and Standard American English. Furthermore, the children who spoke AAE seemed to have more difficulty with dialect-sensitive orthographic patterns, such as inflections, than with dialect-neutral orthographic patterns, such as consonant and vowel patterns (Terry, 2006).

More research is needed to examine the relationship between dialect use and literacy skills, particularly when social and environmental variables are known to impact the learning of reading and writing. For further information, please see the work of Washington and Seidenberg (2021).

Children Who Are Nonverbal or Have Limited Speech (Including Users of Augmentative and Alternative Communication)

Many of the tasks used to assess literacy skills in children require a verbal response. For children who have impaired speech or no speech (including those who use augmentative and alternative communication), it is necessary to modify these tasks so that verbal responses are not required (Barker et al., 2012). Examples of modifications for specific tasks typically used in literacy assessment (and intervention) include the following:

Phoneme blending —given individual spoken phonemes, pointing to a picture of the corresponding word rather than speaking the word by blending the phonemes (Fallon et al., 2004; Truxler & O’Keefe, 2007)
Word segmentation —given a spoken word, writing marks on the word to indicate each phoneme rather than speaking each individual phoneme (Blischak, 1994)
Initial phoneme identification —given a spoken word, pointing to the printed letter(s) that corresponds to the initial phoneme within the word rather than speaking the initial phoneme (Fallon et al., 2004; Millar et al., 2004)
Spelling (oral) —given a spoken word, using letter tiles to spell the word or using a keyboard to type the word rather than speaking the letter names (Blischak, 1994; Johnston et al., 2009)
Word identification (reading at the single-word level) —given a printed word, pointing to a corresponding picture rather than speaking the printed word (Fallon et al., 2004; Hanser & Erickson, 2007)

These assessment modifications can change the nature of the task. For example, by giving a set of stimuli (e.g., pictures, letters, words), the clinician essentially provides a closed set of options (vs. the open-answer format for oral responding) so that the child’s response might be correct by chance alone. When assessment modifications like this are made, standardized scores cannot be used because the tasks are fundamentally different (Barker et al., 2012). Assessment of these students should include elements of dynamic assessment and other informal assessments.

For further information regarding intervention, please see the Intervention for Children With Complex Communication Needs section below.

Eligibility for Services in the Schools

Children and adolescents with written language (reading or writing) disorders are eligible for speech-language services in the schools, regardless of cognitive abilities or performance on cognitive testing.

As mandated by the Individuals with Disabilities Education Improvement Act of 2004 (IDEA), categorically applying a priori criteria (e.g., discrepancies between cognitive abilities and communication functioning, chronological age, or diagnosis) in making decisions on eligibility for services is not consistent with IDEA regulations. See also the National Joint Committee for the Communication Needs of Persons With Severe Disabilities (2002) report for information related to a priori criteria.

Eligibility for speech-language pathology services is documented in the child’s individualized education program, and the child’s goals and the dismissal process are explained to parents and teachers. Dismissal from speech-language pathology services occurs once the criteria for eligibility are no longer met, that is, when the child’s communication problem no longer adversely affects academic achievement and functional performance.

For more information about eligibility for services in the schools, see Eligibility and Dismissal in Schools , IDEA Part B: Individualized Education Programs and Eligibility for Services , and Current IDEA Part C Final Regulations (2011) .

Students with written language disorders are also protected by Section 504 of the Rehabilitation Act of 1973. This law requires that schools provide reasonable accommodations to students with disabilities to ensure academic success and access to the learning environment. A student who requires specialized instruction may have a 504 plan. This plan specifies any necessary accommodation, including modification of assignments, extended time for tests, and sign language interpreters. See Protecting Students With Disabilities .

Common Core State Standards (CCSS) and/or State Standards

Several states implement the CCSS (Common Core State Standards Initiative, 2010), which are internationally benchmarked learning standards. Other states use academic standards that they develop. In both cases, standards define what public school students are expected to learn in reading, math, and other subjects. These standards constitute a framework of knowledge and skills thought necessary to prepare students to enter college and the workforce.

Students who have language disorders may require specialized instruction and support to access the CCSS or state standards because language skills are addressed across subject areas and focus on the use of language for communication and academic success. See Common Core State Standards: A Resource for SLPs for information and guidance on integrating the CCSS into intervention for students with language disorders .

See the Treatment section of the Written Language Disorders (School-Age) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

The goal of intervention is to improve language and communication in spoken and written language in a way that is relevant to the student’s general education curriculum and that helps students achieve mastery of states’ content standards (e.g., Common Core State Standards: A Resource for SLPs ), particularly in English Language Arts. Guidelines for literacy considerations that apply to broad populations of older students are included in the Resources section of this page. Intervention builds on and encourages the reciprocal relationships between spoken and written language. SLPs can take advantage of these interrelationships by showing students how to capitalize on areas of strength while working to improve areas of weakness.

It is also important to consider the child’s functioning in areas related to spoken and written language, including hearing, cognition, and speech sound production. In addition, children bring different backgrounds to the treatment setting. Direct instruction in morphosyntax and dialect-influenced inflections benefit children who use African American English (Terry, 2006). For bilingual children, the clinician must consider the language(s) used during intervention. First language skills may be used to access higher order English literacy skills (e.g., providing definitions and interpreting metaphors) to develop English literacy (August & Shanahan, 2006). For more information, see the ASHA Practice Portal page on Multilingual Service Delivery in Audiology and Speech-Language Pathology .

Treatment Approaches

It is important to design literacy intervention programs with a balanced focus on all areas of difficulty, which may include both sound-, syllable-, or word-level decoding or encoding (spelling) and sentence- or discourse-level comprehension and composition. Although the focus of intervention may be on specific skills, it is important to teach them in the context of authentic language uses whenever possible.

The following reading, writing, and spelling approaches are listed separately and by skill area for descriptive purposes only. Multiple approaches are often used in combination, and more than one skill can be addressed at any given time (Weaver, 1998).

Print-to-speech word structure approaches focus on reading decoding. They are systematic and explicit approaches with lessons and instructional components such as syllable divisions and syllable types organized around the orthographic system. They are designed to teach such elements as
grapheme–phoneme correspondences (for reading and spelling regular words),
irregular orthographic patterns, and
associations of morphemic components of words and orthographic patterns.
Speech-to-print word structure approaches begin with the process of phonological encoding (spelling) to teach reading decoding and develop automatic word recognition. They are systematic and explicit approaches with lessons and instructional components such as syllable divisions and syllable types organized around the phonological system. They are designed to teach such elements as
phoneme–grapheme correspondences,
phoneme–grapheme mapping to establish robust lexical representations in long-term memory for automatic recognition and accurate spelling of all (regular and irregular) words, and
associations of morphological components of words and orthographic patterns.
Language comprehension approaches focus on identifying and closing gaps in comprehension that may be due to problems with
discourse organization,
understanding of cohesive devices,
unpacking of syntactic complexity,
recognition of unknown vocabulary, and/or
the ability to make sense of words in context.
Process-oriented approaches focus on the processes involved in writing, including
developing ideas,
planning (prewriting),
organizing,
reflecting,
revising, and
Product-oriented approaches focus on the written form, including
handwriting/letter formation,
vocabulary,
use of cohesive devices,
use of writing conventions, and
effectiveness of intended communication.
Multilinguistic —instruction that functionally integrates phonological, orthographic, and semantic/morphological components at the lexical and sublexical levels, with application of skills to connected writing.
Multimodality —instruction that actively engages the student in the oral production and writing of words; students say the phonemes and simultaneously write the corresponding graphemes. With this process, they simultaneously see the letters and hear the phonemes.
Metalinguistic— explicit instruction that teaches students how to apply phonological, orthographic, and semantic/morphological knowledge to the spelling of unfamiliar words.
Developmental— instructional sequence that follows a developmental stage approach to facilitate acquisition of conventional spelling skills.
Rote memorization and testing of selected words in list format and in composition. Although memorization may be widely used, there is limited evidence to support its clinical utility (Galuschka et al., 2020).

Intervention Targets

The basic principles of effective intervention include the following (Roth & Worthington, 2015):

Provide intervention that includes ongoing assessment of the child’s progress in relation to each child’s goals, modifying them as necessary.
Provide intervention that is individualized, based on the nature of a child’s deficits and learning style.
Tailor treatment goals to promote a child’s knowledge, one step beyond the current level.

See Intervention Target Areas for a listing of target areas by developmental level.

Treatment Options

Below are brief descriptions of general and specific treatments for addressing disorders of reading and writing. Treatment targets (see Intervention Target Areas ) guide the selection of treatment options. Clinicians may consider a variety of approaches and tools based on the needs of each individual.

SLPs and educators determine which methods and strategies are appropriate by taking into consideration

each individual’s language profile and learning style,
each individual’s cultural background and values,
the severity of the language disorder,
factors related to language functioning (e.g., hearing impairment and cognitive functioning),
each individual’s communication needs, and
available evidence (see the Written Language Disorders (School-Age) Evidence Map ).

General Treatment Strategies and Methods

Graphic organizers.

Graphic organizers (also referred to as knowledge maps , concept diagrams , and cognitive organizers ) are visual displays that show the relationships among facts, terms, and ideas. Examples of graphic organizers used for different tasks include problem–solution maps, sequential episode maps, comparison–contrast maps, and cause–effect maps. Graphic organizers can be used to support reading comprehension by helping students take notes and understand various text genres (e.g., Kim et al., 2004). They can also be used as part of a process to help students write meaningful descriptions (see, e.g., the video clip below; Montgomery, 2018) and to help students organize and cohesively link ideas for multi-paragraph essay writing.

Read-Aloud Interventions

Dialogic reading.

Dialogic reading is an interactive, shared picture book reading activity designed to enhance the language and literacy skills of young children (e.g., Zevenbergen & Whitehurst, 2003). During the shared reading practice, the child and the adult take turns “reading.” In this way, the child learns to become the storyteller with the help of the adult, who takes on the role of an active listener and questioner. Interactive Shared Book Reading and Shared Book Reading are two related practices.

Repeated Reading

Repeated reading is a practice designed to increase oral reading fluency (e.g., Lo et al., 2011). It can be used with students who have word reading skills but demonstrate inadequate reading fluency for their grade level. The student reads a passage aloud to the teacher at least three times. If the student misreads a word or hesitates longer than 5 s, then the teacher reads the word aloud, and the student repeats it correctly. The student can also request help from the teacher on a particular word. The student continues to reread the passage until an adequate level of fluency is achieved. Other methods for improving oral reading fluency include

echo reading (reading while listening),
choral reading (reading aloud in unison as a group), and
neurological impress or shadowing (fluent reader and student read aloud together).

Teaching Story Grammar

Teaching story grammar is a technique for familiarizing students with the components of narrative story structure (e.g., setting, main characters, problem, and resolution) to help them understand stories and make predictions while reading. Visual symbols or manipulables that represent each story component are used as cues to facilitate initial learning and guide later narrative comprehension (e.g., Dymock, 2007). Students are often taught sentence structure (e.g., microstructure) in conjunction with story grammar (macrostructure) instruction.

Comprehension Strategy Instruction

Comprehension strategy instruction involves teaching students (via direct instruction, modeling, guided practice, and application) to use specific strategies to facilitate reading comprehension (e.g., Stahl, 2004). Strategies include

prediction —using inferencing and drawing on prior knowledge;
imagery —creating mental images that help keep track of what was read;
summarizing —condensing/paraphrasing key information from text; and
questioning —monitoring comprehension and generating questions to keep track of what was read and how ideas are related.

Writing Lab Approach

The writing lab approach uses computers to support literacy instruction. Using this approach, SLPs work collaboratively with general and special educators to foster language growth using inclusive, curriculum-based, computer-supported writing process instruction. Students engage in authentic writing projects and use recurrent writing processes consisting of planning, organizing, revising, editing, publishing, and presenting. Students are supported through instructional scaffolding, and their individualized needs can be addressed while working toward general curriculum goals (Nelson & Van Meter, 2006; Nelson et al., 2001).

Specific Treatment Strategies and Methods

Cooperative integrated reading and composition®.

Cooperative Integrated Reading and Composition (e.g., R. J. Stevens et al., 1991) is a reading and writing program for students in Grades 2–6 that consists of story-related activities, reading comprehension instruction, and integrated language arts/writing. Students practice in pairs and small groups. Activities include reading to each other; predicting story endings; discussing the main idea of a story; writing responses to questions; and practicing vocabulary, decoding, and spelling. A Spanish version of the program is available for Grades 2–5.

Dyslexia Training Program

The Dyslexia Training Program (e.g., Beckham & Biddle, 1989) is a reading intervention program that uses direct and systematic instruction to teach reading and spelling. The program has a strong emphasis on phonemic awareness and alphabetic code knowledge. Multisensory lessons target phonemic awareness, phonics, reading fluency, vocabulary, and reading comprehension. A daily lesson plan cycle introduces new concepts and provides the student with opportunities to practice skills in alphabetic knowledge, reading, spelling, reading comprehension, and handwriting. The Dyslexia Training Program is most appropriate for Grades 2–5.

Lindamood Phoneme Sequencing®

Lindamood Phoneme Sequencing (Lindamood & Lindamood, 1998) is a comprehensive multisensory program that uses systematic and explicit instruction to teach phonological awareness, decoding, spelling, and reading skills. The goal of the program is to develop fluent readers and competent spellers. Tasks progress from articulatory movement to sound, then to letter; students develop an oral–motor, auditory, and visual feedback system that enables them to verify the identity, number, and order of phonemes in syllables and words. Phonemic awareness, once established, can be applied to reading, spelling, and speech. Lindamood Phoneme Sequencing can be used with individuals (of all ages), in small groups, and in classrooms.

Orton–Gillingham (OG)-Based Interventions

The OG approach (e.g., Ritchey & Goeke, 2006) is an intensive, sequential, phonics-based system that teaches the basics of word formation over meaning. It is a language-based, multisensory instructional approach that uses visual, auditory, and kinesthetic learning modalities. This approach is used for students with reading, spelling, and writing difficulties typically associated with dyslexia. It is most often associated with one-on-one instruction, but its use in small-group instruction is not uncommon. An adaptation of the approach has been used for classroom instruction as well. Despite widespread use and some states even mandating the use of OG programs for students who have dyslexia, a recent meta-analysis of the research concluded the following regarding students with word-level reading disabilities (WLRD): “OG reading interventions do not statistically significantly improve phonological awareness, phonics, fluency, spelling, vocabulary or comprehension outcomes for students with or at-risk for WLRD. More high quality, rigorous research with larger samples of students with WLRD is needed to fully understand the effects of Orton–Gillingham interventions on the reading outcomes for this population” (E. A. Stevens et al., 2021).

Reading Apprenticeship®

Reading Apprenticeship (e.g., Schoenbach et al., 1999) is an instructional program intended for students in middle school, high school, and community college and is designed to improve their engagement, fluency, and comprehension of content-area materials and texts. It includes professional development activities for teachers and an academic literacy curriculum for students. Teachers model and guide students’ text-based problem-solving to facilitate the development of comprehension strategies. The discussion of the reading processes within content-area classes helps students understand and regulate their own reading processes as well as develop strategies for overcoming reading obstacles and improving comprehension of texts from core academic disciplines.

Road to the Code

Road to the Code (Blachman et al., 2000) is a phonological awareness program for young children focusing on phonemic awareness and letter–sound correspondence. Lessons are developmentally sequenced and provide students with repeated opportunities to practice and enhance beginning reading and spelling skills. Each lesson consists of three activities: Say It and Move It (a phoneme segmentation activity), letter name and sound instruction, and phonological awareness practice.

Self-Regulated Strategy Development (SRSD)

SRSD is an instructional approach designed to help students learn and use the strategies used by skilled writers (Harris & Graham, 1992). For example, skilled writers plan extensively, consider the audience, organize their ideas, recognize problems in the written product, and revise it accordingly. The SRSD approach adds self-regulation to strategy instruction for writing, which encourages students to monitor, evaluate, and revise their writing. Like other types of strategy instruction, the aim of SRSD instruction is to help students develop executive function skills by becoming self-directed writers and integrating strategies into the overall writing process.

SPELL-Links to Reading & Writing™

SPELL-Links to Reading & Writing (Wasowicz et al., 2012) is a speech-to-print multilinguistic word study curriculum that integrates phonological awareness, orthography, and semantics/morphology instruction at the word level and includes structured application of word study skills to reading and writing at the sentence and paragraph levels. It includes dynamic lessons, meta-cognitive reading and writing activities, and guided learning opportunities. Activities can be administered to individuals, small groups, or whole classrooms. The curriculum aims to teach critical word study strategies and promotes word study across the curriculum research. Please see the work of Wanzek et al. (2016) for further information on transcription writing interventions.

Stepping Stones to Literacy (SSL)

SSL (Gonzalez & Nelson, 2003) is a supplemental curriculum for kindergarten and older preschool children who have been identified as at risk for reading failure. SSL focuses on critical skills for reading success, including listening, awareness of print conventions, phonemic awareness, and rapid naming of familiar visual stimuli (e.g., letters and colors). The curriculum consists of 25 intensive daily lessons delivered individually or in small groups.

SPELL-Links Wordtivities TM

SPELL-Links Wordtivities (Wasowicz, 2019) is a collection of activities and materials that develop K–12 students’ literacy and language skills through active engagement with the sounds, letters, and meanings of words. Students learn to apply multiple components of oral and written language to improve their spelling, word decoding, reading fluency, and reading comprehension; build depth and breadth of vocabulary; and enhance oral expression and sentence-level writing performance (syntax).

Words Their Way™

Words Their Way (Bear et al., 2015) is an approach to teaching phonics, vocabulary, and spelling to students in kindergarten through high school. Five developmental stages are targeted: emergent, letter name–alphabetic, within-word pattern, syllables and affixes, and derivational relations. The program provides a practical way to study words (i.e., examine, manipulate, compare, and categorize); discover logic and consistency in written language; and learn to recognize, spell, and define words.

Computer-Based Technologies

A variety of computer-based technologies are available to promote independent and successful reading and writing by enabling individuals to accomplish tasks that were previously difficult for them to perform. These technologies include software programs that help improve phonological awareness, spelling, and decoding skills and facilitate vocabulary acquisition and spelling; convert text to speech (screen readers) and speech to text (voice recognition); predict words while writing; and help students plan, compose, and revise their written work.

Some computer-based technologies are designed for general use or to supplement classroom literacy activities. Others are specifically targeted for use by individuals who struggle with reading and/or writing. A variety of apps are also available for iPads and other tablet devices

The following list is not exhaustive. Treatment targets (see Intervention Target Areas ) should guide the selection of treatment options. Ideally, clinicians use a variety of tools based on the needs of the individual.

ABC Phonics Word Family Writing

ABC Phonics Word Family Writing is an iPad application that uses an interactive game format to help children learn how to write, spell, and read. Using word families and more than 600 vocabulary words, the game helps children recognize common word patterns and understand how the initial consonant, middle vowels, and ending consonant affect pronunciation. The application includes two learning modules— Word Flashcards, which allows the child to see the spelling and hear the word, and Writing Words, which allows the child to practice spelling the words using a “trace letter-by-letter” format.

Co:Writer®

Co:Writer is a type-and-speak writing tool developed to help users write complete and correct sentences with very few keystrokes. As letters are typed, Co:Writer predicts and suggests possible words from its grammar-smart dictionary, and the user can choose the most appropriate word with one keystroke or mouse click. Co:Writer can speak the suggested words and, if needed, can speak letters, words, and finished sentences as they are entered. Co:Writer can be used in combination with other computer applications (e.g., word processor and story-writing programs).

First Author®

First Author is a writing software product used to promote independent writing in students with complex instructional needs (e.g., severe speech and physical impairments). The program helps students plan, compose, revise, and publish by guiding them through a three-step process—choosing a topic, selecting a picture prompt, and writing with the help of built-in accommodations. The student’s writing progress is tracked automatically.

Lexia® Learning Systems

Lexia Learning Systems are software programs designed to supplement classroom reading instruction. They use a variety of activities to enhance phonics skills via word-attack strategies at the letter, word, sentence, and paragraph levels. Lexia Phonics-Based Reading™ for younger children contains three levels of practice, beginning with letter–sound correspondence for short vowels and consonants, advancing to decoding from simple words to more complex words, and moving on to constructing one- and two-syllable words. Lexia Strategies for Older Students™ is designed to help struggling students in the higher grades increase automatic word recognition by reinforcing phonics and sound–symbol correspondence.

READ 180®

READ 180 is a reading program designed to meet the needs of students in elementary through high school whose reading achievement is below the proficient level. The program addresses student needs through use of computer software, literature of interest to the student, and direct reading instruction. Students participate in whole-group and small-group instruction, including computer work as well as reading and writing activities. The software allows for individualized instruction by collecting student response data and adjusting the instructional level accordingly.

Read, Write & Type TM

Read, Write & Type is a software program and set of materials that address phonics, spelling, keyboarding, and word processing skills. The goal of this program is to enable children to write whatever they can say. Read, Write & Type was developed for 6- to 9-year-old students who are just beginning to read and for students who are struggling to read and write. The program helps students develop an awareness of English phonemes by teaching them to associate each phoneme with a letter or a combination of letters and by pairing each phoneme with a finger stroke on the keyboard. Children also learn to identify sounds in words, sound out words fluently, and type and read regularly spelled words.

SPELL-Links WordUP! TM

SPELL-Links WordUP! teaches K–12 students to attend to the phonological structure of spoken English words first and then to connect (map) the sounds they say and hear with the letters they see in the printed word and with the word’s meaning. This iPad app is designed for use as a clinical teaching tool and for student practice to improve reading, spelling, vocabulary, and oral language skills. Choose one of four game-play activities, adjust settings, and select words to support a student at the appropriate level.

WordQ is a writing tool that provides spelling, grammar, and punctuation assistance. It is designed for individuals who struggle with writing. WordQ uses advanced word prediction to suggest words and provide spoken (text-to-speech) feedback so students hear sentences repeated and detect mistakes as they go. WordQ can also assist with reading. Any text (e.g., e-mails and website content) can be selected and “read aloud” using its text-to-speech function.

Intervention for Children With Handwriting Difficulties

SLPs rarely work on the motoric aspects of handwriting, but they may collaborate with occupational therapists to help students develop self-talk strategies associated with performing the systematic, sequential movements required to form letters. Handwriting is not only a motor skill; it is also a written language skill, and handwriting instruction should be integrated with reading and writing instruction. Letter formation may be taught in association with letter recognition and with the pronunciation and perception of related phonemes as part of a comprehensive multisensory or multisystemic approach to developing sound–symbol associations and word structure knowledge (e.g., Andrews & Lombardino, 2014; Gillingham & Stillman, 1997; Wolf, 2005; Wolf et al., 2017).

See Collaboration and Teaming and ASHA’s webpage on Interprofessional Education/Interprofessional Practice (IPE/IPP) .

Intervention for Children With Complex Communication Needs

Children with limited cognitive abilities and/or severe physical impairments often have had limited early literacy experiences, reading instruction, or access to physically manageable writing systems (Koppenhaver et al., 1991; Koppenhaver & Yoder, 1993; J. Light et al., 1994; J. Light & Kelford Smith, 1993; J. Light & McNaughton, 1993).

It is important to provide access to literacy through writing for this population (Sturm, 2012). Intervention may include opportunities to hear written language read aloud (e.g., via text-to-speech programs) and to provide assistive technology (e.g., computers, tablets, augmentative and alternative communication devices) and other supports (e.g., scribes) to foster independent reading and writing. For example, augmentative and alternative communication systems and technologies that support both communication and literacy instruction—and that allow ease of movement between reading, writing, and communicating—would be ideal (Sturm, 2003; Sturm et al., 2002). For further information, please see ASHA’s Practice Portal pages on Augmentative and Alternative Communication , Autism Spectrum Disorder , and Intellectual Disability as well as the section Children Who Are Nonverbal or Have Limited Speech (Including Users of Augmentative and Alternative Communication), above.

Intervention for Children Who Are Deaf or Hard of Hearing (DHH)

Children who are DHH traditionally demonstrate lower reading achievement levels when compared with their hearing peers (e.g., Holt et al., 1997; Karchmer & Mitchell, 2003; Nelson & Crumpton, 2015; Traxler, 2000).

Lack of adequate access to phonological information and problems acquiring grapheme–phoneme knowledge may contribute to lower reading achievement in this population (Perfetti & Sandak, 2000; Trezek et al., 2010). Strategies that have been used to support grapheme–phoneme acquisition, or that serve as an alternate for children who are DHH, include the following (Tucci et al., 2014):

Visual phonics —a system that uses distinct hand shapes for each English phoneme to clarify sound–symbol relationships. Hand shapes represent movements of the mouth, tongue, and throat during oral production that can be associated with the printed letter or letters.
Fingerspelling —a system that uses hand shapes, each of which corresponds to a letter in the English alphabet.

Children who are DHH may also be at a disadvantage when it comes to comprehending what they read. Skilled readers have extensive background knowledge that they can relate to information in the text to help them understand what they read (Pressley, 2002). Children who are DHH often do not have the same amount of background knowledge as their hearing peers (Schirmer, 2000), possibly due to fewer opportunities for incidental learning (e.g., McIntosh et al., 1994). Their background knowledge may also be less richly connected (McEvoy et al., 1999), and they are less likely to make connections while reading (Marschark & Wauters, 2008). Strategies to improve reading comprehension in this population include

giving explicit instruction in using comprehension strategies (e.g., prediction, questioning, and summarizing) and
providing opportunities to gain and activate background knowledge (e.g., in-class experiences, watching videos about a topic, using mental imagery to imagine what you might experience in a story; Luckner & Handley, 2008).

See ASHA’s Practice Portal pages on Hearing Loss in Children, Hearing Loss in Adults , and Language and Communication of Deaf and Hard of Hearing Children .

Transitioning Youth and Postsecondary Students

Difficulties experienced by children and adolescents with written language impairment can continue to affect functioning in postsecondary education and vocational settings. This potential impact highlights the need for continued support to facilitate a successful transition to young adulthood.

A functional curriculum approach is frequently taken for transitioning students. This approach focuses on teaching skills that will help the student function independently in society. Functional goals might include reading and evaluating job ads, reading and completing applications for jobs or for postsecondary school, reading and comprehending a driver’s test manual, and learning to self-advocate for accommodations and services in the classroom and workplace. For more information about transition planning and goals, support services, and relevant laws, see ASHA’s page on Postsecondary Transition Planning .

Service Delivery

See the Service Delivery section of the Written Language Disorders (School-Age) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

In addition to determining the type of speech and language treatment that is optimal for children with written language disorders, SLPs consider other service delivery variables—including format, provider, dosage, timing, and setting—that may affect treatment outcomes. See Cirrin et al. (2010) for a review of research on the effects of different service delivery models on communication outcomes in elementary school–age children.

Format —whether a person is seen for treatment one-on-one (i.e., individual) or as part of a group
Provider —the person providing treatment (e.g., SLP, trained volunteer, caregiver)
Dosage —the frequency, intensity, and duration of service
Timing —when the intervention is conducted relative to the diagnosis
Setting —the location of treatment (e.g., home, community-based, school)

ASHA Resources

The ASHA Leader : Education Department Issues Dyslexia Guidance
Building Your Child’s Listening, Talking, Reading and Writing Skills: Kindergarten to Second Grade [PDF]
Building Your Child’s Listening, Talking, Reading and Writing Skills: Third Grade to Fifth Grade [PDF]
Cognitive Referencing
Developmental Norms for Speech and Language
Disorders of Reading and Writing
Dynamic Assessment
Identify the Signs of Communication Disorders
Impact of Literacy Intervention on Achievement Outcomes of Children With Developmental Language Disorders: A Systematic Review [PDF]
Information for School-Based SLPs
Intervention Target Areas
Language In Brief
Let’s Talk: For People with Special Communication Needs
Multilingual Service Delivery in Audiology and Speech-Language Pathology
Operationalizing the NJCLD Definition of Learning Disabilities for Ongoing Assessment in Schools
Phonemic Inventories and Cultural and Linguistic Information Across Languages
Preferred Practice Patterns for the Profession of Speech-Language Pathology
Response to Intervention (RTI)
Roles and Responsibilities of Speech-Language Pathologists in Schools
Signs and Symptoms of Written Language Disorders
Speech Sound Disorders: Articulation and Phonology
Spoken Language Disorders
Understanding Dyslexia in the Context of Developmental Language Disorders
Understanding the Individuals with Disabilities Education Act (IDEA)
Your Child’s Communication Development: Kindergarten Through Fifth Grade

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

Adolescent Literacy
Alliance for Excellent Education
Assistive Technology Tools for Learning Differences, ADHD, and Executive Function Challenges
Center for Applied Linguistics
Collaboration for Effective Educator Development, Accountability and Reform (CEEDAR Center)
Common Core State Standards for English Language Arts & Literacy in History/Social Studies, Science, and Technical Subjects
Evidence-Based Practices for Writing Instruction [PDF]
Five Questions Everyone Should Ask Before Choosing Early Literacy Apps
Get Ready to Read !
International Literacy Association (formerly the International Reading Association)
The Link Between Language and Spelling: What Speech-Language Pathologists and Teachers Need to Know
National Center for Families Learning
National Forum on Information Literacy
From the National Joint Committee on Learning Disabilities (NJCLD)
Report: Learning Disabilities and Achieving High Quality Education Standards [PDF] (2016)
Report Summary: Learning Disabilities and Achieving High Quality Education Standards [PDF] (2017)
Infographic: Learning Disabilities and Achieving High Quality Education Standards [PDF] (2017)
RCSLT: New Long COVID Guidance and Patient Handbook
Reach Out & Read
Reading Next: A Vision for Action and Research in Middle and High School Literacy [PDF]
Reading Rockets
Systematic and Engaging Early Literacy (SEEL)
Time to Act: An Agenda for Advancing Adolescent Literacy for College and Career Success
What Works Clearinghouse: Literacy
Wrightslaw: Understanding Dysgraphia
Writing Next: Effective Strategies to Improve Writing of Adolescents in Middle and High Schools [PDF]
Writing to Read: Evidence for How Writing Can Improve Reading [PDF]

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About This Content

Acknowledgments.

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Written Language Disorders page:

Virginia W. Berninger, PhD
Lena G. Caesar, EdD, PhD, CCC-SLP
Barbara E. Culatta, PhD, CCC-SLP
Carol Scheffner Hammer, PhD, CCC-SLP
Elizabeth Ijalba, PhD, CCC-SLP
Alan Kamhi, PhD, CCC-SLP
Julie J. Masterson, PhD, CCC-SLP
Nichole A. Mulvey, PhD, CCC-SLP
Nickola W. Nelson, PhD, CCC-SLP
Rhea Paul, PhD, CCC-SLP
Elizabeth D. Peña, PhD, CCC-SLP
Celeste A. Roseberry-McKibbin, PhD, CCC-SLP
Elaine R. Silliman, PhD, CCC-SLP
Gary A. Troia, PhD, CCC-SLP
Jan Waskowicz, PhD, CCC-SLP

In addition, ASHA thanks the members of the Ad Hoc Committee on Reading and Writing, whose work was foundational to the development of this content. Members of the Committee were Nickola Nelson (chair), Hugh Catts, Barbara Ehren, Froma Roth, Cheryl Scott, Maureen Staskowski, and Roseanne Clausen (ex officio). Diane Paul-Brown, Kathleen Whitmire, and Susan Karr provided consultation. Alex Johnson, 2001–2002 vice president for professional practices in speech-language pathology, and Nancy Creaghead, 1997–1999 vice president for professional practices in speech-language pathology, served as monitoring officers.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Written Language Disorders. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Written-Language-Disorders/ .

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Because differences are our greatest strength

What is written expression disorder?

By Gail Belsky

Expert reviewed by Karen Wilson, PhD

Updated January 12, 2024

What you’ll learn

Snapshot: what written expression disorder is, written expression disorder signs and symptoms, how written expression disorder is diagnosed.

Written expression disorder is a learning disorder that makes it hard for people to put their ideas into writing. It also creates difficulty with grammar and punctuation. It’s a type of learning disability that’s common and lifelong.

Written expression disorder is a learning challenge that impacts writing. The formal diagnosis is “specific learning disorder with impairment in writing.” Schools might call it a learning disability in writing.

This lifelong disorder makes it hard to express thoughts in writing . People might have great ideas. But their writing is disorganized and full of grammar and punctuation mistakes.

Written expression disorder is caused by differences in the brain. While it’s not as well-known as dyslexia , it may actually be more common. Experts think between 8 and 15 percent of people have it.

Written expression disorder often co-occurs with other learning challenges. Two of the most common are dyslexia and ADHD .

There aren’t any major teaching programs to help with these writing challenges. But there are strategies and techniques that can help people manage the difficulties and improve their skills.

People can be tested for writing challenges at any age. Parents can request a free evaluation at school. Adults typically have them done privately. The tests are different for kids and adults.

Written expression disorder impacts learning. And it can make certain tasks at work difficult. But it’s important to know that people who have it are just as smart as other people.

Dive deeper

Learn about the six skills of written expression .

Find out when kids develop different writing skills .

Explore assistive technology for writing .

When people struggle with written expression, it doesn’t mean they also have trouble expressing themselves when speaking. They might tell a story that’s well organized and detailed. But it looks very different when they try to write it out.

The difficulties can show up in different ways . Here are some things you might see in their written work:

Words that are misused or that have the wrong meaning

The same words used over and over

Basic grammar mistakes, like missing verbs or incorrect noun-verb agreement

Sentences that don’t make sense

Disorganized essays and papers

Written work that seems incomplete

Missing facts and details

Slow writing and typing

There are behavioral signs, too. These include:

Making excuses and avoiding writing assignments

Complaining about not being able to think of what to write or not knowing where to start

Sitting for a long time at a desk without writing

Finishing a writing task quickly without giving it much thought

Learn about dictation (speech-to-text) technology .

For families: Explore ways to help your child with writing .

For teachers: Explore strategies to teach kids self-regulation in writing .

The only way to know if someone has written expression challenges is to have a full evaluation . Parents can request that the school evaluate their child. School evaluations are free.

Certain professionals do private evaluations. But they can be very costly. In some cases, there are ways to get private evaluations for free or at a low cost .

Evaluators use a series of tests to look at writing skills . They also test for strengths and challenges in other areas. Many people with written expression disorder also have other learning and thinking differences, like dyslexia or ADHD.

There are a few types of professionals who do evaluations. These include:

School psychologists

Clinical psychologists

Speech-language pathologists

Neuropsychologists

Getting a diagnosis (schools call it an identification) can lead to extra help at school. It can also lead to accommodations at college and at work.

For teachers: Explore five things to look for in your students’ IEPs .

For families: Learn how to request a free school evaluation .

For college students: Research types of accommodations at college .

Trouble with written expression can impact people of all ages and create challenges at school and work. But there are supports that can help. Find out how accommodations work . Learn how to apply for them for the SAT and ACT and how to request them at work .

Explore related topics

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

Case Studies of Fictional Characters

Disorder of Written Expression (315.2)

Bill Pelz and Herkimer Community College

DSM-IV-TR criteria

A. Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given the person’s chronological age, measured intelligence, and age-appropriate education.
B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g., writing grammatically correct sentences and organized paragraphs).
C. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.
Coding note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.

Associated features

This disorder was previously called developmental expressive writing disorder. This disabilitiy affects both the physical reproduction of letters and the organization of thoughts and ideas in written compositions. Disorder of written expression is one of the more poorly understood learning disorders. Learning disabilities that only manifested themselves in written work were first described in the late 1960’s. These early studies described three types of written disorders: 1.) Inability to form letters and numbers correctly, also called dysgraphia 2.) inability to form words spontaneously or form dictation 3.) inability to organize words into meaningful thoughts.
There are several in studying disorder of written expression and in implementing a remedial program. Disorder of written expression usually appears in conjunction with other reading and learning disorders, making it difficult to seperate manifestations of the disability related to only to written expression. Delays are noted in attention, visual-motor integration, visual processing, and expressive language.
Children with Disorder of Written Expression experience great difficulty with the use of their writing skills. The writing skills of these students are significantly lower than their peers according to a typical child’s age, acumen, and schooling. Writing complete sentences and forming adequate paragraphs are challenges for those with disorder of written expression. Also, the individuals with the disorder tend to make excessive errors and appear to have poor understanding in the areas of punctuation, grammar, and spelling. Some common symptoms of people with disorder of written expression include: poor or illegible handwriting, poorly formed letters or numbers, excessive spelling errors, excessive punctuation errors, excessive grammar errors, sentences that lack logical cohesion, paragraphs and stories that are missing elements and that do not make sense or lack logical conclusions, and dificient writing skills that significantly impact academic achievement or daily life.
Disorder of written expression is almost always associated with other learning disorders like a reading or mathematics disorder, and it is frequently accompanied by low self-esteem, social problems, increased rates of school dropout, conduct disorder, attention deficit disorder, and possibly depression. Often times, people assume because a person is diagnosed with a learning disability, such as disorder of written expression, the individual must also have lower intelligence. However, people diagnosed with disorder of written expression often have average or above average intelligence.

Child vs. adult presentation

Gender and cultural differences in presentation

Epidemiology

Three to ten percent of school aged children in the United States are estimated to have disorder of written expression. Fifteen percent of the United States population are said to have a type of Learning Disability. When it is not comorbid with other learning disorders, a solitary experience with the disorder of written expression is extremely rare.
Deficits in written work may be attributed to a reading, language, or attention disorder, limited educational background, or lack of fluency in the language of the institution.
The cause of disorder of written expression is unknown because of lack of research surrounding the disorder. Certain facts support the idea that biological and environmental factors can contribute to learning disorders. Research has shown that high levels of testosterone in the fetus may cause language delays. Which could contribute to the idea that disorder of written expression is more prevalent in boys. Also, the particular conditions to which the fetus is exposed to while in utero may be linked to learning disorders, but not just specifically disorder of written expression. Environmental factors can also cause learning disorders, however, there is no certain cause of disorder of written expression.
There are different factors that could contribute to written expression disorder. Some of these factors include: prenatal, environmental, and intrinsic factors. Prenatal factors refer to potential toxins, infections, and/or nutritional deficits to a fetus. Intrinsic factors refers to neurobiology, biochemical, genetic, and other medical conditions.

Empirically supported treatments

There are no standard tests specifically designed to evaluate disorder of written expression.
Some tests that might be helpful in diagnosing disorder of written expression include the Diagnostic Evaluation of Writing Skills (DEWS), the Test of Early Written Language (TEWL), and the Test of Adolescent Language (TAL).
Intense writing remediation may help, but no specific method or approach has proved particularly successful. The person being evaluated should also perform tasks such as writing from dictation or copying written material as part of diagnostic testing.
The most effective treatment approach for disorder of written expression is remedial education. Because little is known about disorder of written expression, treatment is often aimed toward learning disorders that are more common or familiar. Noticeable improvement is frequently seen after treatment, but the degree to which one recovers depends on the severity of the disorder.
A qualified evaluator should compare multiple samples of the student’s written work with the written work normally expected from students of comparable backgrounds. The symptoms should be evaluated in light of a person’s age, intelligence, educational experience, and culture or life experience. Written expression must be substantially below the samples of produced by other’s of the same age, intelligence, and background.

Disorder of Written Expression (315.2) Copyright © 2020 by Bill Pelz and Herkimer Community College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Written Expression Learning Disorder Clinical Presentation

Author: Bettina E Bernstein, DO, DFAACAP, DFAPA; Chief Editor: Caroly Pataki, MD more...
Sections Written Expression Learning Disorder
Practice Essentials
Epidemiology
Pathophysiology
Patient Education
Approach Considerations
Other Tests
Medical Care

A detailed and comprehensive assessment benefits the child. Ideally, assessment information is collected from various sources, such as school and medical records, teachers, and parents, and includes scores on norm-referenced tests and a review of samples of the child's writing. Consider a child's difficulties with writing in the context of the type and amount of instruction received in writing. School evaluations that include observations of the child in class can offer crucial information about coexisting issues. For example, a child who is unable to attend to and complete tasks, or a child who has difficulty understanding spoken instructions, may produce inadequate written work.

Neuropsychological literature suggests obtaining the writing samples used in assessment by more than one method. The child should produce samples while copying from stimuli near and far, writing from dictation, and writing spontaneously with and without time constraints. Standardized test scores from psychometrically sound tests are considered the most valuable source of information in diagnosing learning disorders; however, historically, the development of standardized tests of written language has been considered a less refined area. Tests of achievement in written language vary in their make-up and methods of measuring skills. Consideration of test scores should include knowledge of what subskills are measured and how the test measures the skill. A determination of a disorder of written expression should provide information as to which components of writing cause significant problems for the child.

Components of written expression

Components of written expression are usually considered to include handwriting, capitalization and punctuation, spelling, vocabulary, word usage, sentence and paragraph structure, production (amount), overall quality, automaticity or fluency, and understanding of types of written material (text structure). In one analysis of the essential components of writing that require mastery, Baker and Hubbard included the child's level of knowledge about the writing process. [ 10 ]

Evaluation of written expression

Children's writing always should be evaluated with an awareness of skills that are developmentally appropriate. Evaluation of the child's mastery of the mechanics of written language is more straightforward than assessing quality.

When assessing handwriting, consider the child's posture, pencil grip, and paper position along with any issues related to hand dominance of the child. Evaluate the writing for letter formation quality, size, spacing, slant alignment, rate, and overall legibility.

Expectations of punctuation and capitalization skill mastery coincide with developmental levels. For example, Greene and Petty have formulated punctuation and capitalization rules that are mastered by each year of elementary school. Measurement of spelling skills should include not only a percentage of errors, but the types of errors made; therefore, a determination can be made if the child has mastered word analysis skills, including phonological techniques.

An assessment of sentence and paragraph formation evaluates adherence to conventions of grammar, logic, and success in communicating ideas. Attempts to evaluate quality of content are less quantifiable; these are aspects of the assessment that are often considered informal. Methods such as the scoring of included traits of the writing sample and holistic assessments of the functional success of the writing sample have been used. Mather and Roberts provide a thorough review of informal writing assessment and, also, instruction in written expression.

A significant difficulty in written expression can interact with other aspects of the child's functioning. An ecological approach to assessment is recommended for the design of the most effective treatment approach, which considers children in their environments and evaluates not only written expression issues, but other learning, psychosocial, family, and community issues. This type of assessment helps in identifying what resources are available to the child and what obstacles to treatment may be encountered.

Etiologically, children with learning disorders are a heterogeneous group and manifest numerous specific learning problems. The concept of disordered learning hinges on comparing children's functioning in a specific academic area with their overall intellectual functioning. The consideration of learning problems has a background in the medical and educational fields.

Acquired brain injuries in adults and the impact of such injuries on cognitive skills were considered early in the twentieth century. This consideration was extended to include children's learning difficulties. In the 1960s, the term minimal brain dysfunction was used to refer to children with learning problems of implied neurological basis. Today, the etiology of learning disorders includes consideration of intrinsic, perinatal, and extrinsic (environmental) factors. Intrinsic factors include neurobiological, biochemical, genetic, and other medical conditions. Twin studies have given evidence that a group of children with both mathematics and language disorders have shared genetic influences.

Neurobiological factors

Abnormally high testosterone levels, especially during male fetal gestation at 16-24 weeks' gestation, may correlate with left hemispheric hypofunctioning and language delays. Other prenatal factors that may play a role in learning disorders include eclampsia, placental insufficiency, cord compression, malnutrition and bleeding during pregnancy.

Neurobiological factors are assumed to underlie some written expression disorder and other learning disorder cases. Studies have compared EEGs of patients with dyslexia with control groups and have found a significantly higher prevalence of abnormal EEG findings in the former group. Other studies have used functional neuroimaging techniques to compare children who are learning disabled and children who are not learning disabled. Based on CT scan and MRI findings, deviations from normal brain symmetry have been found in patients with dyslexia, and unusual patterns of brain asymmetry may also be related to expressive language dysfunction.

Neuropsychological factors

Neuropsychological research suggests that abnormalities in cognitive processes (eg, visual-motor, linguistic, attentional, memory) underlie learning disorders. Measurement of these neuropsychological process deficits is not universally accepted as reliable and valid; however, the following subtypes of written expression disorders based on neuropsychological performance patterns may be useful to consider: fine-motor and linguistic deficits, visual-spatial deficits, attention and memory deficits, and sequencing deficits.

Genetic factors

Evidence for a genetic component in learning disorders is suggested by family and twin studies. The mode of inheritance has not been determined. Perinatal exposure to infections and toxins, early nutritional deficits, and other medical conditions are possibly related to learning disorders. Conditions highly associated with learning disorders include carbon monoxide poisoning, lead poisoning, and fetal alcohol syndrome (FAS). However, many children with learning disorders have no history of medical or neurological conditions. The notion that food allergies are related to learning problems has not been proven by randomized controlled trials. Although controversial, some investigators have attempted to link deterioration in handwriting legibility to exposure to foods or toxins. Mega vitamin treatment of learning disorders does not have proven efficacy in placebo-controlled trials and may be unsafe due to potential for neurological toxicity, especially from B-complex vitamins.

Poor school performance does not always indicate a learning disorder. Environmental factors (eg, lack of accessibility to teaching) alone can potentially impede learning, but evaluating the contribution is often not simple. In reality, a range of causes is observed with the interactions of the physical, psychological, and environmental. Although further understanding of the etiology of a learning disorder such as written expression disorder is relevant to determining the best interventions, current educational practices may be slow to adopt new research findings.

Adverse reactions to medications may be mediated by genetic factors and negatively impact written expression. A recent case study suggested that treatment with topiramate might cause impairment in written expression in vulnerable individuals; therefore, a careful history including medication history is important to exclude other iatrogenic causes of impairment in written expression. [ 11 ]

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Contributor Information and Disclosures

Bettina E Bernstein, DO, DFAACAP, DFAPA Distinguished Fellow, American Academy of Child and Adolescent Psychiatry; Distinguished Fellow, American Psychiatric Association; Clinical Assistant Professor of Neurosciences and Psychiatry, Department of Psychiatry/Psychiatric Medicine, Philadelphia College of Osteopathic Medicine; Clinical Affiliate Medical Staff, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia; Consultant to Gemma Services, Private Practice; Consultant PMHCC/CBH at Family Court, Philadelphia Bettina E Bernstein, DO, DFAACAP, DFAPA is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry , American Psychiatric Association Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Nothing to disclose.

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry , New York Academy of Sciences , Physicians for Social Responsibility Disclosure: Nothing to disclose.

Angelo P Giardino, MD, PhD, MPH, FAAP Wilma T Gibson Presidential Professor and Chair, Department of Pediatrics, University of Utah School of Medicine; Chief Medical Officer, Intermountain Primary Children's Hospital Angelo P Giardino, MD, PhD, MPH, FAAP is a member of the following medical societies: Academic Pediatric Association , American Academy of Pediatrics , American Professional Society on the Abuse of Children , Harris County Medical Society , International Society for the Prevention of Child Abuse and Neglect , Ray E Helfer Society Disclosure: Nothing to disclose.

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Case Study: Reading and Written Expression Disorders

Clinician Sandra Giglio , Professionally Certified Educational Therapist, Charlotte Christian School

Background Client name: “M” Gender/Age: female/12 years of age Diagnoses: reading disorder; disorder of written expression Previous therapies: M has received educational therapy for 2 years. iLs was done as a supplement to her educational therapy during the last year of her therapy.

Presenting Problems Reading disorder and written expression disorder

Therapeutic Goals To increase fluency in reading, writing and math To increase written expression skills

iLs Program Used Program name: Concentration & Attention Frequency: forty 45-minute sessions at a frequency of two-three per week over a period of five months

History M was first diagnosed with a learning disorder in the fall of 2008. At that time she was given a full battery of psychoeducational testing.

When M changed schools in 2010 she was experiencing some anxiety in the classroom. She displayed difficulty with reading and written expression, particularly with phonetic decoding, spelling and organizing her thoughts to transfer to writing.

M’s reading fluency was extremely halted. She would use stalling techniques to help camouflage the breaks and allow more “thinking time” for decoding. She displayed multiple hesitations, repetitions and would frequently omit endings and punctuation.

M appeared to have no defined dominance. She would switch from her right hand to her left, depending on the task and the speed in which she wanted to perform the task.

M was highly distractible. She would often interrupt her thoughts and side-track with a story of something totally unrelated. Noises or activity around her would disrupt her concentration and attention.

M is a vivacious and outspoken young lady. She is a twin who plays the role of the underdog. Her twin is a high achiever and easily earns good grades. M, on the other hand, worked hard to earn the grades that she got and seemed to be in constant competition with her sister.

M’s performance in the classroom and in therapy was often sabotaged by her lack of emotional control. She would shut down emotionally if a task was too challenging or not enjoyable enough. M also had a difficult time handling failure and criticism.

Other Interventions Used M participated in the NILD (National Institute for Learning Differences) educational therapy program offered at her school. I have been M’s therapist since 2010, and I have had a long standing working relationship with her prior to beginning iLs.

Education therapy targeted:

Reading fluency
Language processing

In the first year of therapy there was a significant decline noted in the area of written expression. M seemed to develop an aversion to writing and was quite resistant to writing activities in therapy.

M began her second year of therapy at the beginning of the 2011-2012 school year, upon entering the 6 th grade. We started the year implementing the iLs Concentration & Attention Program. Sessions were limited to 45 min. to fit into the school schedule.

Summary of Changes (Tests, Observations, Feedback, etc.) Results from the pre- and post-testing of the Woodcock-Johnson III Achievement Test:

Conclusions and Recommendations Adding iLs to M’s educational therapy regime during an academic year appears to have helped her make significant gains in reading and writing. Her scores on the Woodcock-Johnson writing tests went from a percentile ranking of 13% to 66%. Her aversion to writing has decreased while her ability to write a concise and informative paragraph has increased considerably.

M also made gains in the following academic areas:

reading and math fluency have increased
no longer employs her stalling technique as she reads
13 point increase in her measured vocabulary scores
although she continues to struggle with decoding, reading for pleasure has become her favorite pastime
organized a reading club with her peers and is tackling more difficult books

In the areas of cognitive and emotional function:

is much improved in her ability to handle stress
has more control over her emotions
has more staying power – even when not enjoying a task she will push through to completion
is now able to show response inhibition, task initiation, planning and prioritizing along with improvements in time management
has established dominance on her right side

As shown with the percentile data above, some of the gains were not as significant compared to the observed changes in behavior and performance. Quite often, emerging qualitative changes are not always immediately reflected in the test scores. It is also worth noting that a child with learning disabilities has often fallen behind their peers; therefore, gains made may indicate significant growth for that individual even though they are still not testing at grade level.

Prior to adding iLs to her educational therapy, M had been on a downward trend. Her academic scores were showing an overall decline each year. It seems apparent that with the addition of iLs, we have reversed this downward trend.

In light of the overall growth from this past year, I would conclude that including iLs with her educational therapy was efficacious and I would recommend that M continue with iLs therapy. The next logical step might be the iLs Reading & Auditory Processing Program, given her continuing struggle with decoding and reading fluency.

Comments by Ron Minson, MD, iLs Clinical Director The presenter wisely remarks that qualitative changes often precede test score improvement. I would add that this is true of grades, as well. In working with children academically behind in school, I always counseled parents to not expect the grades to go up for at least a year. What we are doing in iLs is putting in place the neurological foundation for learning, improving the subcortical processing of sensory input and increasing the speed of processing. This takes time.

Once this foundation is established, learning is poised to take off. Parents need this admonition because they tend to react to their anxiety around their child’s failure by putting undue pressures on themselves, the child, the teacher and often the therapist or educational specialist, as well. This only makes matters worse and continued failure is the result. In this presentation, the child losing ground while in good educational therapy must be a fearful experience for the parents and confusing to the specialist. Until subcortical organization is established, often cognitive-based therapies and learning tools fail to reach their expected results.

I want to emphasize one of the most important outcomes, namely M having established right dominance! This is critical to improved brain organization. I would hazard an educated guess that the lack of laterality played a major role in M’s struggles. I would strongly urge that the iLs Interactive Language Program (ILP) be included in her next phase. M may very well still have a left dominant ear and will benefit from encouraging a right ear dominance which is possible with the ILP. Her difficulties continue to be with decoding and reading for which the ILP is ideally suited.

Abnormal Psychology

Disorder of written expression (315.2), dsm-iv-tr criteria.

A. Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given the person's chronological age, measured intelligence, and age-appropriate education.
B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g., writing grammatically correct sentences and organized paragraphs).
C. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.
Coding note: If a general medical (e.g., neurological) condition or sensory deficit is present, code the condition on Axis III.

Associated features

This disorder was previously called developmental expressive writing disorder. This disabilitiy affects both the physical reproduction of letters and the organization of thoughts and ideas in written compositions. Disorder of written expression is one of the more poorly understood learning disorders. Learning disabilities that only manifested themselves in written work were first described in the late 1960's. These early studies described three types of written disorders: 1.) Inability to form letters and numbers correctly, also called dysgraphia 2.) inability to form words spontaneously or form dictation 3.) inability to organize words into meaningful thoughts.
There are several in studying disorder of written expression and in implementing a remedial program. Disorder of written expression usually appears in conjunction with other reading and learning disorders, making it difficult to seperate manifestations of the disability related to only to written expression. Delays are noted in attention, visual-motor integration, visual processing, and expressive language.
Children with Disorder of Written Expression experience great difficulty with the use of their writing skills. The writing skills of these students are significantly lower than their peers according to a typical child’s age, acumen, and schooling. Writing complete sentences and forming adequate paragraphs are challenges for those with disorder of written expression. Also, the individuals with the disorder tend to make excessive errors and appear to have poor understanding in the areas of punctuation, grammar, and spelling. Some common symptoms of people with disorder of written expression include: poor or illegible handwriting, poorly formed letters or numbers, excessive spelling errors, excessive punctuation errors, excessive grammar errors, sentences that lack logical cohesion, paragraphs and stories that are missing elements and that do not make sense or lack logical conclusions, and dificient writing skills that significantly impact academic achievement or daily life.
Disorder of written expression is almost always associated with other learning disorders like a reading or mathematics disorder, and it is frequently accompanied by low self-esteem, social problems, increased rates of school dropout, conduct disorder, attention deficit disorder, and possibly depression. Often times, people assume because a person is diagnosed with a learning disability, such as disorder of written expression, the individual must also have lower intelligence. However, people diagnosed with disorder of written expression often have average or above average intelligence.

Child vs. adult presentation

Gender and cultural differences in presentation, epidemiology.

Three to ten percent of school aged children in the United States are estimated to have disorder of written expression. Fifteen percent of the United States population are said to have a type of Learning Disability. When it is not comorbid with other learning disorders, a solitary experience with the disorder of written expression is extremely rare.
Deficits in written work may be attributed to a reading, language, or attention disorder, limited educational background, or lack of fluency in the language of the institution.
The cause of disorder of written expression is unknown because of lack of research surrounding the disorder. Certain facts support the idea that biological and environmental factors can contribute to learning disorders. Research has shown that high levels of testosterone in the fetus may cause language delays. Which could contribute to the idea that disorder of written expression is more prevalent in boys. Also, the particular conditions to which the fetus is exposed to while in utero may be linked to learning disorders, but not just specifically disorder of written expression. Environmental factors can also cause learning disorders, however, there is no certain cause of disorder of written expression.
There are different factors that could contribute to written expression disorder. Some of these factors include: prenatal, environmental, and intrinsic factors. Prenatal factors refer to potential toxins, infections, and/or nutritional deficits to a fetus. Intrinsic factors refers to neurobiology, biochemical, genetic, and other medical conditions.

Empirically supported treatments

There are no standard tests specifically designed to evaluate disorder of written expression.
Some tests that might be helpful in diagnosing disorder of written expression include the Diagnostic Evaluation of Writing Skills (DEWS), the Test of Early Written Language (TEWL), and the Test of Adolescent Language (TAL).
Intense writing remediation may help, but no specific method or approach has proved particularly successful. The person being evaluated should also perform tasks such as writing from dictation or copying written material as part of diagnostic testing.
The most effective treatment approach for disorder of written expression is remedial education. Because little is known about disorder of written expression, treatment is often aimed toward learning disorders that are more common or familiar. Noticeable improvement is frequently seen after treatment, but the degree to which one recovers depends on the severity of the disorder.
A qualified evaluator should compare multiple samples of the student's written work with the written work normally expected from students of comparable backgrounds. The symptoms should be evaluated in light of a person's age, intelligence, educational experience, and culture or life experience. Written expression must be substantially below the samples of produced by other's of the same age, intelligence, and background.

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Disorder of written expression and dysgraphia: definition, diagnosis

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Disorder of written expression and dysgraphia: definition, diagnosis
Dysgraphia and disorders of written expression can have lifelong impacts, ... As in the case for other learning disorders, a key factor should be the degree of difficulty that the writing impairment imposes on the child's access to the general education curriculum. ... An fMRI study. Hum Brain Mapp 2011; 32:1250-9. 10.1002/hbm.21105 [PMC free ...
(PDF) Disorder of written expression and dysgraphia: definition
Dysgraphia is a learning condition that impairs a person's ability to write in a variety of ways. Dysgraphia, in its widest sense, refers to problems with letter formation/legibility, letter ...
Disorders of Written Expression
Disorders of Written Expression very often co-occur with other specific learning disorders and developmental disorders. We will describe how the manifestation of the writing disability may vary depending on which of the key components are impacted by the learning or developmental disorder. ... Box 4.1 Case Study 1 Sample Essay in Response to ...
Disorder of Written Expression (315.2)
99 Disorder of Written Expression (315.2) DSM-IV-TR criteria. A. Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given the person's chronological age, measured intelligence, and age-appropriate education.
Disorder of written expression and dysgraphia: definition, diagnosis
Abstract. Writing is a complex task that is vital to learning and is usually acquired in the early years of life. 'Dysgraphia' and 'specific learning disorder in written expression' are terms used to describe those individuals who, despite exposure to adequate instruction, demonstrate writing ability discordant with their cognitive level and age.
Disorder of Written Expression (315.2)
These early studies described three types of written disorders: 1.) Inability to form letters and numbers correctly, also called dysgraphia 2.) inability to form words spontaneously or form dictation 3.) inability to organize words into meaningful thoughts. There are several in studying disorder of written expression and in implementing a ...
PDF Vanderbilt University
Vanderbilt University
PDF Disorders of Written Expression 4
Incidence and Impact of Disorders of Written Expression Research into the incidence and prevalence of Disorders of Written Expression dates back only about 20 years. In 2009, Katusic et al. used a population-based birth cohort between 1976 and 1982 in Rochester, Minnesota, to estimate the prevalence of Disorders of Written Expression in
A Qualitative Case Study Exploring Best Practices for ...
A qualitative case study was conducted to explore best practices for accommodating elementary, middle, and high school students with written expressive disorders. Students with disorders of written expression experience significant impairments in writing for their age, intelligence, and educational experience. Accommodations are crucial interventions for students with written expressive ...
Disorder of written expression and dysgraphia: definition, diagnosis
Disorder of written expression and dysgraphia: definition, diagnosis, and management ... As in the case for other learning disorders, a key factor should be the degree of difficulty that the writing impairment imposes on the child's access to the general education curriculum. ... Gubbay SS, de Klerk NH. A study and review of developmental ...
(PDF) Disorders of written expression
We report a case of disorder of written expression because of its rarity. Read more. Article. Language through Reading. May 2007 · British Journal of Special Education. Muriel Gillies;
Written Language Disorders
A disorder of written language involves a significant impairment in fluent word reading (i.e., reading decoding and sight word recognition), reading comprehension, written spelling, and/or written expression (Ehri, 2000; Gough & Tunmer, 1986; Kamhi & Catts, 2012; Tunmer & Chapman, 2007, 2012). A word reading disorder is also known as dyslexia.. An appropriate assessment and treatment of ...
Disorder of written expression
Dysgraphia is as common as other learning disorders. A child can have dysgraphia only or with other learning disabilities, such as: Developmental coordination disorder (includes poor handwriting) Expressive language disorder. Reading disorder. Attention deficit hyperactivity disorder (ADHD)
What is written expression disorder?
Written expression disorder is a learning challenge that impacts writing. The formal diagnosis is "specific learning disorder with impairment in writing.". Schools might call it a learning disability in writing. This lifelong disorder makes it hard to express thoughts in writing. People might have great ideas.
Case Study: Reading and Written Expression Disorders
Reading disorder and written expression disorder. Therapeutic Goals. To increase fluency in reading, writing and math. To increase written expression skills. iLs Program Used. Program name: Concentration & Attention. Frequency: forty 45-minute sessions at a frequency of two-three per week over a period of five months.
Disorder of Written Expression (315.2)
Disorder of Written Expression (315.2) Bill Pelz and Herkimer Community College. DSM-IV-TR criteria. A. Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given the person's chronological age, measured intelligence, and age-appropriate education.
Disorder of written expression: A case report
Abstract. Disorders of written expression often accompany reading or other learning difficulties. Not enough research has been carried out in isolated written expression problems in confrast isin ...
Written Expression Learning Disorder Clinical Presentation
Other prenatal factors that may play a role in learning disorders include eclampsia, placental insufficiency, cord compression, malnutrition and bleeding during pregnancy. Neurobiological factors are assumed to underlie some written expression disorder and other learning disorder cases. Studies have compared EEGs of patients with dyslexia with ...
6.69: Disorder of Written Expression (315.2)
These early studies described three types of written disorders: 1.) Inability to form letters and numbers correctly, also called dysgraphia 2.) inability to form words spontaneously or form dictation 3.) inability to organize words into meaningful thoughts. There are several in studying disorder of written expression and in implementing a ...
Disorder of written expression and dysgraphia: definition, diagnosis
Introduction: definitions and disagreement. At its broadest definition, 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. Acquired dysgraphia occurs when existing brain pathways are disrupted ...
PDF Case Studies for Written Expression Difficulties
Age 14.1 Grade 8.9. Poor study skills resulted in mandatory summer school for failing science and history. Study skills class scheduled for 9th grade. Difficulty completing/submitting assignments. Very resistant to academic tasks, especially writing tasks. Slow verbal responses. Justin Case.
Case Study: Reading and Written Expression Disorders
Clinician Sandra Giglio, Professionally Certified Educational Therapist, Charlotte Christian School Background Client name: "M" Gender/Age: female/12 years of age Diagnoses: reading disorder; disorder of written expression Previous therapies: M has received educational therapy for 2 years. iLs was done as a supplement to her educational therapy during the last year of her therapy ...
Disorder of Written Expression (315.2)
These early studies described three types of written disorders: 1.) Inability to form letters and numbers correctly, also called dysgraphia 2.) inability to form words spontaneously or form dictation 3.) inability to organize words into meaningful thoughts.

Disorder of written expression and dysgraphia: definition, diagnosis, and management

Dilip R. Patel

Iman Nizami

Introduction: definitions and disagreement

Writing development

Mechanisms and etiology

Co-morbidities

Accommodations

Modifications

Remediation

Conclusions

Acknowledgments

99 Disorder of Written Expression (315.2)

Associated features

Child vs. adult presentation

Gender and cultural differences in presentation

Epidemiology

Empirically supported treatments

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