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Written Expression Learning Disorder

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


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.[1]

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.[2]

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.[3]

Specific learning disorder with impairment in written expression includes possible deficits in:

  • Spelling accuracy
  • 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.[3]

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.

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.

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