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Written Expression Learning Disorder Clinical Presentation

  • Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD  more...
Updated: May 27, 2016


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


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

Components of written expression

Components of written expression are usually considered to include handwriting, capitalization and punctuation, spelling, vocabulary, word usage, sentence and paragraph structure, production (amount), overall quality, automaticity or fluency, and understanding of types of written material (text structure). In one analysis of the essential components of writing that require mastery, Baker and Hubbard included the child's level of knowledge about the writing process.[4]

Evaluation of written expression

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

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

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

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

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



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

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

Neurobiological factors

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

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

Neuropsychological factors

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

Genetic factors

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

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

Adverse reactions to medications may be mediated by genetic factors and negatively impact written expression. A recent case study suggested that treatment with topiramate might cause impairment in written expression in vulnerable individuals; therefore, a careful history including medication history is important to exclude other iatrogenic causes of impairment in written expression.[5]

Contributor Information and Disclosures

Bettina E Bernstein, DO Distinguished Fellow, American Academy of Child and Adolescent Psychiatry; Distinguished Fellow, American Psychiatric Association; Clinical Assistant Professor of Neurosciences and Psychiatry, Philadelphia College of Osteopathic Medicine; Clinical Affiliate Medical Staff, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia; Consultant to theVillage, Private Practice; Consultant PMHCC/CBH at Family Court, Philadelphia

Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Psychiatric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Angelo P Giardino, MD, MPH, PhD Professor and Section Head, Academic General Pediatrics, Baylor College of Medicine; Senior Vice President and Chief Quality Officer, Texas Children’s Hospital

Angelo P Giardino, MD, MPH, PhD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, International Society for the Prevention of Child Abuse and Neglect, Ray E Helfer Society

Disclosure: Received grant/research funds from Health Resources and Services Administration (HRSA) Integrated Community Systems for CSHCN Grant for other; Received advisory board from Baxter Healthcare Corporation for board membership.

  1. Berninger VW, May MO. Evidence-based diagnosis and treatment for specific learning disabilities involving impairments in written and/or oral language. J Learn Disabil. 2011 Mar-Apr. 44(2):167-83. [Medline].

  2. Handler SM, Fierson WM, Section on Ophthalmology. Learning disabilities, dyslexia, and vision. Pediatrics. 2011 Mar. 127(3):e818-56. [Medline].

  3. American Psychiatric Association. Neurodevelopmental Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013. 66-74.

  4. Baker S, Hubbard D. Best practices in the assessment of written expression. Thomas A, Grimes J, eds. Best Practices in School Psychology-III. 1995. 717-30.

  5. Andrade C, Bhakta SG, Fernandes PP. Familial vulnerability to an unusual cognitive adverse effect of topiramate: Discussion of mechanisms. Indian J Psychiatry. 2010 Jul. 52(3):260-3. [Medline]. [Full Text].

  6. Semrud-Clikeman M, Harder L. Neuropsychological correlates of written expression in college students with ADHD. J Atten Disord. 2011 Apr. 15(3):215-23. [Medline].

  7. Hammil DD, Larsen SC. Test of Written Language-3. 1996.

  8. Hresko WP, Herron SR, Peak PK. Test of early Written Language-3. 1998.

  9. Larsen SC, Hammill DD, Moats L. Test of Written Spelling. 4th ed. 2000.

  10. Kaufman AS, Kaufman NL. Kaufman Test of Educational Achievement. 1993.

  11. Wechsler D. Wechsler Individual Achievement Test. 1992.

  12. Woodcock RW, Johnson MB. Woodcock-Johnson Psycho-Educational Battery-Revised. 1989.

  13. Englert C, Mariage TV. Shared Understandings: Structuring the writing experience through dialogue. Carmine D, Kameenue E, eds. Higher Order Thinking. 1992. 107-37.

  14. Swanson HL. Interventions for Students with Learning Disabilities. 1999.

  15. Schmalzl L, Nickels L. Treatment of irregular word spelling in acquired dysgraphia: selective benefit from visual mnemonics. Neuropsychol Rehabil. Feb 2006. 16(1):1-37.

  16. Balasubramanian V. Dysgraphia in two forms of conduction aphasia. Brain Cogn. 2005 Feb. 57(1):8-15. [Medline].

  17. Beeson PM, Magloire JG, Robey RR. Letter-by-letter reading: natural recovery and response to treatment. Behav Neurol. 2005. 16(4):191-202. [Medline].

  18. Bradley-Johnson S, Lesiak JL. Problems in Written Expression: Assessment and Remediation. 1989.

  19. Burgio-Murphy A, Klorman R, Shaywitz SE, et al. Error-related event-related potentials in children with attention-deficit hyperactivity disorder, oppositional defiant disorder, reading disorder, and math disorder. Biol Psychol. 2007 Apr. 75(1):75-86. [Medline].

  20. Chacko A, Uderman J, Feirsen N, Bedard AC, Marks D. Learning and cognitive disorders: multidiscipline treatment approaches. Child Adolesc Psychiatr Clin N Am. 2013 Jul. 22(3):457-77. [Medline].

  21. Downie AL, Frisk V, Jakobson LS. The impact of periventricular brain injury on reading and spelling abilities in the late elementary and adolescent years. Child Neuropsychol. 2005 Dec. 11(6):479-95. [Medline].

  22. Elbert JC. Learning and motor skills disorders. Netherton S, Holmes D, Walker CE, eds. Child and Adolescent Psychology. 1999.

  23. Gout A, Seibel N, Rouviere C, et al. Aphasia owing to subcortical brain infarcts in childhood. J Child Neurol. 2005 Dec. 20(12):1003-8. [Medline].

  24. Hale JB, Naglieri J, Kaufman AS. Specific learning disability classifcation in the new Individuals with Disabilities Education Act: The danger of good ideas. The School Psychologist. 2004. Vol 58: 6-14.

  25. Hooper SR, Swartz CW, Wakely MB, de Kruif RE, Montgomery JW. Executive functions in elementary school children with and without problems in written expression. J Learn Disabil. 2002 Jan-Feb. 35(1):57-68. [Medline].

  26. Lloyd JW, Hallahan DP, Kaufman JM. Academic problems. Morris RJ, Kratochwil TR, eds. The Practice of Child Therapy. 1998. 167-98.

  27. Markwardt FC. Peabody Individual Achievement Test-Revised. 1989.

  28. Mayes SD, Calhoun SL. Test of the definition of learning disability based on the difference between IQ and achievement. Psychol Rep. 2005 Aug. 97(1):109-16. [Medline].

  29. Mayes SD, Calhoun SL, Crowell EW. Learning disabilities and ADHD: overlapping spectrumn disorders. J Learn Disabil. 2000 Sep-Oct. 33(5):417-24. [Medline].

  30. Mayes SD, Calhoun SL, Lane SE. Diagnosing children's writing disabilities: different tests give different results. Percept Mot Skills. 2005 Aug. 101(1):72-8. [Medline].

  31. Meng H, Smith SD, Hager K, Held M, Liu J, Olson RK. DCDC2 is associated with reading disability and modulates neuronal development in the brain. Proc Natl Acad Sci U S A. 2005 Nov 22. 102(47):17053-8. [Medline].

  32. Papagno C, Girelli L. Writing through the phonological buffer: a case of progressive writing disorder. Neuropsychologia. 2005. 43(9):1277-87. [Medline].

  33. Pennington BF. From single to multiple deficit models of developmental disorders. Cognition. 2006 Sep. 101(2):385-413. [Medline].

  34. Peterson RL, McGrath LM, Smith SD, Pennington BF. Neuropsychology and genetics of speech, language, and literacy disorders. Pediatr Clin North Am. 2007 Jun. 54(3):543-61, vii. [Medline].

  35. Reynolds D, Nicolson RI, Hambly H. Evaluation of an exercise-based treatment for children with reading difficulties. Dyslexia. 2003 Feb. 9(1):48-71; discussion 46-7. [Medline].

  36. Sandler AD, Watson TE, Footo M, Levine MD, Coleman WL, Hooper SR. Neurodevelopmental study of writing disorders in middle childhood. J Dev Behav Pediatr. 1992 Feb. 13(1):17-23. [Medline].

  37. Sattler J. The Assessment of Children. 3rd ed. Revised; 1992.

  38. Schuele CM. The impact of developmental speech and language impairments on the acquisition of literacy skills. Ment Retard Dev Disabil Res Rev. 2004. 10(3):176-83. [Medline].

  39. Shaywitz BA, Lyon GR, Shaywitz SE. The role of functional magnetic resonance imaging in understanding reading and dyslexia. Dev Neuropsychol. 2006. 30(1):613-32. [Medline].

  40. Shaywitz BA, Skudlarski P, Holahan JM, Marchione KE, Constable RT, Fulbright RK. Age-related changes in reading systems of dyslexic children. Ann Neurol. 2007 Apr. 61(4):363-70. [Medline].

  41. Silver CH, Ruff RM, Iverson GL, et al. Learning disabilities: the need for neuropsychological evaluation. Arch Clin Neuropsychol. 2008 Mar. 23(2):217-9. [Medline].

  42. Stagg V, Burns S. Specific developmental disorders. Ammerman RT, Hersen M, eds. Handbook of Prescriptive Treatments for Children. 1999. 48-62.

  43. Stromswold K. The genetics of speech and language impairments. N Engl J Med. 2008 Nov 27. 359(22):2381-3. [Medline].

  44. Takaiwa A, Yamashita K, Nomura T, Shida K, Taniwaki T. [A case of carbon monoxide poisoning by explosion of coal mine presenting as visual agnosia: re-evaluation after 40 years]. No To Shinkei. 2005 Nov. 57(11):997-1002. [Medline].

  45. Varley R, Cowell PE, Gibson A, Romanowski CA. Disconnection agraphia in a case of multiple sclerosis: the isolation of letter movement plans from language. Neuropsychologia. 2005. 43(10):1503-13. [Medline].

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