Handwriting difficulties in children with attention deficit hyperactivity disorder (ADHD)

Is There a Deficit in Product and Process of Handwriting in Children with Attention Deficit Hyperactivity Disorder? A Systematic Review and Recommendations for Future Research

Handwriting abnormalities in children with attention deficit hyperactivity disorder (ADHD) have sometimes been reported both (i) at the product level (i.e., quality/legibility of the written trace and speed of writing) and (ii) at the process level (i.e., dynamic and kinematic features, such as on-paper and in-air durations, pen pressure and velocity peaks, etc.). Conversely, other works have failed to reveal any differences between ADHD and typically developing children. The question of the presence and nature of handwriting deficits in ADHD remains open and merits an in-depth examination. The aim of this systematic review was, therefore, to identify studies that have investigated the product and/or process of handwriting in children with ADHD compared to typically developing individuals. This review was conducted and reported in accordance with the PRISMA statement. A literature search was carried out using three electronic databases. The methodological quality of the studies was systematically assessed using the Critical Appraisal Skills Program (CASP) criteria. Twenty-one articles were identified. Of these, 17 described handwriting quality/legibility, 12 focused on speed and 14 analyzed the handwriting process. All the studies (100%) with satisfactory methodology procedures reported an impaired product and process in children with ADHD, while 25% evidenced a difference in the speed of production. Most importantly, the studies differed widely in their methodological approaches. Substantial gaps remain, particularly with regard to ascertaining comorbidities, ADHD subtypes and the medical status of the included children. The lack of overall homogeneity in the samples calls for higher quality studies. We conclude with recommendations for further studies.

Tools and Methods for Diagnosing Developmental Dysgraphia in the Digital Age: A State of the Art

Handwriting is a complex perceptual motor task that requires years of training and practice before complete mastery. Its acquisition is crucial, since handwriting is the basis, together with reading, of the acquisition of higher-level skills such as spelling, grammar, syntax, and text composition. Despite the correct learning and practice of handwriting, some children never master this skill to a sufficient level. These handwriting deficits, referred to as developmental dysgraphia, can seriously impact the acquisition of other skills and thus the academic success of the child if they are not diagnosed and handled early. In this review, we present a non-exhaustive listing of the tools that are the most reported in the literature for the analysis of handwriting and the diagnosis of dysgraphia. A variety of tools focusing on either the final handwriting product or the handwriting process are described here. On one hand, paper-and-pen tools are widely used throughout the world to assess handwriting quality and/or speed, but no universal gold-standard diagnostic test exists. On the other hand, several very promising computerized tools for the diagnosis of dysgraphia have been developed in the last decade, but some improvements are required before they can be available to clinicians. Based on these observations, we will discuss the pros and cons of the existing tools and the perspectives related to the development of a universal, standardized test of dysgraphia combining both paper-and-pen and computerized approaches and including different graphomotor and writing tasks.

Psychomotor intervention to improve handwriting skills in children with ADHD: A single-case experimental design with direct inter-subject and systematic replications

Dysgraphia is highly prevalent in children with attention deficit hyperactivity disorder (ADHD) and adversely affects academic and developmental trajectories. To date, no study has rigorously examined the effects of a training program on handwriting quality in this specific population. Our objective was thus to develop an innovative program - we entitled PRO-PEN - and to evaluate its effects. We planned a multiple-baseline design across participants from grade 3-5, with direct inter-subject and systematic replications. Children of Group 1 (n = 4) were diagnosed with ADHD. Systematic replication was conducted in a second group of participants (Group 2, n = 4) with a diagnosis of developmental coordination disorder in addition to ADHD. The primary assessment focused on quality of handwriting. Generalization measures evaluated diverse neuropsychological and behavioural domains. In Group 1, effect sizes regarding handwriting quality were large (Taus > .60). Improvement was also observed for children of Group 2 (Taus > .50). Importantly, the positive effects persisted three months after the end of the training. Generalization effects extended beyond handwriting sphere. Therefore, PRO-PEN can be considered a promising training program for improving handwriting quality in ADHD, with a possible impact on wide cerebral regulation loops underpinning both handwriting and other neuropsychological and behavioural domains.

Anticipatory Awareness and Actual Handwriting Performance Measures among Adolescents with Deficient Executive Functions

This secondary analysis explores differences and correlations between handwriting anticipatory awareness (time estimation, expected performance, and expected difficulty) before a paragraph copying task and actual performance time and legibility among adolescents with executive function deficits (EFD) versus neurotypical adolescents. Eighty-one adolescents (10–18 years old; 41 with EFD and daily functioning difficulties as per parent reports) estimated their time, expected performance, and expected difficulty before the paragraph copying task using the Self-Awareness of Performance Questionnaire (SAP-Q). Time duration was assessed using the Computerized Penmanship Evaluation Tool (ComPET) software, and legibility was scored using the Handwriting Legibility Scale (HLS). Significant between-group differences were found in actual time duration (ComPET), HLS total score and legibility components, and three SAP-Q questions. Both groups estimated significantly more performance time than their actual performance duration. The adolescents with EFD underestimated their performance before the handwriting task. Significant correlations were found between actual performance, anticipatory awareness, and Executive Function (EF) in both groups. Their performance predictions were significantly correlated with their EF and product’s legibility. The results highlight the potential relationships between anticipatory awareness and actual handwriting performance (time duration and legibility) of adolescents with and without EFD. Further studies may analyze the benefits of focusing on both EF and anticipatory awareness for handwriting improvement among populations with EF deficits.

The performance and predictors of Chinese character writing in children with attention deficit hyperactivity disorder

Writing difficulties are common in children with attention deficit hyperactivity disorder (ADHD). Preliminary evidence suggests that early character writing ability is fundamental for later writing composition and academic achievement. Critical factors of different character writing tasks in children with ADHD, however, remain unclear. This study aims to describe the performance and identify predictors of Chinese character writing in children with ADHD. Thirty Mandarin Chinese-speaking children with ADHD (7.16 ± 0.59 years) and thirty matched peers (7.21 ± 0.57 years) were recruited from northern Taiwan. They were evaluated with the Battery of Chinese Basic Literacy (BCBL); the Chinese version of the Test of Nonverbal Intelligence, fourth edition (C-TONI-4); the Chinese version of the Peabody Picture Vocabulary Test-Revised (C-PPVT-R); orthographic awareness test; character naming test; and the Bruininks Oseretsky Test of Motor Proficiency, second edition (BOT-2). The results showed that Mandarin Chinese-speaking children with ADHD scored lower than their typically developing peers on both dictation and copying subtests. After controlling for age, orthographic awareness and inattention were identified as important predictors of character dictation; while, manual dexterity was a critical predictor of character copying in children with ADHD. The results demonstrated that character writing problems may exist in Mandarin Chinese-speaking children with ADHD, and cognitive-linguistic and fine-motor skills have varying contributions to Chinese character writing tasks.

Enhancing Executive Functions and Handwriting with a Concentrative Coordination Exercise in Children with ADHD: A Randomized Clinical Trial

Handwriting difficulties are common in children with Attention-Deficit/Hyperactivity Disorder (ADHD), and they have been associated with lower academic achievement and self-esteem. Our aim in this study was to determine if training coordination of the head, eyes, and arm and engaging in the necessary visual concentration associated with table tennis would improve executive functions and school-based handwriting among children with ADHD. We designed a randomized controlled trial to explore the therapeutic efficacy of this table tennis training and recruited 48 children with ADHD that we randomly assigned to one of three equal-sized training groups: (a) actual table tennis, (b) simulated table tennis (exergame), or (c) a control group receiving no additional training. The training intervention lasted 12-weeks in which the two different table tennis trainings (i.e., actual or simulated) were scheduled for three one-hour sessions per week. Outcome measures included a computerized handwriting evaluation, the Stroop test, and the Wisconsin Card Sorting Test (WCST). Participants in each table tennis training group showed significant improvements in handwriting performance, response time, and required time to achieve automation. Both intervention groups also showed significant improvements on the Stroop Color-Word test, but only the actual table tennis training group showed a significant improvement on the WCST. This study provided evidence of at least short-term improvements in executive functions and handwriting problems in children with ADHD through their participation in table tennis motor coordination activities.

Visual-motor attention in children with ADHD: The role of automatic and controlled processes

BACKGROUND

there are evidence that children with ADHD exhibit a deficit both in automatic and controlled processes.

AIMS

the present study aimed to examine the visual-motor attention and the influence of cognitive load through a dual task paradigm in children with ADHD compared with typical developing children (TD).

METHODS AND PROCEDURES

113 children with ADHD: 40 with subtype inattentive (ADHD- I group), 16 with subtype hyperactive (ADHD-H group), 57 with subtype combined (ADHD-C group), and 113 TD children (TD group) were recruited. We used a dual-task paradigm in which the primary task was a figure-tracing test whereas the second task was a digit span test. A figure-tracing test was used to evaluate visual motor attention. Based on the length and intersection of the lines, the figures of the primary task were categorized into simple and complex.

OUTCOMES AND RESULTS

the ADHD groups compared to the TD group showed a worse accuracy of performance in both condition with and without cognitive load.

CONCLUSIONS AND IMPLICATIONS

The findings were discussed in light of the relationship between automatic and controlled processes involved in the visual-motor attention.

The Role of Working Memory on Writing Processes

Literature has extensively demonstrated the coordination role of working memory (WM) in complex tasks such as writing. However, previous studies mostly concentrated on the relation between passive WM (e.g., WM span) components and specific writing tasks (e.g., dictation). Here, we aimed to investigate the relationship between different writing skills and the performance on a WM updating task measuring the more active components of WM. From a pool of 160 Italian pupils (grades 3-5), we selected 46 children divided in two groups based on their WM updating performance. The first group consisted of 21 children with low WM updating performance (≤10th percentile), the second group consisted of 25 children with high WM updating performance (≥90th percentile). All children were tested on a battery of writing tasks to assess writing speed, orthographic skills, and competences in expressive writing. MANOVAs and a discriminant analysis were computed to assess group differences and the contribution of the different writing tests in correctly predicting group membership. The results revealed that children with high WM updating performance scored significantly higher than children with low WM updating performance on most of the writing tasks. These results highlight the relevant role of the active components of WM on writing processes. In addition, they suggest that the improvement of writing skills should rely not only on the training of the specific processes implied in this complex task, but also on the training of the cognitive processes that support them, such as active WM processes.

Handwriting Analysis in Children and Adolescents with Hemophilia: A Pilot Study

Background: Handwriting is a complex task that requires the integrity of different sensorimotor components to be performed successfully. Patients with hemophilia suffer from recurrent joint bleeds that may occur in the elbow, causing elbow dysfunction with handwriting performance impairment. In our study, we described instrumental dysgraphia that is related to functional disturbances. This pilot study aims to evaluate the handwriting performance in a group of patients with hemophilia. Methods: The study was performed at the Angelo Bianchi Bonomi Hemophilia and Thrombosis Center in Milan. Boys with severe and moderate hemophilia A and B regularly followed-up at that Center, with age between 6–19 years, were eligible. Patients were invited to the Center for one multidisciplinary evaluation of the upper limbs that included: Clinical examination, surface electromyography, and handwriting assessment. Results: All patients, but one, completed handwriting assessment. Overall, 14/19 (74%) had abnormal handwriting, which was overt instrumental dysgraphia in six (32%). There was no difference in Hemophilia Joint Health Score (HJHS) between dysgraphic and non-dysgraphic boys, while surface electromyography (sEMG) revealed a prevalence of flexor muscles of the upper limb in dysgraphic as compared with non-dysgraphic boys. Conclusions: The rather high prevalence of instrumental dysgraphia found in this pilot study deserves a further development of this preliminary experience by increasing the number of examined patients and comparing them with a control group, including quality of life and psychological assessment.

Motor skill learning with impaired transfer by children with developmental coordination disorder

BACKGROUND

DSM-5 criteria for developmental coordination disorder (DCD) emphasize deficits in the acquisition and execution of coordinated motor skills. Previous studies of motor skill learning in DCD suggest deficits in the execution of motor skills but do not reveal a deficit in learning new skills, possibly because of the heterogeneity of motor deficits in DCD.

AIM

In light of the high prevalence of handwriting difficulties among children with DCD, the current study compared motor skill learning in 5-6-year-old children with DCD and their peers using a grapho-motor learning task that resembles a letter-writing practice.

METHODS

Thirty-two boys, 16 with DCD, learned to produce a new "letter" formed by connecting three dots. Training, following-day consolidation, 1-week post-training retention, and far-transfer to a no-dot condition were tested.

RESULTS

Children with DCD exhibited rates of learning similar to those of their peers, but with overall poorer performance, replicating previous findings. Contrary to reports of intact skill transfer following a consolidation period in DCD, impaired transfer of the learned symbol was observed.

CONCLUSIONS

These findings may explain some of the motor difficulties experienced by children with DCD as well as contribute to the discussion on mechanisms involved in skill learning in these children.

Handwriting skills of children with tic disorders

INTRODUCTION

Although circumstantial evidence suggests children with tic disorders (TD) experience challenges in handwriting which may be attributed to their tics, few studies have systematically investigated handwriting performance among children with TD. This study examined the relationship between handwriting deficits and TD using a causal comparative research design.

METHODS

Thirty-four children with TD completed the Test of Handwriting Skills-Revised (THS-R). The overall percentile ranks of the THS-R were analysed to determine if children with TD have lower scores compared to the test's normative values. Writing speed, letter reversals, touching letters and case errors were also evaluated.

RESULTS

Data revealed the median percentile rank of the THS-R for the participants was significantly lower than the median percentile score of the THS-R for the normative sample. Close to 80% (n = 27) of writing samples were scored below 50th percentile. More than one-third (35.3%, n = 12) of the writing samples were scored greater than one standard deviation below the normative mean on the THS-R. Of the four ancillary scores, 82.4% (n = 28) of the participants' writing samples scored below 50th percentile (in the categories of watch or test further) on case errors and 67.6% (n = 23) scored below 50th percentile on writing speed.

CONCLUSION

Findings suggested that children with TD took longer to complete the writing task, and committed more case substitution errors than the normative sample of the THS-R and were likely to exhibit handwriting deficits.

Atypical Visual Scan Path Affects Remembering in ADHD

OBJECTIVE

Several studies agree on the link between attention and eye movements during reading. It has been well established that attention and working memory (WM) interact. A question that could be addressed to better understand these relationships is: to what extent can an attention deficit affect eye movements and, consequently, remembering a word? The main aims of the present study were (1) to compare visual patterns of word stimuli between children with Attention Deficit Hyperactivity Disorder (ADHD) and typically developing (TD) children, during a visual task on word stimuli; (2) to examine the WM accuracy of the word stimuli; and (3) to compare the dynamic of visual scan path in both groups.

METHOD

A total of 49 children with ADHD, age and sex matched with 32 TD children, were recruited. We used eye-tracking technology in which the Word Memory Test was implemented. To highlight the scan path of participants, two measures were used: the ordered direction of reading and the entropy index.

RESULTS

ADHD groups showed a poorer WM than TD group. They did not follow a typical scan path across the words compared with TD children, but their visual scanning was discontinuous, uncoordinated, and chaotic. ADHD groups showed an index of entropy among the four categories of saccades higher than TD group.

CONCLUSIONS

The findings were discussed in light of two directions: the relationship between atypical visual scan path and WM and the training implications related to the necessity of redirecting the dynamic of visual scan path in ADHD to improve WM.

Working memory and decision making in children with ADHD: an analysis of delay discounting with the use of the dual-task paradigm

BACKGROUND

Deficits in working memory tasks have been widely documented in Attention Deficit Hyperactivity Disorder (ADHD) studies. The aim of this study is to evaluate the effects of working memory load in impulsivity during decision-making processes. A delayed discounting (DD) paradigm was used, comparing children with ADHD and age-matched controls.

METHOD

Thirty-two children equally divided between typically developing and ADHD, from 8 to 10 years of age were assigned to sessions of a dual-task paradigm. In the primary task the child has to choose between two different amounts of money at different time delays, while in the secondary task the child has to repeat a random series of digits with different lengths. The experiment was conducted in a school setting.

RESULTS

Compared to peers with typical development, delayed discounting was significantly stronger in children with ADHD and discounting rates increased in both groups for heavier memory loads. Furthermore, the memory load impact on frequency of immediate rewards was stronger in children with ADHD compared to typically developing children.

DISCUSSION

Results are discussed in terms of the relation between working memory load and decision-making processes, their impact on impulsive behaviour in ADHD and the need for future research to understand possible neurocognitive correlates and use that information to develop better inclusive policies.

Effects of external focus of attention on learning static balance among girls with ADHD

Study aim: The purpose of this study was to examine the effects of adopting an external focus of attention on motor learning among girls with ADHD aged seven and eleven years.

Material and methods: Twenty-four seven-year-old and 24 eleven-year-old female children with symptoms of ADHD were randomly assigned to groups receiving either external focus of attention (EXT) instructions or internal focus of attention (INT) instructions, making four experimental groups: EXT-7, INT-7, EXT-11, and INT-11. Participants performed a pretest followed by five training blocks under an external or internal instruction and were then given a retention test one day later. After training, we employed a manipulation check to verify the children’s type and intensity of focus.

Results: Adopting an external focus of attention, compared to an internal focus of attention, led to better motor learning among girls with ADHD (F 1, 44 = 5.08, p = 0.029, η2 = 0.10). In addition, adopting an external focus of attention reduced the children’s tendency to focus on self. Older children performed better than younger children in balance time (F 1, 44 = 16.10, p < 0.001, η2 = 0.26).

Conclusions: Our results indicate that propositions of the OPTIMAL theory can be extended to children with ADHD.

Interactive Avatar Boosts the Performances of Children with Attention Deficit Hyperactivity Disorder in Dynamic Measures of Intelligence

This study examined both children with attention deficit hyperactivity disorder (ADHD) and typically developing students in dynamic measures of intelligence through the use of a virtual avatar. Three conditions were compared: in the first condition, the avatar simply gave the instructions; in the second condition, the avatar presented the instructions and gave feedback on the attention of the learner; in the third condition, the avatar was not presented. Results indicated that ADHD subtypes do not differ in problem solving and the interactive avatar improved the performance of groups with ADHD in the dynamic intelligence test. Overall, these results support the hypothesis that the function of regulation and feedback of the avatar improve the attention process and, consequently, boosts performance.