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Learning Disorder: Written Expression
Updated: Dec 3, 2008
Introduction
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.
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.
Etiology
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.
Diagnostic Criteria
The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) and the International Classification of Diseases, 9th edition (ICD-9) offer medical classification systems that are similar to, but not always consistent with, educational definitions of learning problems.1 The medical diagnosis of a learning disorder does not automatically provide a child with eligibility for assistance at school. Therefore, understanding the educational definitions and school processes that allow for school interventions is important for clinicians who diagnose learning problems.
The disorder of written expression, like the other learning disorder diagnoses provided in the DSM-IV, is coded on Axis I. The DSM-IV uses the terminology learning disorders, replacing the former term, academic skills disorders, used by the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition revised (DSM-III-R). Previously, in DSM-III-R, the disorder of written expression was called developmental writing disorder and was coded on Axis II.
Criteria for diagnosis
The DSM-IV diagnosis of disorder of written expression includes writing skills substantially below those expected for the child by age and measured intelligence. Poor writing skills must result in a significant interference with academic achievement and/or the activities of daily living that require the composition of texts (ie, grammatically correct sentences and organized paragraphs). In contrast to the previous editions, the DSM-IV allows for concurrent diagnosis of disorder of written expression with sensory, motor, neurological, and intellectual conditions; however, if a patient is concurrently diagnosed with any of these, the writing skills difficulties must be in excess of those usually associated with the condition.
Further, poor spelling or handwriting alone, in the absence of other writing difficulties, is insufficient for the diagnosis of disorder of written expression. For children with poor motor coordination that causes poor handwriting, a diagnosis of developmental coordination disorder may be appropriate. The DSM-IV specifically indicates individually administered standardized tests or functional assessment of writing skills and measured intelligence. Therefore, diagnosis according to DSM-IV criteria involves psychoeducational evaluation.
Special education and learning disabilities
In educational settings, the terminology specific learning disability is used. The term learning disability originated with Public Law 94-142, which defined handicapping conditions of children as disorders in understanding or using language that result in specific academic deficits, including writing. Law mandates that public schools provide special education services for students who have such disabilities. The Individuals with Disabilities Education Act (IDEA) guides the actions of school committees on special education in determining the eligibility for special services of students through age 21 years.
Differential diagnosis
Similar to the DSM-IV criteria, special education committees' determinations do not define a learning disability in written expression as handwriting and spelling unless accompanied by other written expression problems. As with all learning disorders, differentiating situations in which children who have difficulty writing have other medical, developmental, physical, or sensory impairments, deficient educational opportunities, environmental deprivation, or cultural differences (including English as a second language), which may contribute to the poor achievement in written expression, is necessary.
A diagnosis of mental retardation usually rules out any learning disorder, as the general deficit in intellectual skills is equivalent to a picture of overall low academic performance. In some cases of mild mental retardation, a specific learning disorder such as disorder of written expression could occur if the skills in writing are lower than would be expected given the potential intellectual functioning of the child.
Careful attention to the neurological history and examination should rule out other factors that can cause symptoms of dysgraphia or phonological agraphia, such as injury to or vascular abnormalities in the posterior corpus callosum or superior temporal gyrus or epilepsy (a cause of acquired epileptic dysgraphia).
Symptoms of anxiety or frustration (breaking pencils, crumpling or tearing up homework papers, avoidance of academic work) should not be ignored because, for many children, these symptoms correlate with an untreated learning disorder and should not be regarded as only reflecting the presence of a comorbid disorder.
Taking a careful history for comorbid disorders is important because some children present with comorbid attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, features of obsessive-compulsive disorder (OCD), and/or seizure disorders.
Learning disability determination in educational settings
In school settings, a teacher often first notes indicators of a learning disorder. At that point, a child may be referred to the committee on special education to determine if the child is eligible for special services. Those outside of the school, such as parents or physicians, may also refer a child for this determination. If parents consent to a special education evaluation, schools provide a professional assessment, including a psychoeducational evaluation, for the committee's review. Parents have the right to present additional information and assessments obtained from other professionals.
The law mandates that children be provided with the least restrictive environment in school that addresses their disability. This means that a diagnosis of a learning disorder and a determination of eligibility by the committee on special education will not result in unnecessary changes in the child's class or school assignments. For many children, the special education services are the main avenue of treatment available to them. Specific laws define the parents' and child's rights to disagree with and to appeal committee determinations.
A medical diagnosis of a learning disorder may or may not be sufficient to establish eligibility for special services, depending on the discrepancy between intellect and achievement used for the diagnosis and the individual school district. The discrepancy needed to diagnose a learning disorder is defined by DSM-IV criteria as achievement that is substantially below intellect. Substantially below refers to more than 2 standard deviations between the scores on 2 tests; this is a standardized measure of achievement and a measure of intellectual functioning. This difference can be less, between 1 and 2 standard deviations, if the intellectual assessment has been impacted negatively by a cognitive or other mental or medical disorder.
In assessments of written language, functional writing skills are also used as a measure of achievement. Although the evaluation of the writing samples is always recommended and is necessary for a functional assessment of the disorder, some subjectivity is involved in this type of assessment. Inter-rater reliability of writing samples can be poor.
Committees on special education generally determine which children are designated as having a learning disability by applying a specific discrepancy formula to the difference between intellectual and achievement test scores to all cases in their school district. States and individual school districts vary considerably in which statistical method they use to determine the intellectual/achievement test score discrepancy.
Formulas that include consideration of standard scores and the regression effects of intellectual/achievement discrepancies are considered most accurate; however, all methods can be criticized as being less than scientific. A child can meet the criteria for eligibility for special services in one school district and not in another. Criticism of this system of determining disabilities is not uncommon. Consulting professionals familiar with the psychometric properties of achievement and intellectual tests and their use in special education determinations may be helpful. In addition, many school districts now include failure of response to remedial educational interventions as a criteria for diagnosis.
Prevalence
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. Estimates suggest that 5% of school-aged children are diagnosed with learning disorders in the United States, and 4% are diagnosed with a reading disorder. Other higher estimates suggest that about 6% of the school-aged population has a disorder of written expression.
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.
Course and Comorbidity
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.
Assessment of Written Expression
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.
Methods
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 theessential components of writing that require mastery, Baker and Hubbard included the child's level of knowledge about the writing process.2
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.
Treatment of Disorder of Written Expression
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.3
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."4
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.5
Referenced Tests Assess Written Expression
- Test of Written Language, 3rd edition measures (1) contrived writing including vocabulary, spelling, style (capitalization and punctuation); logical sentences (writing conceptually sound sentences); and sentence combining (measuring syntax) subtests; and (2) spontaneous writing (scored for thematic maturity, contextual vocabulary, syntactic maturity) for children aged 7 years and 6 months to those aged 17 years and 11 months.6
- Test of Early Written Language, 2nd edition measures basic, global, and contextual writing quotients for children aged 3 years to those younger than 11 years.7
- Test of Written Spelling, 3rd edition measures the spelling of phonetically regular and irregular words for children aged 6-18 years.8
- Kaufman Test of Educational Achievement includes a spelling subtest with analysis of error types for children aged 6-17 years.9
- Wechsler Individual Achievement Test includes spelling and written expression subtests for children aged 5-19 years.10
- Peabody Individual Achievement Test includes a spelling subtest with a multiple-choice format and a written expression subtest for children aged 5-18 years.
- Woodcock-Johnson Psychoeducational Battery, revised includes dictation, proofing, writing fluency, and writing samples subtests for children aged 5 years to adulthood.11
- Slingerland Screening Tests for Identifying Children with Specific Language Disabilities may be helpful.
- McCarthy Scales of Children’s Abilities is a normed test that can be helpful in identifying multiple deficit areas.
- Detroit Tests of Learning Aptitude is another normed test that is also helpful in identifying multiple deficit areas.
Keywords
learning disability, writing disability, writing disorder, written language disorder, written expression difficulty, cognitive processes, language skills, motor skills, dysgraphia, agraphia, phonological agraphia, constructional apraxia, learning disorder, minimal brain dysfunction, dyslexia, left hemispheric hypofunctioning, language delay, eclampsia, placental insufficiency, cord compression, malnutrition, bleeding during pregnancy, learning disabled, expressive language dysfunction, fine-motor deficits, linguistic deficits, visual-spatial deficits, attention deficits, memory deficits, sequencing deficits, carbon monoxide poisoning, lead poisoning, fetal alcohol syndrome, FAS, academic skills disorders, developmental writing disorder, developmental coordination disorder, dysgraphia, phonological agraphia
The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Hilary Luttinger and Melvin Gertner, MD, to the development and writing of this article.
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References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders- TR (Text Revision). 4th ed. 2000.
Baker S, Hubbard D. Best practices in the assessment of written expression. In: Thomas A, Grimes J, eds. Best Practices in School Psychology-III. 1995:717-30.
Englert C, Mariage TV. Shared Understandings: Structuring the writing experience through dialogue. In: 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. [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.
Balasubramanian V. Dysgraphia in two forms of conduction aphasia. Brain Cogn. Feb 2005;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. Apr 2007;75(1):75-86. [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. Dec 2005;11(6):479-95. [Medline].
Elbert JC. Learning and motor skills disorders. In: 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. Dec 2005;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. In: The School Psychologist. Vol 58. 2004:6-14.
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. Jan-Feb 2002;35(1):57-68. [Medline].
Lloyd JW, Hallahan DP, Kaufman JM. Academic problems. In: 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. Aug 2005;97(1):109-16. [Medline].
Mayes SD, Calhoun SL, Crowell EW. Learning disabilities and ADHD: overlapping spectrumn disorders. J Learn Disabil. Sep-Oct 2000;33(5):417-24. [Medline].
Mayes SD, Calhoun SL, Lane SE. Diagnosing children's writing disabilities: different tests give different results. Percept Mot Skills. Aug 2005;101(1):72-8. [Medline].
Meng H, Smith SD, Hager K, et al. DCDC2 is associated with reading disability and modulates neuronal development in the brain. Proc Natl Acad Sci U S A. Nov 22 2005;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. Sep 2006;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. Jun 2007;54(3):543-61, vii. [Medline].
Reynolds D, Nicolson RI, Hambly H. Evaluation of an exercise-based treatment for children with reading difficulties. Dyslexia. Feb 2003;9(1):48-71; discussion 46-7. [Medline].
Sandler AD, Watson TE, Footo M, Levine MD, et al. Neurodevelopmental study of writing disorders in middle childhood. J Dev Behav Pediatr. Feb 1992;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. Apr 2007;61(4):363-70. [Medline].
Silver CH, Ruff RM, Iverson GL, et al. Learning disabilities: the need for neuropsychological evaluation. Arch Clin Neuropsychol. Mar 2008;23(2):217-9. [Medline].
Stagg V, Burns S. Specific developmental disorders. In: 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. Nov 27 2008;359(22):2381-3. [Medline].
Takaiwa A, Yamashita K, Nomura T, et al. [A case of carbon monoxide poisoning by explosion of coal mine presenting as visual agnosia: re-evaluation after 40 years]. No To Shinkei. Nov 2005;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].
Further Reading
Keywords
learning disability, writing disability, writing disorder, written language disorder, written expression difficulty, cognitive processes, language skills, motor skills, dysgraphia, agraphia, phonological agraphia, constructional apraxia, learning disorder, minimal brain dysfunction, dyslexia, left hemispheric hypofunctioning, language delay, eclampsia, placental insufficiency, cord compression, malnutrition, bleeding during pregnancy, learning disabled, expressive language dysfunction, fine-motor deficits, linguistic deficits, visual-spatial deficits, attention deficits, memory deficits, sequencing deficits, carbon monoxide poisoning, lead poisoning, fetal alcohol syndrome, FAS, academic skills disorders, developmental writing disorder, developmental coordination disorder, dysgraphia, phonological agraphia
