Written Expression Learning Disorder
- Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD more...
Proficiency in written expression skills can be viewed as the culmination of a child's education. Along with reading, expressing oneself in writing is an essential accomplishment of childhood that facilitates the necessary and rewarding tasks of adult life. The ability to write at an age-appropriate level is required for all academic progress. For some children, the acquisition of written expression skills is a difficult and enduring problem.
Disorders of written expression often accompany reading or other learning difficulties; less research has been performed in isolated written expression problems than in other learning areas. In fact, whether written expression exists is an isolated disorder is uncertain. Not infrequently, writing is the most significant stumbling block for a child. The diagnosis of written language disorder can help point the way toward necessary treatment and support. Although individualized teaching strategies may change epigenetic gene expression and improve reading and writing during earlier stages of education, the underlying gene sequences may continue to play an etiological role for individuals with expressive writing disorder, especially as curriculum requirements increase in nature, complexity, and volume with increasing academic complexity.
Vision problems can interfere with the process of reading, but children with dyslexia or related learning disabilities have the same visual function and ocular health as children without such conditions; however, there is no valid evidence at this point that children who participate in vision therapy are more responsive to educational instruction than children who do not participate.
Writing is a complex task requiring the mastery and integration of a number of subskills. The process of writing connects cognition, language, and motor skills. Some children have difficulties in one aspect of the process, such as producing legible handwriting or spelling, whereas other children have difficulty organizing and sequencing their ideas. Difficulties in one area can delay skill development in the other areas, as practice of all writing skills may be impeded. Children often experience this disorder as thoughts that move faster than their hand can translate them into written ideas on the page.
Children with written expression difficulties can find essential activities at school, such as note taking, to be insurmountable tasks. Note taking requires listening, comprehending, retaining information while continuing to process new information, and summarizing the important points into a useful format. The physical acts involved in writing notes must occur simultaneously with these cognitive processes. All of this must be accomplished with sufficient speed, automaticity, and with a quality of production leading to writing legibly enough for the notes to be useful later.
Diagnostic Criteria (DSM5)
In 2013, the American Psychiatric Association released the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM5). In this latest edition, specific learning disorder (SLD) is the umbrella term for mathematics, reading, and written expression disorders. It is now a single, overall diagnosis, incorporating deficits that impact academic achievement. Rather than limiting learning disorders to diagnoses particular to reading, mathematics, and written expression, the criteria describe shortcomings in general academic skills and provide detailed specifiers for the areas of reading, mathematics, and written expression. The diagnosis requires persistent difficulties in reading, writing, arithmetic, or mathematical reasoning skills during formal years of schooling.
Specific learning disorder with impairment in written expression includes possible deficits in:
Grammar and punctuation accuracy
Clarity or organization of written expression
A lack of agreement on definitions of learning disorders, as well as variation in the procedures that lead to school determinations among states and among individual school districts, lead to widely varying estimates of incidence. Most information available about the prevalence of the disorder of written expression is based on studies of reading disorders or learning disorders in general. Disorder of written expression is assumed to occur with a similar frequency to other learning disorders. The prevalence of specific learning disoder across the academic domains of reading, writing, and mathematics is 5%-15% among school-age children across different languages and cultures.
In neuropsychological research with adults with acquired deficits, reading and writing appear to be independent skills areas, with dysgraphia occurring without dyslexia. This has not been well studied in children. Disorder of written expression, without preoccurring or concurrent learning disorders of reading and/or mathematics, is considered rare.
Evidence suggests that disorder of written expression is accompanied by language and perceptual-motor deficits and often occurs in combination with reading disorder, mathematics disorder, or both. Some research points to preschool-aged and early school-aged difficulties with language and phonological skills in children who later are diagnosed with learning disorders, which may include written expression. Difficulties with phonological awareness appear to underlie spelling difficulties and may be related to, or concurrent with, other aspects of a disorder of written expression.
To allow for sufficient formal instruction, a disorder of written expression is not usually diagnosed until after the end of a child's first grade year in school. The poor progress with writing and, often, reading is usually apparent in the first grade; a diagnosis can often be made by second grade. Written expression problems often persist throughout school and can continue into postsecondary and adult years. College students with learning problems have difficulty with speed and automaticity of writing.
The writing skills of children with other learning disorders often are similar to the writing skills of children of a younger age group, as much as 3-6 years younger. That is to say, a 12-year-old child with learning disorders may write similar to a 6-year-old or 9-year-old child who does not have learning disorders rather than to a 12-year-old child without learning disorders. Children with other learning problems perform at levels below their peers without learning disorders in written expression at every age. The gap between the writing of children with learning disorders and their peers without learning disorders widens with age.
Frequently, learning disorders are comorbid with behavior disorders, most frequently ADHD and oppositional defiant disorder. Clinical experience with children with ADHD often reveals that they have poor written expression skills. Writing is a task that requires planning, organizational skills, and persistence of attention and effort. The nature and direction of the relationship of learning disorders, behavior disorders, and disorders of attention is unclear and may differ in gender specific ways.
Learning disorders of all types are associated with other mental health problems. The DSM-IV mentions low self-esteem, demoralization, and social skill deficits as associated with learning disorders. The school dropout rate is significantly higher for children with learning disorders than for children without learning disorders. Some research points to an increased incidence of subsequent substance abuse problems and lower levels of employment. Viewing these as factors that can occur with the disorder of written expression but also as factors that can be positively impacted by appropriate treatment of the academic and associated issues is important.
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].
Handler SM, Fierson WM, Section on Ophthalmology. Learning disabilities, dyslexia, and vision. Pediatrics. 2011 Mar. 127(3):e818-56. [Medline].
American Psychiatric Association. Neurodevelopmental Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013. 66-74.
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.
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].
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].
Hammil DD, Larsen SC. Test of Written Language-3. 1996.
Hresko WP, Herron SR, Peak PK. Test of early Written Language-3. 1998.
Larsen SC, Hammill DD, Moats L. Test of Written Spelling. 4th ed. 2000.
Kaufman AS, Kaufman NL. Kaufman Test of Educational Achievement. 1993.
Wechsler D. Wechsler Individual Achievement Test. 1992.
Woodcock RW, Johnson MB. Woodcock-Johnson Psycho-Educational Battery-Revised. 1989.
Englert C, Mariage TV. Shared Understandings: Structuring the writing experience through dialogue. Carmine D, Kameenue E, eds. Higher Order Thinking. 1992. 107-37.
Swanson HL. Interventions for Students with Learning Disabilities. 1999.
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.
Balasubramanian V. Dysgraphia in two forms of conduction aphasia. Brain Cogn. 2005 Feb. 57(1):8-15. [Medline].
Beeson PM, Magloire JG, Robey RR. Letter-by-letter reading: natural recovery and response to treatment. Behav Neurol. 2005. 16(4):191-202. [Medline].
Bradley-Johnson S, Lesiak JL. Problems in Written Expression: Assessment and Remediation. 1989.
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].
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].
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].
Elbert JC. Learning and motor skills disorders. Netherton S, Holmes D, Walker CE, eds. Child and Adolescent Psychology. 1999.
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].
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.
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].
Lloyd JW, Hallahan DP, Kaufman JM. Academic problems. Morris RJ, Kratochwil TR, eds. The Practice of Child Therapy. 1998. 167-98.
Markwardt FC. Peabody Individual Achievement Test-Revised. 1989.
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].
Mayes SD, Calhoun SL, Crowell EW. Learning disabilities and ADHD: overlapping spectrumn disorders. J Learn Disabil. 2000 Sep-Oct. 33(5):417-24. [Medline].
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].
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].
Papagno C, Girelli L. Writing through the phonological buffer: a case of progressive writing disorder. Neuropsychologia. 2005. 43(9):1277-87. [Medline].
Pennington BF. From single to multiple deficit models of developmental disorders. Cognition. 2006 Sep. 101(2):385-413. [Medline].
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].
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].
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].
Sattler J. The Assessment of Children. 3rd ed. Revised; 1992.
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].
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].
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].
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].
Stagg V, Burns S. Specific developmental disorders. Ammerman RT, Hersen M, eds. Handbook of Prescriptive Treatments for Children. 1999. 48-62.
Stromswold K. The genetics of speech and language impairments. N Engl J Med. 2008 Nov 27. 359(22):2381-3. [Medline].
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].
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].