Medscape is available in 5 Language Editions – Choose your Edition here.


Written Expression Learning Disorder Treatment & Management

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

Approach Considerations

A 2010 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]


Medical Care

Treatment of learning problems generally occurs outside of medical environments. Treatment approaches include educational remediation of poor skills, making accommodations to the learning environment, and addressing any comorbid medical and mental health issues (possibly including pharmacotherapy).

When the child meets special education eligibility criteria, the academic remediation can be delivered through special services at school. The child receives an individual education plan (IEP), which sets goals for improving specific skills. This plan may include a specially designed curriculum and designate instructional and evaluation methods geared toward improving written expression and coexisting learning problems. When special education services are not designated, assistance by tutors or others after school can be helpful.

The treatment of language disorders including disorders of written expression should include skill development (decoding), a holistic approach to remediation, as well as necessary accommodations. Decoding to remediate gaps in skill acquisition is especially important for younger children who are not reading fluently.

A holistic approach should begin with the student’s own ideas and follow a series of highly structured steps to narrow ideas to one topic, then help the student to create a first draft. The student reads aloud to another person or an audience of peers to refine organizations and language to work towards a final draft.

Accommodations such as the use of a computer with spell check and grammar check are helpful because a keyboard allows for a more rapid production of letters, compensating for any dysgraphia (fine–motor skills disorder). If the student is not able to effectively use the keyboard, the use of a scribe (person who writes the student’s ideas down from dictation) or computer programs that transform dictation into typed print (eg, Dragon Naturally Speaking) can be effective. Getting past the student’s intrinsic fear of failure using all necessary accommodations is important, especially in the beginning stages of writing remediation.

Writing as a process

In remediating poor writing skills, using methods of teaching writing that have proven most effective is helpful. Recent educational research in this area has pointed to benefits of teaching writing as a process. This contrasts with more traditional approaches, which emphasized adherence to the conventions of mechanics (eg, grammar, punctuation, spelling, penmanship). Teaching a process to a child can be referred to as metacognitive because it requires reflection on cognitive skills as they are being used.

The process of writing includes prewriting activities, the writing itself, and postwriting activities. Prewriting begins with planning, which includes analyzing the purpose of the writing and generating and organizing ideas. To develop prewriting skills, the child is taught to recognize types of recurring patterns and structures that relate to types of text. Narrative text (eg, a temporally ordered story) differs from expository text. The child is taught to include elements that match the identified text structure. Discussion and interaction appear to benefit the development of prewriting planning skills. In some instructional approaches, teachers model brainstorming or think-aloud techniques.

Teaching children to organize and sequence their ideas can be facilitated by the use of prepared templates for the mapping or webbing of ideas on paper. These graphic organizers can be created in various shapes. For example, the child may write ideas into the spokes of a topic wheel or other child-friendly designs. After writing, a child uses self-evaluation skills to monitor the written product for necessary elements and for adherence to conventions of language mechanics.

A frequently cited example of a process approach to teaching writing is the one devised by Englert and Mariage, which teaches the acronym P-O-W-E-R as a mnemonic device that refers to the processes that are taught: plan, organize, write, edit, and revise.[13]

Accommodations to the learning environment

Accommodations to the learning environment can be helpful additions for a student with a disorder of written expression. Depending on the individual needs of the child, these may include preferential seating, assistance with note taking (eg, using a buddy system, teacher prepared notes, technologies such as tape recording, Franklin spellers, and laptop computers), allowance of additional time for written assignments and tests, the use of a scribe in situations where handwriting is crucial, the opportunity to demonstrate knowledge through means other than written work, and dual grades on written work for content and writing mechanics.

These accommodations can have an important positive effect, especially in later grades when the need for producing longer written assignments and note taking increases, as long as the student self-advocates for the needed assistance. The use of assistive technology can be a challenge when the student studies a foreign language; when available, the choice of American Sign Language can be "a life saver."[14]

Using new technologies

The use of new technologies may be helpful for some children. Although some children may find writing on a computer easier than writing with pencil and paper, the additional task of mastering the technology (eg, keyboarding skills) is burdensome for others, and the ability to write legibly remains an important skill. Especially for older children, the use of word processors in creating written assignments offers the obvious advantages of eliminating the need to recopy and the assistance of computerized editing of spelling and grammar. Some children and adults with disorder of written expression have benefited from computer programs that translate their spoken words to text. Examples of other new products that may be helpful include those in which the computer speaks text as it is typed. This may offer some children help in learning to detect written language errors. New technologies are being rapidly devised, and professionals may want to introduce these technologies on a case-by-case basis.

Motivational strategies

A trend in addressing learning problems includes the use of motivational strategies to teach problem solving, goal setting, and the modification of beliefs that negatively impact achievement. These techniques can be particularly helpful in improving academics of children who have poor self-regulatory skills; however, only view motivational techniques as adjuncts to specific instruction in academic skills. For many children with disorder of written expression, coaching in basic study skills may be very helpful in developing an expanded repertoire of techniques to improve school performance. Mastering study skills may help to improve negative emotional reactions to school and schoolwork.

Mental health services

Mental health services (eg, counseling or treatment of ADHD, oppositional defiant disorder, OCD) may be required in addition to special academic services. Issues addressed in counseling children with learning disorders can include frustration, anxiety related to school performance, poor peer relationships, and depression. The mental health professional who works with the child needs to keep the family and school staff informed about issues that are impacted by the learning problem. The successful coordination of the services provided to a child is essential, as is periodic reassessment of the child's progress in written expression and in related areas. The participation of a child and adolescent psychiatrist in treatment planning and medication management should be considered in particularly complex (multiproblem) cases.

Additional strategies

The use of visual mnemonics can be helpful to improve word spelling and, thus, writing fluency.[15]

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].

All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.