Written Expression Learning Disorder 

Updated: Sep 22, 2016
Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD 

Overview

Practice Essentials

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. In real-world situations, children with primary impairment in handwriting often have associated spelling problems without reading problems. In addition, for some people, impairment in attention due to Attention Deficit Hyperactivity Disorder may be associated with dysgraphia.[1]

Students with Specific Learning Disabilities that impair writing skills (handwriting, spelling, and/or composing) may not only need accommodations (e.g., allowing more time to complete written work or using a laptop) but also continuing explicit instruction in alphabet letter access, retrieval, and production and copying words in sentence context and using multiple modes of letter production in spelling and composition instruction. The use of different approaches to handwriting (writing by hand, typing) may be helpful to strengthen the orthographic loop of working memory that supports written language learning by connecting the mind's eye with the serial movements of hands and fingers in producing the sequential component strokes of letter forms.[2]

Recent research looked at DTI and fMRI to elucidate the brain regions involved and found that connections from the supramarginal gyrus to the anterior cingulate and from the inferior frontal gryus to the frontal gyrus may be involved and are affected in word-specific spelling impairment in children with dysgraphia.[3]

Background

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.[4]

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.[5]

Dysgraphia can also be associated with other medical conditions such as absence seizures.[6]

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.[7]

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

  • Spelling accuracy
  • Grammar and punctuation accuracy
  • Clarity or organization of written expression

Epidemiology

Frequency

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.[7]

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.

Mortality/Morbidity

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.

Pathophysiology

Genetic studies have focused attention on the area of DYX2 on chromosome 6p21.3 as several genes in this locus have been associated with reading disabilities as well as the gene areas DCDC2 and KIAA0319 appear to both contribute to reading and writing disabilities. Another important factor in reading and writing disabilities, READ1, a polymorphic compound with a short tandem repeat within intron 2 of risk gene DCDC2 may have a non-additive genetic interaction with KIAHap, a risk haplotype in risk gene KIAA0319 may be a transcriptional regulator of ETV and so also a transcriptional regulator of KIAA0319.[8]

.

Prognosis

Prognosis is guarded. Disorders of written expression can remain as a lifelong barrier to fluent writing for persons unable to access assistive technologies such as computer-assisted dictation systems or spellcheck computer programs.

Patient Education

Use of assistive technologies is critical to a person being able to accommodate and function despite the disability. The use of assistive technology such as computer-assisted dictation systems and the use of spellcheck not just in computer documents but also in email communication can be extremely helpful. The use of a human being to proofread written documents can be extremely helpful as computer-assisted technology is not yet sophisticated enough to ensure that the words chosen by spellcheck reflect the true meaning that the person wishes to communicate.[9]

 

Presentation

History

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 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.

Causes

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]

 

DDx

Diagnostic Considerations

Similar to the DSM5 criteria, special education committees' determinations do not define a student as having a specific learning disorder (with impairment in written expression) until excluding other potential causes. 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.[12]

 

Workup

Approach Considerations

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) and the International Classification of Diseases, 10th edition (ICD-10) offer medical classification systems that are similar to, but not always consistent with, educational definitions of learning problems.[7] 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.

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.

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.

Other Tests

Some tests used to assess written expression include the following:

  • 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.[13]

  • 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.[14]

  • Test of Written Spelling, 3rd edition measures the spelling of phonetically regular and irregular words for children aged 6-18 years.[15]

  • Kaufman Test of Educational Achievement includes a spelling subtest with analysis of error types for children aged 6-17 years.[16]

  • Wechsler Individual Achievement Test includes spelling and written expression subtests for children aged 5-19 years.[17]

  • 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.[18]

  • 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.

 

Treatment

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.[11]

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.[19]

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."[20]

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.[21]