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]
