Handwriting performance of children with attention deficit hyperactive disorders: a pilot study

Effects of methylphenidate and physiotherapeutic treatment on graphomotor movements in children with ADHD

In addition to the core symptoms defining ADHD, affected children often experience motor problems; in particular, graphomotor movements including handwriting are affected. However, in clinical settings, there is little emphasis on standardized and objective diagnosing and treatment of those difficulties. The present study investigated for the first time the effects of methylphenidate as well as physiotherapeutic treatment on objectively assessed graphomotor movements compared to a control condition, i.e. parental psychoeducation, in 58 children (mean age: 9.52 ± 1.91 years) newly diagnosed with ADHD in an outpatient clinic for child and adolescent psychiatry. Families were invited to join one of the treatment groups. Before and after 8 weeks of treatment, children performed six different tasks on a digitizing tablet which allowed the objective analysis of three important kinematic parameters of graphomotor movements (fluency, velocity, and pen pressure) in different levels of visual control and automation. Graphomotor movement fluency and velocity improves over time across the groups, especially in tasks with eyes closed. We did not find clear evidence for beneficial effects of methylphenidate or physiotherapeutic treatment on children's overall graphomotor movements suggesting that treatments need to be better tailored towards specific and individual deficits in graphomotor movements.

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.

Spiral drawing deficits in children with prenatal alcohol exposure

AIMS

Empirical investigations reveal that, in comparison to their typically developing peers, children with histories of prenatal alcohol exposure experience deficits in writing but not drawing skills, both of which require fine motor control. This study examines drawing skills in this clinical group by assessing simple free-form spiral drawings with indices of spectral features and structural organization.

METHODS

Children with (n = 15) and without (n = 24) prenatal alcohol exposure used their dominant and nondominant hands to draw a series of spirals using a wireless pen stylus that either provided concurrent visual feedback in the form of a black ink trace or left no visible ink trace of each drawing. Spirals were drawn on a sheet of paper placed on a digitizing table, which facilitated online data acquisition. The data were assessed by power spectral density function analysis and sample entropy analysis.

RESULTS

In comparison to their typically developing peers, children with prenatal alcohol exposure produced spirals with a lower mean frequency and less spectral variability. Spirals in the prenatally exposed group were also lower in complexity and structural organization than in the control group. These results occurred independently of hand dominance or the availability of visual feedback.

CONCLUSIONS

The drawing skills of children with prenatal alcohol exposure have inherent signal characteristics that differ significantly from those produced by typically developing peers. Simple tasks requiring fine motor control may be useful in identifying individuals with fetal alcohol spectrum disorders.

Motor Functional Characteristics in Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorders: A Systematic Review

BACKGROUND

The development of attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorders (ASDs) has various influences on physical abilities. Identification of specific physical abilities of people with ADHD/ASDs as biomarkers for diagnosing these conditions is necessary. Therefore, in the present review, we aimed firstly to extract the difference in physical abilities of people with ADHD or ASDs compared to those of normal individuals. Secondly, we aimed to extract the specific physical ability characteristics for identifying potential diagnostic biomarkers in people with ADHD/ASDs.

METHODS

A systematic literature review was performed. The databases were searched for relevant articles on motor function deficits and characteristics of ADHD or ASD.

RESULTS

Forty-one cross-sectional studies and three randomized controlled trials were identified, comprising 33 studies of ADHD, 10 studies of ASDs, and 1 study of both ADHD and ASDs. The quality of studies varied. Three types of physical activities/exercises were identified, including coordinated movement, resistance-type sports, and aerobic-type sports. People with ADHD/ASDs generally exhibited poorer physical abilities for all types of activities, possibly because of low levels of physical activity. Specifically, we found temporal discoordination of movement in ADHD and integration or synchronization of separate movements in ASDs.

CONCLUSION

Specific deficits in physical ability may be attributed to ADHD/ASDs. However, there is not enough research on the physical abilities of people with ADHD and ASDs to clarify the specific deficits. Investigation of specific motor functions that characterize ADHD/ASDs should be facilitated.

How effective is fine motor training in children with ADHD? A scoping review

BACKGROUND

Motor deficiencies are observed in a large number of children with ADHD. Especially fine motor impairments can lead to academic underachievement, low self-esteem and frustration in affected children. Despite these far-reaching consequences, fine motor deficiencies have remained widely undertreated in the ADHD population. The aim of this review was to systematically map the evidence on existing training programs for remediating fine motor impairments in children with ADHD and to assess their effectiveness.

METHODS

The scoping review followed the PRISMA-ScR guidelines. In March 2020, PsycINFO, MEDLINE (PubMed), Web of Science, Google Scholar and The Cochrane Database of Systematic Reviews were searched for evidence. The eligibility criteria and the data charting process followed the PICO framework, complemented by study design. The investigated population included children with a formal ADHD diagnosis (either subtype) or elevated ADHD symptoms aged between 4 and 12 years, both on and off medication. All training interventions aiming at improving fine motor skills, having a fine motor component or fine motor improvements as a secondary outcome were assessed for eligibility; no comparators were specified.

RESULTS

Twelve articles were included in the final report, comprising observational and experimental studies as well as a review. Both offline and online or virtual training interventions were reported, often accompanied by physical activity and supplemented by training sessions at home. The training programs varied in length and intensity, but generally comprised several weeks and single or multiple training sessions per week. All interventions including more than one session were effective in the treatment of fine motor deficiencies in children with ADHD and had a wide range of additional positive outcomes. The effects could be maintained at follow-up.

CONCLUSIONS

Fine motor training in children with ADHD can be very effective and multiple approaches including specific fine motor and cognitive training components, some kind of physical activity, feedback mechanisms, or multimodal treatments can be successful. Training programs need to be tailored to the specific characteristics of the ADHD population. A mHealth approach using serious games could be promising in this context due to its strong motivational components.

Literacy and Numeracy Underachievement in Boys and Girls With ADHD

Objective: To determine literacy and numeracy outcomes, among children with and without ADHD by gestational age and gender. Method: De-identified linked population data from the Western Australian Monitoring of Drug Dependence Systems, Western Australian Literacy and Numeracy Assessment database, and the Midwives Notification System used information on 6,819 children with ADHD compared with 14,451 non-ADHD children. Results: Twenty-three percent of boys and 28% of girls with ADHD had numeracy scores below the benchmark in School Year 3, compared with 11% of children without ADHD. These differences were also evident in reading, writing, and spelling through primary school. Children with ADHD and reduced gestational age were at a greater risk of not meeting numeracy and reading benchmarks, compared with children born at term. Conclusion: Children with ADHD are disadvantaged from an early age in key areas of learning, and this risk increased with reduction in gestational age at birth.

Literacy and Numeracy Underachievement in Boys and Girls With ADHD

Objective: The aim was to determine literacy and numeracy outcomes, among children with and without ADHD by gestational age and gender. Method: De-identified linked population data from the Western Australian Monitoring of Drugs of Dependence System and Western Australian Literacy and Numeracy Assessment databases, and the Midwives Notification System used information on 6,819 children with ADHD compared with 14,451 non-ADHD children. Results: A total of 23% of boys and 28% of girls with ADHD had numeracy scores below the benchmark in School Year 3, compared with 11% of children without ADHD. These differences were also evident for reading, writing, and spelling through primary school. Children with ADHD and reduced gestational age were at a greater risk of not meeting numeracy and reading benchmarks, compared with children born at term. Conclusion: Children with ADHD are disadvantaged from an early age in key areas of learning, and this risk increased with reduction in gestational age at birth.

High Prevalence of Dysgraphia in Elementary Through High School Students With ADHD and Autism

OBJECTIVE

Prevalence of dysgraphia by age across all grade levels was determined in students with ADHD or autism.

METHOD

Referred children with normal intelligence and ADHD-Combined, ADHD-Inattentive, or autism ( N = 1,034) were administered the Developmental Test of Visual-Motor Integration (VMI) and Wechsler Intelligence Scale for Children (WISC).

RESULTS

VMI and WISC Coding scores were significantly lower than IQ and the normal mean of 100 for all diagnoses. More than half (59%) had dysgraphia, and 92% had a weakness in graphomotor ability relative to other abilities. Dysgraphia prevalence did not differ between diagnostic or age groups (6-7 years, 56%; 8-10 years, 60%; and 11-16 years, 61%).

CONCLUSION

Dysgraphia is common at all ages in children and adolescents with ADHD and autism. Accommodations and strategies for addressing this problem are discussed.

Kinematic analysis of fast pen strokes in children with ADHD

In this study, we aimed to determine whether a new measure of fine motor skills, the Pen Stroke Test (PST), can discriminate between children with and without attention-deficit/hyperactivity disorder (ADHD). Twelve children with ADHD and 12 controls age 8-11 were asked to produce handwriting strokes on a digitizer. The sigma-lognormal model derived from the Kinematic Theory of rapid human movements was used to analyze the strokes. Standard measurements of fine motor skills and handwriting were also obtained. Children with ADHD demonstrated poorer motor planning (t₀, D) and execution (nbLog) and greater variability in motor control (SNR/nbLog) than did controls. Parameters extracted from the PST were significantly correlated with performance on other motor and handwriting measures. This study provides preliminary evidence that the PST may be useful as a tool for rapidly detecting motor skill problems in the context of ADHD.

Handwriting assessment to distinguish comorbid learning difficulties from attention deficit hyperactivity disorder in Chinese adolescents: A case-control study

OBJECTIVES

Attention deficit hyperactivity disorder (ADHD) and learning difficulties (LDs) are proposed as 2 overlapping disorders. The objective of this study was to investigate the handwriting performance in ADHD and comorbid ADHD-LD adolescents.

METHODS

The study examined the Chinese and English handwriting performance and sensorimotor skills of 32 ADHD, 12 ADHD-LD, and their matched controls.

RESULTS

Participants with ADHD had comparable writing time and speed, but the readability was lower than their controls. Participants with ADHD-LD had lower writing speeds in both Chinese and English handwriting than their controls. The ADHD and ADHD-LD groups also showed larger variations in either speed or pen pressure than their controls. Chinese handwriting assessment effectively classified ADHD and ADHD-LD with good sensitivity and positive predictive value.

CONCLUSIONS

Clinicians should be aware of the fundamental difference between the 2 disorders and make good use of handwriting assessment as a reference to deliver effective therapies and trainings.

Pressure distributions on the chair seat and backrest correlate with handwriting outcomes of school children

BACKGROUND

Postures while sitting are believed to have an important influence on the process of writing and quality of handwriting, but data in this field are sparse.

OBJECTIVES

The current study was undertaken to investigate correlations between 'ordinary' children's handwriting skills and their posture and stability while sitting.

METHODS

Twenty-nine children with typical development (age 9.2±0.8 years) underwent the Hebrew Handwriting Evaluation, while the pressure distributions on their seats and backrests were recorded using a pressure mapping system.

RESULTS

There was an increase in the odds of erasing and overwriting letters in dictation tasks when body displacements of the buttocks increased [Odds Ratio (OR) = 1.01, 95% CI 1.000-1.02, p = 0.050]. Children who did not lean on the backrest were more likely to have legible handwriting in copying tasks (OR = 0.136, 95% CI 0.026-0.723, p = 0.019).

CONCLUSIONS

The awareness and involvement of health practitioners in sitting postures of children at school might promote activities such as writing. Further investigation of movement patterns while writing and of the correlations of these patterns with handwriting outcomes is recommended. More research regarding adjustments at the school environment for children with developmental disorders is also warranted.

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

Handwriting is fundamental in school and everyday life situations. Legibility guarantees that writing productions communicate information, and speed is often crucial, especially in children with attention deficit and hyperactivity disorder (ADHD), in order to increase the likelihood of their being able to work efficiently and stay on-task during school activities. Preliminary reports have shown an impairment in handwriting of children with ADHD, but evidence is still unclear, especially in the case of speed where research has offered contradictory results. Children's performance, furthermore, has yet to be investigated under the cognitive loading conditions typical of academic tasks in classroom. To shed light on this matter, we examined the handwriting performance in a simple condition but also under (verbal or spatial) working memory (WM) load in 16 fourth- and fifth-grade children with symptoms of ADHD and 16 matched control children. Our results showed that the groups speed differed significantly only in the verbal WM loading condition, where children with symptoms of ADHD wrote more slowly and showed a greater intra-individual variability than controls. Handwriting legibility was affected by verbal WM loading too. These findings are discussed in relation to their educational and clinical implications.

Development of the Handwriting Legibility Scale (HLS): A preliminary examination of Reliability and Validity

BACKGROUND

Demands for the production of legible handwriting produced in a timely manner increase as children progress through school. Despite the considerable number of children faced with handwriting difficulties, there is no quick and practical tool to assess legibility in this population.

AIM

The aim of this study was to develop the Handwriting Legibility Scale (HLS) and to establish the scale's reliability and validity.

METHODS

The HLS is a non-language dependent scale which assesses global legibility, based on five criteria applied to samples of 'free writing'. Content validity, inter-rater reliability and internal consistency were initially examined using scripts from 20 children aged 8-14 years. Construct validity was established by Principal Component Analysis (PCA) of data from 150 school children aged 9-14 years, with an additional examination of gender effects. Discriminant validity of the HLS score was examined in 29 children with Developmental Coordination Disorder (DCD) and 29 typically developing (TD) children.

RESULTS

The results indicated high internal consistency (α=0.92). The inter-rater reliability was acceptable but indicates the need to refine the scoring instructions. PCA of the five components revealed a one factor solution explaining 61% of the variance. In the discriminant analysis, 86.2% of the children with DCD and 89.7% of the TD children were correctly classified to their groups based on the total HLS score.

CONCLUSIONS

The overall findings suggest that the HLS may be a useful tool to identify poor handwriting legibility, with application across different languages and writing scripts.

The role of inattention and hyperactivity/impulsivity in the fine motor coordination in children with ADHD

OBJECTIVE

Deficits in fine motor coordination have been suggested to be associated with Attention-Deficit/Hyperactivity Disorder (ADHD). However, despite the negative impact of poor fine motor skills on academic achievement, researchers have paid little attention to this problem. The aim of this study was to explore the relationship between ADHD dimensions and fine motor performance.

METHOD

Participants were 43 children with a diagnosis of ADHD aged between 7 and 14 years (M=9.61; 81% male) and 42 typically developing (TP) children in the same age range (M=10.76; 75.2% male).

RESULTS

Children with ADHD performed worse than TP on all tasks (δ^{Fine_motor_tasks,} -0.19 to -0.44). After controlling for age and ADHD-HY (hyperactivity/impulsivity), higher scores on ADHD-IN (inattentiveness) predicted a larger number of mistakes among all psychomotricity tasks and conditions (β 0.39-0.58, ps<0.05).

CONCLUSION

The ADHD group showed poorer fine motor performance than controls across all fine motor coordination tasks. However, lower performance (more mistakes), was related to the inattention dimension but not to the hyperactivity/impulsivity dimensions. Authors recommend including training and enhancement of the fine motor skills for more comprehensive ADHD treatment.

Understanding handwriting difficulties: A comparison of children with and without motor impairment

The nature of handwriting difficulties have been explored in children with specific developmental disorders. The aim of this study was to investigate the nature of handwriting difficulties in children with dysgraphia, a less studied group who have significant handwriting difficulties in the absence of motor control or cognitive difficulties. The performance of a dysgraphia group aged 8-14 years was compared to a group with Developmental Coordination Disorder and to typically developing (TD) controls. Participants completed two handwriting tasks on a digitizing writing tablet. The amount and accuracy of the handwriting product was measured, plus various temporal and spatial features of the writing process. There were no significant differences in performance between the two groups with handwriting difficulties but both performed more poorly than the TD group. Individual differences in the type and severity of handwriting impairments suggest the need for a range of classroom assessments to tailor intervention appropriately.

The ADHD Concomitant Difficulties Scale (ADHD-CDS), a Brief Scale to Measure Comorbidity Associated to ADHD

Introduction: Although the critical feature of attention-deficit/hyperactivity disorder (ADHD) is a persistent pattern of inattention and/or hyperactivity/impulsivity behavior, the disorder is clinically heterogeneous, and concomitant difficulties are common. Children with ADHD are at increased risk for experiencing lifelong impairments in multiple domains of daily functioning. In the present study we aimed to build a brief ADHD impairment-related tool -ADHD concomitant difficulties scale (ADHD-CDS)- to assess the presence of some of the most important comorbidities that usually appear associated with ADHD such as emotional/motivational management, fine motor coordination, problem-solving/management of time, disruptive behavior, sleep habits, academic achievement and quality of life. The two main objectives of the study were (i) to discriminate those profiles with several and important ADHD functional difficulties and (ii) to create a brief clinical tool that fosters a comprehensive evaluation process and can be easily used by clinicians.

Methods: The total sample included 399 parents of children with ADHD aged 6–18 years (M = 11.65; SD = 3.1; 280 males) and 297 parents of children without a diagnosis of ADHD (M = 10.91; SD = 3.2; 149 male). The scale construction followed an item improved sequential process.

Results: Factor analysis showed a 13-item single factor model with good fit indices. Higher scores on inattention predicted higher scores on ADHD-CDS for both the clinical sample (β = 0.50; p < 0.001) and the whole sample (β = 0.85; p < 0.001). The ROC curve for the ADHD-CDS (against the ADHD diagnostic status) gave an area under the curve (AUC) of.979 (95%, CI = [0.969, 0.990]).

Discussion: The ADHD-CDS has shown preliminary adequate psychometric properties, with high convergent validity and good sensitivity for different ADHD profiles, which makes it a potentially appropriate and brief instrument that may be easily used by clinicians, researchers, and health professionals in dealing with ADHD.

Persistent Handwriting Difficulties in Children With ADHD After Treatment With Stimulant Medication

OBJECTIVE

Children with ADHD often present with handwriting difficulties. However, the extent to which motor and attention skills influence performance in this group has not yet been explored. The objective of this study was to examine the factors associated with change in handwriting performance.

METHOD

This study examines the factors associated with change in handwriting performance of 49 children newly diagnosed with ADHD (mean age = 8.4 [SD=1.3] years) prior to and 3 months following use of a stimulant medication.

RESULTS

Handwriting legibility and speed improved significantly at follow-up evaluation. However, most of the children with legibility difficulties at baseline continued to demonstrate difficulties when evaluated 3 months after initiation of medication. Change in handwriting legibility was best determined by improvements in visual-motor integration skills (β = 0.07-0.10; p < .001), while the change in speed did not appear to be consistently related to a single factor.

CONCLUSION

Handwriting difficulties are common in children with ADHD, and medication alone is not sufficient to resolve these challenges.

Handwriting Proficiency Screening Questionnaire for Children (HPSQ–C): Development, Reliability, and Validity

OBJECTIVE. To adapt the Handwriting Proficiency Screening Questionnaire (HPSQ), previously designated for adults, into a children’s self-report version (the HPSQ for Children, or HPSQ–C) and to examine its reliability and validity.

METHOD. Participants included 230 children ages 7–14 yr from regular schools in Israel. The questionnaire’s content validity, internal consistency, and concurrent and construct validity were assessed.

RESULTS. The tool demonstrated good internal consistency (α = .77). We found a significant moderate correlation between final HPSQ–C scores and the HPSQ, r = .51, p &lt; .001, establishing the HPSQ–C’s concurrent validity. Construct validity was also confirmed. Results demonstrated that the HPSQ–C significantly distinguished between children with and without handwriting deficiencies on the basis of measures of handwriting product (Hebrew Handwriting Evaluation) and handwriting process (Computerized Penmanship Evaluation Tool).

CONCLUSION. The HPSQ–C is suitable for identification of handwriting deficiency among school-aged children and is appropriate for varied academic and clinical uses.

What is the evidence of impaired motor skills and motor control among children with attention deficit hyperactivity disorder (ADHD)? Systematic review of the literature

This article presents a review of the studies that have analysed the motor skills of ADHD children without medication and the influence of medication on their motor skills. The following two questions guided the study: What is the evidence of impairment of motor skills and aspects of motor control among children with ADHD aged between 6 and 16 years? What are the effects of ADHD medication on motor skills and motor control? The following keywords were introduced in the main databases: attention disorder and/or ADHD, motor skills and/or handwriting, children, medication. Of the 45 articles retrieved, 30 described motor skills of children with ADHD and 15 articles analysed the influence of ADHD medication on motor skills and motor control. More than half of the children with ADHD have difficulties with gross and fine motor skills. The children with ADHD inattentive subtype seem to present more impairment of fine motor skills, slow reaction time, and online motor control during complex tasks. The proportion of children with ADHD who improved their motor skills to the normal range by using medication varied from 28% to 67% between studies. The children who still show motor deficit while on medication might meet the diagnostic criteria of developmental coordination disorder (DCD). It is important to assess motor skills among children with ADHD because of the risk of reduced participation in activities of daily living that require motor coordination and attention.

Acoustic noise improves motor learning in spontaneously hypertensive rats, a rat model of attention deficit hyperactivity disorder

The spontaneously hypertensive (SH) rat model of ADHD displays impaired motor learning. We used this characteristic to study if the recently described acoustic noise benefit in learning in children with ADHD is also observed in the SH rat model. SH rats and a Wistar control strain were trained in skilled reach and rotarod running under either ambient noise or in 75 dBA white noise. In other animals the effect of methylphenidate (MPH) on motor learning was assessed with the same paradigms. To determine if acoustic noise influenced spontaneous motor activity, the effect of acoustic noise was also determined in the open field activity paradigm. We confirm impaired motor learning in the SH rat compared to Wistar SCA controls. Acoustic noise restored motor learning in SH rats learning the Montoya reach test and the rotarod test, but had no influence on learning in Wistar rats. Noise had no effect on open field activity in SH rats, but increased corner time in Wistar. MPH completely restored rotarod learning and performance but did not improve skilled reach in the SH rat. It is suggested that the acoustic noise benefit previously reported in children with ADHD is shared by the SH rat model of ADHD, and the effect is in the same range as that of stimulant treatment. Acoustic noise may be useful as a non-pharmacological alternative to stimulant medication in the treatment of ADHD.

Handwriting in children with ADHD

OBJECTIVE

Children with ADHD-combined type (ADHD-CT) display fine and gross motor problems, often expressed as handwriting difficulties. This study aimed to kinematically characterize the handwriting of children with ADHD using a cursive letter l's task.

METHOD

In all, 28 boys (7-12 years), 14 ADHD-CT and 14 typically developing (TD), without developmental coordination disorder (DCD) or comorbid autism, wrote a series of four cursive letter l's using a graphics tablet and stylus.

RESULTS

Children with ADHD-CT had more inconsistent writing size than did TD controls. In addition, ADHD-CT symptom severity, specifically inattention, predicted poorer handwriting outcomes.

CONCLUSION

In a sample of children with ADHD-CT who do not have DCD or autism, subtle handwriting differences were evident. It was concluded that handwriting might be impaired in children with ADHD in a manner dependent on symptom severity. This may reflect reports of underlying motor impairment in ADHD.

Handwriting speed in children with Developmental Coordination Disorder: are they really slower?

Handwriting difficulties are often included in descriptions of Developmental Coordination Disorder (DCD). They are cited as the most common reason for referral to health professionals following parent and teacher concerns about slow and untidy writing. The aim of this study was to compare handwriting performance in English children with and without DCD across a range of writing tasks, to gain a better understanding of the nature of 'slowness' so commonly reported. Twenty-eight 8-14 year-old children with a diagnosis of DCD participated in the study, with 28 typically developing age and gender matched controls. Participants completed the four handwriting tasks from the Detailed Assessment of Speed of Handwriting (DASH) and wrote their own name; all on a digitising writing tablet. The number of words written, speed of pen movements and the time spent pausing during the tasks were calculated. The findings confirmed what many professionals report, that children with DCD produce less text than their peers. However, this was not due to slow movement execution, but rather a higher percentage of time spent pausing. Discussion centres on the understanding of the pausing phenomenon in children with DCD and areas for further research.

Handwriting performance and underlying factors in children with Attention Deficit Hyperactivity Disorder

Preliminary evidence suggests that handwriting difficulties are common to children with Attention Deficit Hyperactivity Disorder (ADHD). However, the nature of the task-specific impairments is needed to be clarified. The aim of this study was to describe handwriting capacity in ADHD children without DCD and identify underlying factors of performance by use of outcome-oriented assessments and a digitizing tablet. Twenty-one children with ADHD (8.59±1.25 years) and 21 match controls (8.5±1.08 years) were recruited. Children with ADHD scored lower than controls on Tseng Handwriting Problem Checklist and writing composite of Basic Reading and Writing Test, indicating the ADHD group wrote less legibly. The ADHD group spent more on-paper time to copy 50 Chinese characters and exhibited more writing time during the writing process. The ADHD group scored significantly lower on tasks demanding upper limb and eye-hand coordination and visual-motor integration compared with controls. Furthermore, motor skill and visual-motor integration were positively correlated with the legibility. Motor skill was negatively correlated with writing time, in-air time, and in-air trajectory.

Handwriting difficulties in children with autism spectrum disorders: a scoping review

Functional handwriting involves complex interactions among physical, cognitive and sensory systems. Impairments in many aspects of these systems are associated with Autism spectrum disorders (ASD), suggesting a heightened risk of handwriting difficulties in children with ASD. This scoping review aimed to: (1) survey the existing evidence about potential contributions to compromised handwriting function in children with ASD, and (2) map out the existing studies documenting handwriting difficulties in children with ASD. The current evidence implicates impairments in fine motor control and visual-motor integration as likely contributors to handwriting difficulties in children with ASD, though the role of the latter is not well-understood. Moreover, diminished overall legibility and compromised letter formation are emerging points of convergence among existing studies of handwriting quality in children with ASD.

Handwriting capacity in children newly diagnosed with Attention Deficit Hyperactivity Disorder

Preliminary evidence suggests that children with Attention Deficit Hyperactivity Disorder (ADHD) may exhibit handwriting difficulties. However, the exact nature of these difficulties and the extent to which they may relate to motor or behavioural difficulties remains unclear. The aim of this study was to describe handwriting capacity in children newly diagnosed with ADHD and identify predictors of performance. Forty medication-naïve children with ADHD (mean age 8.1 years) were evaluated with the Evaluation Tool of Children's Handwriting-Manuscript, the Movement Assessment Battery for Children (M-ABC), the Developmental Test of Visual Motor Integration (VMI) and the Conner Global Index. An important subset (85.0%) exhibited manual dexterity difficulties. Handwriting performance was extremely variable in terms of speed and legibility. VMI was the most important predictor of legibility. Upper extremity coordination, as measured by the M-ABC ball skills subtest, was also a good predictor of word legibility.

CONCLUSION

Poor handwriting legibility and slow writing speed were common in children newly diagnosed with ADHD and were associated with motor abilities. Future studies are needed to determine whether interventions, including stimulant medications, can improve handwriting performance and related motor functioning.

Written-language disorder among children with and without ADHD in a population-based birth cohort

OBJECTIVE

We determined the incidence of written-language disorder (WLD) among children with and without attention-deficit/hyperactivity disorder (ADHD) in a population-based birth cohort.

METHODS

Subjects included a birth cohort of all children born in 1976-1982 who remained in Rochester, Minnesota, after 5 years of age (N = 5718). Information from medical, school, and private tutorial records was abstracted. Cumulative incidences of WLD with or without reading disability (RD), identified with any of 3 formulas, among children with and without ADHD and hazard ratios (HRs) were calculated.

RESULTS

For both genders, the cumulative incidence of WLD by 19 years of age was significantly higher for children with ADHD than for children without ADHD (boys: 64.5% vs 16.5%; girls: 57.0% vs 9.4%). The magnitude of association between ADHD and WLD with RD was significantly higher for girls than for boys (adjusted HR: girls: 9.8; boys: 4.2; P < .001). However, this was not true for WLD without RD (adjusted HR: girls: 7.4; boys: 6.6; P = .64).

CONCLUSIONS

ADHD is strongly associated with an increased risk of WLD (with or without RD) for both boys and girls. Girls with ADHD are at higher risk of having WLD with RD compared with boys with ADHD, whereas boys and girls are at the same risk of having WLD without RD.

Changes in kinetics and kinematics of handwriting during a prolonged writing task in children with and without dysgraphia

Handwriting difficulties or dysgraphia have a profound impact on children's psychosocial development, and yet, 10-30% of school-aged children are reported to experience difficulties mastering this skill. Several studies have examined the nature and biomechanical underpinnings of handwriting difficulties in children with and without dysgraphia. While the majority of these studies have considered short handwriting activities involving a sentence or a paragraph, handwriting quality and speed are reported to vary with the length of the writing task. Further, it is suggested that the biomechanics of handwriting also evolve over extended writing periods, and that these changes may be distinct between children with and without dysgraphia. The nature and specificity of these biomechanical alterations remain unknown. To address this knowledge gap, we examined changes in writing speed, grip forces on the pen barrel, and normal forces on the writing surface, over the course of a 10-min writing task, in a large cohort of 4th grade children with and without dysgraphia. Horizontal stroke speed, grip force and normal force increased over time while vertical stroke speed decreased in all children. These biomechanical changes may be attributable to physical and psychological fatigue and the corresponding compensatory processes invoked by the motor system.