Writing, a cornerstone of learning and communication, typically develops in early childhood. However, for some individuals, this process is significantly challenging. Terms like “dysgraphia” and “specific learning disorder in written expression” describe those who struggle with writing skills despite adequate education, exhibiting abilities that are inconsistent with their cognitive level and age. Dysgraphia manifests differently across ages, and various theories attempt to explain its underlying mechanisms. Often misunderstood and underdiagnosed, dysgraphia frequently co-occurs with other learning and mental health disorders. While diagnosis and intervention are often centered in educational settings, pediatricians and other healthcare professionals play a crucial role in early identification, comorbidity assessment, and providing essential guidance and support.
Keywords: Dysgraphia Diagnosis, specific learning disorder, written expression difficulties, learning disability assessment, dysgraphia symptoms, interventions for dysgraphia
Defining Dysgraphia and Addressing Disagreements
Dysgraphia, broadly defined, is a disorder affecting writing abilities at any stage. This encompasses a range of challenges, from forming legible letters and proper spacing to spelling, fine motor coordination, writing speed, grammar, and composition. While acquired dysgraphia results from brain pathway disruption due to injury or disease, this article focuses on developmental dysgraphia diagnosis: the difficulty in acquiring writing skills despite sufficient learning opportunities and cognitive capacity. We will use “dysgraphia” and “specific learning disorder with impairment in written expression” to broadly cover any challenges in written communication.
Significant debate surrounds the precise definition and characteristics of dysgraphia, often influenced by the theoretical perspectives on its origins (1). Historically, dysgraphia was primarily seen as a problem in producing written text, often attributed to poor muscle coordination. Assessments of affected children pointed to subtle differences in fine motor skills (e.g., finger tapping speed) or reduced hand strength and endurance (2). These deficits, rooted in fine motor coordination, visual perception, and proprioception, resulted in slow and illegible handwriting. Importantly, oral spelling was usually unaffected. This view of dysgraphia was classified as “motor” or “peripheral” dysgraphia (3).
Subsequently, Deuel (4) proposed “spatial dysgraphia” as another subtype. This form was believed to stem from spatial perception issues, leading to problems with letter spacing and significantly impacting drawing ability. Individuals with spatial dysgraphia typically had preserved oral spelling and finger tapping skills but struggled with drawing, spontaneous writing, and copying text.
However, a different perspective emphasizes language processing deficits as the core issue in written expression, minimizing the role of motor problems. Terms like “dysorthography,” “linguistic dysgraphia,” or “dyslexic dysgraphia” are used to describe this type (5). This perspective highlights inefficiency in the “graphomotor loop,” where phonological memory (sound-phoneme associations) interacts with orthographic memory (written letter representations). Impaired verbal executive functions, including storage and working memory, are also linked to this subtype (5). In linguistic dysgraphia, oral spelling, drawing, copying, and finger tapping skills are generally intact. Contrastingly, dyslexia is theorized to arise from dysfunction in the “phonologic loop,” the communication between orthographic and phonologic processes, which is related to but distinct from dysgraphia.
The Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) (6) includes dysgraphia under the broader category of specific learning disorders, not as a separate diagnosis. DSM-5 criteria require persistent symptoms (Table 1) for at least six months, despite appropriate interventions. A diagnosis of specific learning disorder necessitates that academic skills, measured by standardized individual assessments, are significantly below what is expected for the child’s age. Learning difficulties typically emerge during early school years but become more pronounced as academic demands increase in higher grades. It is critical to rule out other potential causes of learning difficulties, such as intellectual disability, sensory impairments (vision or hearing), underlying mental or neurological disorders, and inadequate learning support or instruction.
Table 1. Symptoms of specific learning disorder: APA DSM-5.
| 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, provides a broad definition of “Specific Learning Disability” (7):
- ❖ A child does not achieve adequately for their age or meet state-approved grade-level standards in one or more of the following areas, when provided with appropriate learning experiences and instruction: oral expression, listening comprehension, written expression, basic reading skills, reading fluency skills, reading comprehension, mathematics calculation, or mathematics problem-solving.
- ❖ A child does not make sufficient progress to meet age or state-approved grade-level standards in one or more of these areas when using a process based on their response to scientific, research-based intervention; or exhibits a pattern of strengths and weaknesses in performance, achievement, or both, relative to age, state-approved grade-level standards, or intellectual development, as determined by a group and deemed relevant to identifying a specific learning disability, using appropriate assessments. Furthermore, the group must determine that these findings are not primarily due to visual, hearing, or motor disability; intellectual disability; emotional disturbance; cultural factors; environmental or economic disadvantage; or limited English proficiency.
Between 10% and 30% of children experience writing difficulties, with prevalence varying based on the definition of dysgraphia used (8). Like many neurodevelopmental conditions, dysgraphia is more common in boys than girls (9. Handwriting issues are a frequent reason for occupational therapy referrals. Dysgraphia and written expression disorders can have lasting impacts, affecting vocational progress and daily living activities into adulthood (10).
The Developmental Stages of Writing
Writing development is a gradual process, progressing from basic transcription to complex composition. Writing skills are crucial for academic success and are linked to overall academic achievement (11). Writing tasks can occupy up to half of the school day (12, highlighting the significant impact of writing difficulties. Students with dysgraphia are often mislabeled as careless or unmotivated rather than recognized as having a learning disorder. Poor handwriting is associated with lower self-perception, self-esteem, and social functioning (13,14).
Writing acquisition follows a step-by-step progression in early childhood. Children struggling with foundational writing skills are likely to fall further behind as their peers advance. In preschool, children learn to copy symbols and shapes, developing visual-motor coordination essential for transcription. Letter awareness typically begins in kindergarten and continues through second grade, during which children learn sound-phoneme relationships and refine motor skills (15). Automaticity, where letter writing becomes a rote skill, is usually achieved by third grade (16). With some curricula reducing explicit instruction in letter formation, children who struggle to develop automaticity may not acquire this crucial skill (5,17. Automaticity and handwriting should continue to improve throughout elementary school (18, impacting long-term outcomes. Automaticity is linked to higher quality and length of written work in high school and college (19,20).
Beyond early grades, writing projects demand organization, planning, and completion of a full written piece. These tasks rely on executive functions and higher-order language processing. For instance, writing a sentence involves several steps: (I) formulating the intended statement; (II) breaking down the statement into transcribable sections; (III) holding these sections in verbal working memory while writing; and (IV) verifying that the written product matches the original thought. More complex writing, like paragraphs or essays, requires additional planning, organization, and revision to connect multiple ideas coherently. Failure to develop writing automaticity by third grade significantly increases the likelihood of difficulties with complex writing tasks, as cognitive resources become consumed by the mechanics of letter formation.
Mechanisms and Underlying Causes of Dysgraphia
Many theories about dysgraphia’s mechanisms come from studies of acquired dysgraphia (21,22). Writing is a complex process requiring higher-order cognition (language, verbal working memory, and organization) integrated with motor planning and execution to form a functional writing system (23). Different writing tasks engage different cognitive processes, and dysgraphia can stem from impairments in one or more of these areas. For example, spelling a dictated word involves phonological awareness to access phonological long-term memory and related lexical-semantic representations. This then activates orthographic long-term memory for abstract letter representations, requiring motor planning and coordination, all managed within working memory. Spelling pseudowords or new words requires sublexical spelling processes, applying phoneme-grapheme rules. Spontaneous word generation begins with orthographic skills accessing lexical representations. Rapid, fluent writing relies on cerebellar-mediated motor planning and coordination. Throughout writing, visual and auditory processing and attention are vital for legible output.
Impairment in any part of this writing process can hinder age-appropriate writing ability (24). While subtypes of dysgraphia were initially linked to distinct mechanisms (25), recent research shows interconnectedness between brain areas for automaticity, language, and motor coordination. The perceived differences between dysgraphia theories may be less pronounced than previously thought. For instance, children with dyslexia also show increased risk for subtle motor deficits in tasks like finger tapping, cycling, and shoe-tying.
The cerebellum’s role in dysgraphia is gaining attention. Case studies of cerebellar injury causing acquired dysgraphia suggest its importance in writing coordination (21). Functional imaging studies also highlight the cerebellum’s role in language and automaticity (26). One hypothesis suggests the cerebellum helps develop a neural framework, which, if disrupted in various ways, can lead to different functional impairments (1).
Genetics and their role in learning disorder etiology and mechanisms are an emerging field. Genetic studies suggest verbal executive function, orthographic skills, and spelling ability have a genetic basis. Genes on chromosome 15 have been linked to poor reading and spelling (27, and chromosome 6 genes to phonemic awareness (28). Individuals with learning disabilities and their family members show different brain activation patterns in fMRI studies, suggesting a genetic component, though not direct causation (29). As genetics research advances, more insights into the genetic underpinnings of learning disorders like dysgraphia are expected.
Common Co-occurring Conditions with Dysgraphia
Dysgraphia can occur in isolation, but it commonly coexists with dyslexia and other learning disorders. Depending on definitions, 30% to 47% of children with writing problems also have reading problems. Writing difficulties are also seen in neurodevelopmental disorders such as attention-deficit/hyperactivity disorder (ADHD), cerebral palsy, and autism spectrum disorder (ASD). Research indicates that 90–98% of children with these disorders struggle with writing (29–32). Developmental coordination disorder (DCD), characterized by motor development and skill acquisition deficits, often impacts writing; about half of those with DCD also have impaired writing abilities (33). Regarding learning and mental health disorders, comorbidity is common (34,35. Given this high comorbidity risk, clinicians should screen patients for related conditions. For example, a patient with ASD should be monitored for reading, writing, and math problems, while a patient with dysgraphia may warrant assessment for comorbid ADHD.
Recognizing Red Flags for Dysgraphia
As academic demands increase and neurodevelopment progresses, dysgraphia symptoms can vary. It can affect one or more aspects of writing. Handwriting skills develop in early school years, so dysgraphia may not be apparent then. Isolated dysgraphia, in particular, may remain undiagnosed even into young adulthood. Dysgraphia co-occurring with dyslexia is more readily identified, though reading impairments often take priority over writing issues. The National Center for Learning Disabilities provides a summary of dysgraphia warning signs by age and developmental stage (Table 2) (36). Symptoms progress from concrete impairments at younger ages to more abstract difficulties later on.
Table 2. Signs of dysgraphia: United States National Center for Learning Disabilities.
| 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 |
| Difficulty with written syntax and written grammar that is not duplicated with oral tasks |
The Process of Dysgraphia Diagnosis
Dysgraphia diagnosis is typically made in educational settings through a team assessment, often involving occupational therapists, speech therapists, physical therapists, special education teachers, and educational psychologists. In the US, diagnosis most often follows assessment for eligibility for an Individualized Education Program (IEP) (36). Psychoeducational evaluations outside the school system can also diagnose learning disabilities or dysgraphia. As “dysgraphia” isn’t recognized as a distinct diagnostic category by the American Psychological Association, there is no strict professional consensus on specific diagnostic criteria. As with other learning disorders, a key diagnostic factor is the degree to which writing impairment hinders a child’s access to the general education curriculum. Evidence should be gathered from multiple sources and contexts, including observations, anecdotal reports, work samples, and normative data.
Expert recommendations for dysgraphia diagnosis include: slow writing speed, illegible handwriting, inconsistency between spelling ability and verbal IQ, and processing delays in graphomotor planning, orthographic awareness, and/or rapid automatized naming. Secondary assessments to consider include pencil grip and writing posture evaluations. Standardized handwriting assessments (Table 3) can measure writing speed and legibility when copying letters, words, sentences, and pseudowords. Visual-motor integration assessments, such as the Beery Developmental Test of Visuomotor Integration (VMI) (37), may be used, but these often don’t specifically analyze orthographic processing difficulties. Children suspected of having dysgraphia should also be evaluated for other potential learning problems due to the high comorbidity with dyslexia and other learning disorders.
Table 3. Examples of standardized writing assessment tools.
| 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) |
No specific medical tests are required or available for dysgraphia diagnosis. However, given the high comorbidity with psychiatric, neurodevelopmental, and learning disorders, physicians should investigate for symptoms of related conditions. A thorough neurological exam should be conducted, including assessment for “soft” neurological signs like poor coordination, dysrhythmias, mirror movements, and overflow movements. Comorbid neurodevelopmental disorders (e.g., ASD, ADHD) and mood disorders (e.g., anxiety, depression) can be assessed using semi-structured interviews and/or validated parent and teacher rating scales. If screening raises concerns, referral to specialists like child neurologists, child psychiatrists, developmental-behavioral pediatricians, or other mental health professionals should be considered for further diagnostic evaluation and treatment recommendations.
Management and Interventions for Dysgraphia
The primary intervention for dysgraphia and other learning disorders takes place within the educational setting. Interventions generally fall into three levels: (I) accommodation, providing supportive resources without changing educational content; (II) modification, adapting learning goals and providing services to mitigate disability effects; and (III) remediation, offering specific interventions to reduce disability severity. As dysgraphia symptoms and learning demands evolve, management is an ongoing process that must adapt to the individual’s current needs. As mandated by IDEA, the school system is responsible for assessing and providing necessary educational supports.
Accommodations for Dysgraphia
Accommodations aim to reduce writing-related stress. These can include specialized tools like larger pencils with grips and paper with raised lines for tactile feedback. Extended time for assignments and tests is often beneficial. Alternative knowledge demonstration methods (e.g., oral or recorded responses) can be considered. Technological aids like spellcheck, voice-to-text software, tablets, and computer keyboards are valuable. As technology advances, new tools should be considered for classroom use. However, handwriting practice should continue as written language remains essential for many daily tasks. Research also suggests that handwriting may uniquely enhance learning (38). It is important to note that accommodations may not directly address executive function challenges related to writing, such as planning and organization. While computers and voice-to-text can reduce stress for those with automaticity issues, they don’t solve higher-level writing difficulties (39).
Modifications for Dysgraphia
Dysgraphia may necessitate modifications to a student’s academic program, especially regarding written work. Teachers can reduce the length of written assignments, break down large projects, or grade based on a single aspect of work (e.g., content or spelling, but not both). Following the principle of the “least restrictive environment,” schools should aim to keep students in mainstream education as much as possible.
Remediation Strategies for Dysgraphia
Remediation intensity should be tailored to the student’s specific writing difficulties. Early intervention is crucial for maximizing gains (24). A tiered approach, like the response-to-intervention (RTI) model, can be used. RTI involves three intervention tiers, with students progressing to higher tiers if they continue to struggle. Tier 1 involves universal screening for learning differences. Expert guidelines exist for general education teachers on fostering good writing habits (9). Tier 2 provides targeted interventions for students with specific learning issues. Tier 3 offers the most intensive support for students who continue to struggle significantly. Most intervention studies show student improvement after around 20 lessons over several weeks.
Early elementary interventions often focus on fine motor skill development. Activities to improve hand coordination and strength include tracing, mazes, clay play, finger tapping, and hand exercises. Teaching grip control and good posture is also included. However, research indicates that combining motor skills training with orthographic skills instruction is most effective (40). One orthographic teaching method, described by Berninger (19), involves students visually learning letter formation steps (using numbered arrow cues), visualizing letter writing, using cues to write the letter, and comparing the written product to the sample (41). Other techniques emphasize movement-based learning over product-focused learning, such as using video models instead of static guides (42) and using placeholder pens without ink (43).
Families should encourage enjoyable writing activities outside of school to foster a positive association with writing. Educational games and activities can help students practice retrieving letters from long-term memory (44).
Students with dysgraphia may also need help with complex writing aspects like planning, drafting, and revising, especially in middle and high school. Randomized controlled trials have shown “writing clubs” can improve these skills. The self-regulated strategy development (SRSD) program is another validated approach with sustained effectiveness (45). SRSD explicitly teaches writing strategies and self-regulation, with students actively involved in the learning process. Students with persistent writing difficulties in middle and high school may require specialized composition instruction (46,47. Several psychoeducational programs (Table 4), handwriting programs (Table 5), and support groups (Table 6) are valuable resources for children with dysgraphia, their families, and professionals.
Table 4. Psychoeducational resources for parents.
| 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 (http://www.interdys.org/ewebeditpro5/upload/Understanding_Dysgraphia_Fact_Sheet_12-01-08.pdf) |
| What is Dysgraphia? | This webpage includes an overview of dysgraphia as well as links to resources for parents (http://www.ncld.org/types-learning-disabilities/dysgraphia/what-is-dysgraphia) |
| The Importance of Teaching Handwriting | This site includes information regarding different accommodations and modifications for dysgraphia (http://www.readingrockets.org/article/27888/) |
| Strategies for the Reluctant Writer | This page provides instruction on home-based writing intervention administered by parents (http://www.ldonline.org/article/Strategies_for_the_Reluctant_Writer/6215) |
| TechMatrix | A database of assistive technology options (software and hardware) that includes stratification for grade and educational diagnosis (http://techmatrix.org/) |
Table 5. Handwriting supplemental program.
| Name | Handwriting supplemental programs |
|---|---|
| Zaner-Bloser | Apps, writing games, and other resources covering writing and reading (http://www.zaner-bloser.com/) |
| Handwriting without Tears | A popular writing intervention program usable by parents or teachers (www.hwtears.com/) |
| 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 (http://www.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=076-1641-890) |
Table 6. Support groups.
| Name | Support groups |
|---|---|
| Parent Center Network | A hub for providing support to parents of children with disabilities on a regional level (http://www.parentcenternetwork.org) |
| Eye to Eye | A mentoring program that matches children and young adults who have similar learning and attention issues (http://eyetoeyenational.org/) |
Conclusion: The Importance of Early Dysgraphia Diagnosis
Writing is a fundamental skill for learning and daily life, developing from childhood through school years. Dysgraphia and written expression disorders are common yet often overlooked, mistakenly attributed to personal flaws rather than a genuine learning disability. Various cognitive mechanisms are proposed for dysgraphia, and ongoing research is crucial for clarifying its definition and causes. Regardless of symptoms, early dysgraphia diagnosis and intervention are linked to better outcomes. Due to typical delays in dysgraphia diagnosis, primary care providers play a vital role in recognizing the condition and initiating appropriate assessment and intervention. Screening for comorbid medical, neurodevelopmental, psychiatric, and learning disorders is also essential. Providing family education and support, coordinating care with schools, making referrals to specialists, and conducting follow-up screenings for comorbidities are important responsibilities for primary care providers.
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.
Footnotes
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.
