Written Expression Learning Disorder Clinical Presentation

Updated: Nov 30, 2021
  • Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD  more...
  • Print


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. [10]

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. [11]