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

Evaluation of a 3D-Printed Writing Assistive Device for People With Brain Injury

Three-dimensional-printed assistive devices hold promise for improving writing abilities, yet factors influencing device selection and their impact on satisfaction and effectiveness remain unclear, especially in adults, as they are typically tested on children. The aim of this article is to assess the efficacy and satisfaction with a writing assistive device at different angles among individuals with brain injury and explore device selection factors. Twenty-six participants with brain injuries selected their preferred device angle. Writing speed, quality, and satisfaction were recorded. Immediate speed improvements were significant at 5° and 30° (p = .006, .013, respectively). Satisfaction scores did not significantly differ among angles. Normotonia in elbow (p < .001; odds ratio: 3.403) and wrist (p ≤ .001; odds ratio: 2.695) muscles increased the likelihood of selecting the 5° device. Immediate speed improvements at specific angles highlight the influence of muscle normotonia on device selection, vital for tailored brain injury rehabilitation.

Methylphenidate alleviates cognitive dysfunction caused by early manganese exposure: Role of catecholaminergic receptors

Environmental manganese (Mn) exposure is associated with impaired attention and psychomotor functioning, as well as impulsivity/hyperactivity in children and adolescents. We have shown previously that developmental Mn exposure can cause these same dysfunctions in a rat model. Methylphenidate (MPH) lessens impairments in attention, impulse control, and psychomotor function in children, but it is unknown whether MPH ameliorates these dysfunctions when induced by developmental Mn exposure. Here, we sought to (1) determine whether oral MPH treatment ameliorates the lasting attention and sensorimotor impairments caused by developmental Mn exposure, and (2) elucidate the mechanism(s) of Mn neurotoxicity and MPH effectiveness. Rats were given 50 mg Mn/kg/d orally over PND 1-21 and assessed as adults in a series of attention, impulse control and sensorimotor tasks during oral MPH treatment (0, 0.5, 1.5, or 3.0 mg/kg/d). Subsequently, selective catecholaminergic receptor antagonists were administered to gain insight into the mechanism(s) of action of Mn and MPH. Developmental Mn exposure caused persistent attention and sensorimotor impairments. MPH treatment at 0.5 mg/kg/d completely ameliorated the Mn attentional dysfunction, whereas the sensorimotor deficits were ameliorated by the 3.0 mg/kg/d MPH dose. Notably, the MPH benefit on attention was only apparent after prolonged treatment, while MPH efficacy for the sensorimotor deficits emerged early in treatment. Selectively antagonizing D1, D2, or α2A receptors had no effect on the Mn-induced attentional dysfunction or MPH efficacy in this domain. However, antagonism of D2R attenuated the Mn sensorimotor deficits, whereas the efficacy of MPH to ameliorate those deficits was diminished by D1R antagonism. These findings demonstrate that MPH is effective in alleviating the lasting attentional and sensorimotor dysfunction caused by developmental Mn exposure, and they clarify the mechanisms underlying developmental Mn neurotoxicity and MPH efficacy. Given that the cause of attention and psychomotor deficits in children is often unknown, these findings have implications for the treatment of environmentally induced attentional and psychomotor dysfunction in children more broadly.

Sensorimotor dysfunction due to developmental manganese exposure is less severe in adult female than male rats and partially improved by acute methylphenidate treatment

Epidemiological studies have reported associations between elevated manganese (Mn) exposure and poorer psychomotor performance in children. Our studies in adult male rats have established that this relationship is causal and that prolonged methylphenidate (MPH) treatment is efficacious in treating this area of dysfunction. However, it is unclear if sensitivity to these Mn deficits differs between females and males, and whether existing pharmacological therapies are efficacious in improving sensorimotor dysfunction in females. To address these questions, we used our rat model of childhood environmental Mn exposure and the Montoya staircase test to determine whether 1) there are sex differences in the lasting sensorimotor dysfunction caused by developmental Mn exposure, and 2) MPH treatment is efficacious in ameliorating the sensorimotor deficits in females. Female and male neonates were treated orally with Mn (50 mg Mn/kg/d) from postnatal day 1 to 21 and evaluated for skilled forelimb sensorimotor performance as adults. Subsequently, the efficacy of acute oral MPH treatment (doses of 0, 0.5, and 3.0 mg MPH/kg/d) was assessed in females using a within-subject MPH treatment design. Developmental postnatal Mn exposure produced lasting sensorimotor reaching and grasping deficits that were milder in females than in males. Acute MPH treatment of Mn-exposed females with the 0.5 mg/kg/d dose attenuated the reaching dysfunction without alleviating grasping dysfunction. These findings show sex-based variations in sensitivity to the sensorimotor impairment caused by developmental Mn exposure, and they are consistent with prior studies showing less vulnerability of females to Mn-induced dysfunction in other functional domains, possibly due to the protective effects of estrogen. Given our previous work showing the efficacy of MPH treatment to alleviate Mn-induced inattention, impulsiveness, and sensorimotor dysfunctions in adult male rats, they also highlight the need for further research into sex-based differences in cognitive and behavioral areas of brain function, and the efficacy of therapeutics in treating behavioral dysfunction in females. Supported by NIEHS R01ES028369.

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.

Methylphenidate alleviates cognitive dysfunction from early Mn exposure: Role of catecholaminergic receptors

Environmental manganese (Mn) exposure is associated with impaired attention and psychomotor functioning, as well as impulsivity/hyperactivity in children and adolescents. We have shown previously that developmental Mn exposure can cause these same dysfunctions in a rat model. Methylphenidate (MPH) lessens impairments in attention, impulse control, and sensorimotor function in children, but it is unknown whether MPH ameliorates these dysfunctions when induced by developmental Mn exposure. Here, we sought to (1) determine whether oral MPH treatment ameliorates the lasting attention and sensorimotor impairments caused by developmental Mn exposure, and (2) elucidate the mechanism(s) of Mn neurotoxicity and MPH effectiveness. Rats were given 50 mg Mn/kg/d orally over PND 1-21 and assessed as adults in a series of attention, impulse control and sensorimotor tasks during oral MPH treatment (0, 0.5, 1.5, or 3.0 mg/kg/d). Subsequently, selective catecholaminergic receptor antagonists were administered to gain insight into the mechanism(s) of action of Mn and MPH. Developmental Mn exposure caused persistent attention and sensorimotor impairments. MPH treatment at 0.5 mg/kg/d completely ameliorated the Mn attentional dysfunction, whereas the sensorimotor deficits were ameliorated by the 3.0 mg/kg/d MPH dose. Notably, the MPH benefit on attention was only apparent after prolonged treatment, while MPH efficacy for the sensorimotor deficits emerged early in treatment. Selectively antagonizing D1, D2, or α2A receptors had no effect on the Mn-induced attentional dysfunction or MPH efficacy in this domain. However, antagonism of D2R attenuated the Mn sensorimotor deficits, whereas the efficacy of MPH to ameliorate those deficits was diminished by D1R antagonism. These findings demonstrate that MPH is effective in alleviating the lasting attention and sensorimotor dysfunction caused by developmental Mn exposure, and they clarify the mechanisms underlying developmental Mn neurotoxicity and MPH efficacy. Given that the cause of attention and psychomotor deficits in children is often unknown, these findings have implications for the treatment of environmentally-induced attentional and psychomotor dysfunction in children more broadly.

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.

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.

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.

Motor functions of higher education students with dysgraphia

This study examines the motor skills and motor-related daily functions of higher education students with and without dysgraphia, and their contribution in predicting handwriting performance. The sample included 82 higher education students aged 20-35 years old. Thirty-four were students without any known developmental disorder (NDD) and 48 students had dysgraphia. We individually administered a test battery evaluating handwriting performance, fine-motor skills, and visual-motor spatial-organization skills. Students also filled out a questionnaire relating to their fine- and gross-motor-related daily functions. Overall, the NDD students had significantly better motor skills and motor-related daily functions. Additionally, the motor skills and daily functions explained 62.9% of the variance in handwriting performance, and they correctly classified 90% of the students into the handwriting performance groups. Yet only visual-motor spatial organization and fine-motor-related daily functions significantly contributed to the fit of the model. These findings suggest that students with dysgraphia continue to encounter handwriting difficulties in higher education. These difficulties are linked to poor motor skills and motor-related daily functions. Therefore, higher education students with dysgraphia may require assistance and accommodations throughout their studies, not only with regard to their academic performance, but also in their motor-related daily functions.

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.

Reduced graphomotor procedural learning in children and adolescents with ADHD

PURPOSE

The present study sought to determine if children and adolescents with ADHD demonstrate reduced procedural learning of a graphomotor program.

METHOD

Thirty-two children and adolescents between age 9 and 15 with (n = 16) and without ADHD (n = 16) participated in the study. Each group of participants practiced a novel grapheme on a digitizing tablet 30 times. Participants with ADHD were off stimulant medication or were medication naïve.

RESULTS

Control participants demonstrated significant improvement in graphomotor fluency from the beginning to the end of practice, T = 2, z = -2.534, p = .009, whereas participants with ADHD did not, T = 4, z = -1.810, p = .074.

CONCLUSIONS

Consistent with findings in adults with ADHD, results indicate that graphomotor procedural learning in children and adolescents with ADHD is attenuated. Findings have implications for future research that may inform remediation of handwriting difficulties, academic accommodations, and using digitizing technology for neuropsychological assessment.

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.

Visuospatial working memory assessment using a digital tablet in adolescents with attention deficit hyperactivity disorder

BACKGROUND AND OBJECTIVE

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder hypothesized to involve impaired visuospatial working memory (VSWM). However, there are few studies utilizing neuropsychological tests to measure VSWM in ADHD adolescents. The Rey-Osterrieth complex figure test (ROCF) is commonly used as a neuropsychological test to assess visuospatial working memory for individuals with ADHD. We assessed working memory using the ROCF test on a digital Galaxy tablet with the technically new Gaussian filter method.

METHODS

Thirty adolescents with ADHD and 30 healthy control adolescents were recruited for participation in the current study. All adolescents were assessed with K-WISC-IV, Children's depression inventory, and the Korean ADHD rating scale. All adolescents were asked to copy the ROCF from paper onto a Galaxy tablet screen using a wireless pen.

RESULTS

There was a significant difference in representative value of the deviation of the original images from template images (R-value) in copy and delayed recall between ADHD adolescents and healthy adolescents. There was no significant difference in R-value of immediate recall between ADHD adolescents and healthy adolescents. In all adolescents (ADHD and healthy) and ADHD adolescents, the R-value of copy was negatively correlated with visuospatial index and working memory index, and the R-value of delayed recall was negatively correlated with WMI. The R-value of copy and delayed recall was positively correlated with K-ARS in all adolescents and ADHD adolescents.

CONCLUSIONS

ADHD adolescents showed differences in the R-values of copy and delayed recall in the digital ROCF version compared to healthy adolescents. The digital ROCF assessment tool can represent different patterns of visuospatial working memory abilities in ADHD adolescents compared to healthy adolescents.

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.

Memory-guided force output is associated with self-reported ADHD symptoms in young adults

Attention-deficit/hyperactivity disorder (ADHD) is the most commonly diagnosed mental health disorder in childhood and persists into adulthood in up to 65 % of cases. ADHD is associated with adverse outcomes such as the ability to gain and maintain employment and is associated with an increased risk for substance abuse obesity workplace injuries and traffic accidents A majority of diagnosed children have motor deficits; however, few studies have examined motor deficits in young adults. This study provides a novel examination of visuomotor control of grip force in young adults with and without ADHD. Participants were instructed to maintain force production over a 20-second trial with and without real-time visual feedback about their performance. The results demonstrated that when visual feedback was available, adults with ADHD produced slightly higher grip force than controls. However, when visual feedback was removed, adults with ADHD had a faster rate of decay of force, which was associated with ADHD symptom severity and trait impulsivity. These findings suggest that there may be important differences in the way that adults with ADHD integrate visual feedback during continuous motor tasks. These may account for some of the motor impairments reported in children with ADHD. These deficits could result from (1) dysfunctional sensory motor integration and/or (2) deficits in short-term visuomotor memory.

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.