Handwriting performance and underlying factors in children with Attention Deficit Hyperactivity Disorder

Preliminary evidence suggests that handwriting difficulties are common to children with Attention Deficit Hyperactivity Disorder (ADHD). However, the nature of the task-specific impairments is needed to be clarified. The aim of this study was to describe handwriting capacity in ADHD children without DCD and identify underlying factors of performance by use of outcome-oriented assessments and a digitizing tablet. Twenty-one children with ADHD (8.59±1.25 years) and 21 match controls (8.5±1.08 years) were recruited. Children with ADHD scored lower than controls on Tseng Handwriting Problem Checklist and writing composite of Basic Reading and Writing Test, indicating the ADHD group wrote less legibly. The ADHD group spent more on-paper time to copy 50 Chinese characters and exhibited more writing time during the writing process. The ADHD group scored significantly lower on tasks demanding upper limb and eye-hand coordination and visual-motor integration compared with controls. Furthermore, motor skill and visual-motor integration were positively correlated with the legibility. Motor skill was negatively correlated with writing time, in-air time, and in-air trajectory.     

Handwriting performance in children with attention deficit hyperactivity disorder (ADHD)

Attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral condition of childhood. Consequences are multifaceted and include activity limitations in daily-living skills, academic challenges, diminished socialization skills, and motor difficulties. Poor handwriting performance is an example of an affected life skill that has been anecdotally observed by educators and clinicians for this population and can negatively impact academic performance and self-esteem. To guide health and educational service delivery needs, the authors reviewed the evidence in the literature on handwriting difficulties in children with ADHD. Existing evidence would suggest that children with ADHD have impaired handwriting performance, characterized by illegible written material and/or inappropriate speed of execution compared to children without ADHD. Studies with larger sample sizes using standardized measures of handwriting performance are needed to evaluate the prevalence of the problem and to better understand the nature of handwriting difficulties and their impact in this population.     

A preliminary study on the effect of methylphenidate on motor performance in children with comorbid DCD and ADHD

Attention Deficit Hyperactive Disorder (ADHD) and Developmental Coordination Disorder (DCD) are two developmental disorders with considerable comorbidity. The impact of Methylphenidate (MPH) on ADHD symptoms is well documented. However, the effects of MPH on motor coordination are less studied. We assessed the influence of MPH on motor performance of children with comorbid DCD and ADHD. Participants were 18 children (13 boys, mean age 8.3 years) diagnosed with comorbid DCD and ADHD. A structured clinical interview (K-SADS-PL) was used to determine psychopathology and the Movement Assessment Battery for Children–Checklist were used to determine criterion for motor deficits. The Movement Assessment Battery for Children (M-ABC) was administrated to all participants once under the influence of MPH and once under a placebo pill condition. The motor tests were administered on two separate days in a double-blinded design. Participants’ motor performance with MPH was significantly superior to their performance in the placebo condition. Significant improvement was observed in all the M-ABC sub-tasks except for static balance performance. The findings suggest that MPH improves motor coordination in children with comorbid DCD and ADHD but clinically significant improvement was found in only 33% of the children.     

A quantitative comparison of handwriting in children with high-functioning autism and attention deficit hyperactivity disorder

Children with high-functioning autism (HFA) and attention deficit hyperactivity disorder (ADHD) often experience significant handwriting difficulties, which can hamper their academic progress and ability to express themselves through symbols and words. Handwriting of children with HFA was compared to those with ADHD based on performance on the speed subtest of the Handwriting Performance Test. Differences in handwriting speed, size and alignment of words, and proportion of handwriting errors, such as corrections and substitutions, were assessed between groups. Results indicated distinct profiles of handwriting problems in HFA and ADHD: children with HFA demonstrated poorer spatial arrangement of words and reduced handwriting speed, and those with ADHD made more handwriting errors, such as corrections and transpositions. These findings have important implications in understanding the similarities and differences for children with HFA and ADHD and lay the groundwork for effective intervention strategies.     

The handwriting performance of children with NF1

The objective of this study was to analyze the process and product of handwriting among children with Neurofibromatosis Type 1 (NF1) in comparison to those of Typically Developing (TD) children. Children with NF1 are at risk for some cognitive deficits, a wide range of deficits in perceptual skills and, motor and visual-motor integration skills which may interfere with handwriting competency, which is an essential ingredient for success at school. Participants were 30 NF1 children and 30 age and gender matched TD children, between the ages 8 and 16.08. The handwriting performance of children with NF1 was evaluated with the Beery–Buktenica Developmental Test of Visual-Motor Integration (VMI), for copying text and free style writing tasks, using: (1) Computerized Penmanship Evaluation Tool (ComPET) to assess mechanical aspects of the writing process. (2) The Hebrew Handwriting Evaluation (HHE) to examine product legibility. (3) The Six-Trait Writing Model to judge the quality of the written product. Significant differences between the NF1 children and the control group were found in the process and product measures. Significant correlations were found between the VMI, the ComPET, the HHE and the Six-Trait Writing Model variables for both groups. We suggest a possible relationship between executive dysfunction and poor performance in handwriting.     

Handwriting features of children with developmental coordination disorder – Results of triangular evaluation

Developmental coordination disorders (DCD) is one of the most common disorders affecting school-aged children. The study aimed to characterize the handwriting performance of children with DCD who write in Arabic, based on triangular evaluation.Participants included 58 children aged 11–12 years, 29 diagnosed with DCD based on the DSM-IV criteria and the M-ABC, and 29 matched typically developed controls. Children were asked to copy a paragraph on a sheet of paper affixed to a digitizer supplying objective measures of the handwriting process. The handwriting proficiency screening questionnaire (HPSQ) was completed by their teachers while observing their performance and followed by evaluation of their final written product.Results indicated that compared to controls, children with DCD required significantly more on-paper and in-air time per stroke while copying. In addition, global legibility, unrecognizable letters and spatial arrangement measures of their written product were significantly inferior. Significant group differences were also found between the HPSQ subscales scores. Furthermore, 82.8% of all participants were correctly classified into groups based on one discriminate function which included two handwriting performance measures.These study results strongly propose application of triangular standardized evaluation to receive better insight of handwriting deficit features of individual children with DCD who write in Arabic.     

Predictive validity of kindergarten assessments on handwriting readiness

We investigated the predictive value of a new kindergarten assessment of handwriting readiness on handwriting performance in first grade as evaluated by the Systematic Screening for Handwriting Difficulties (Dutch abbreviation: SOS). The kindergarten assessment consisted of the Writing Readiness Inventory Tool In Context (WRITIC), the Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery™VMI) and the Nine-Hole Peg Test (9-HPT). The WRITIC evaluates in kindergarten children (aged 5–6 years) prewriting skills, the Beery™VMI and 9-HPT evaluate visual motor integration and fine-motor coordination, all elements important for handwriting readiness. In kindergarten, 109 children (55 boys; mean age 70 months, SD 4.8 months) were tested with the WRITIC, Beery™VMI and 9-HPT and one year later in first grade (mean age 85 months, SD 4.5 months) with the SOS. A multivariable linear mixed model was used to identify variables that independently predict outcomes in first grade (SOS): baseline scores on WRITIC-TP, Beery™VMI, 9-HPT, ‘sustained attention,’ ‘gender,’ ‘age’ and ‘intervention’ in the intermediate period. The results showed that WRITIC-TP, Beery™VMI, and 9-HPT, ‘sustained attention,’ ‘gender’ and ‘intervention’ had all predictive value on the handwriting outcome. Thereby WRITIC-TP was the main predictor for outcome of SOS-Quality, and Beery™VMI and 9-HPT were the main predictors of SOS-Speed. This kindergarten assessment of WRITIC-TP, Beery™VMI, and 9-HPT contributes to the detection of children at risk for developing handwriting problems.     

Handwriting difficulties of children with Charcot‐Marie‐Tooth disease type 1A

Hand weakness and impaired manual dexterity have been reported in children with Charcot‐Marie‐Tooth disease type 1A (CMT1A). This early onset of upper limb involvement might explain frequent clinical referrals for assessment and treatment of impaired handwriting performance. The aim of this study was to examine the impact of CMT1A on handwriting speed and legibility, and identify demographic, anthropometric, and physical measures that might relate to handwriting performance. Handwriting speed (Handwriting Speed Test), handwriting legibility (Evaluation Tool of Children's Handwriting‐Cursive), and hand strength (hand‐held dynamometry of tip pinch, lateral pinch and grip) were assessed in 30 children with CMT1A (aged 8–17 years) and 30 age‐ and sex‐matched controls. Children with CMT1A exhibited 34% slower handwriting speed (p < 0.0001) with 4% reduced legibility (p = 0.001) and 37–48% lower hand strength (p < 0.0001). All measures of strength, age, height, and weight were positively associated with handwriting speed (r = 0.39–0.79, p < 0.01). None of these factors related to handwriting legibility (p > 0.05). Regression modelling identified a diagnosis of CMT1A, lateral pinch weakness and younger age as significant independent predictors of slower handwriting speed, explaining 78% of the variance. Children with CMT1A have considerable handwriting difficulties, primarily with speed, and substantial associated hand and finger weakness. Understanding the cause–effect relationship between strength and function might provide modifiable targets for upper limb intervention.     

Motor impairment in children with anxiety disorders

This study examined the frequency and degree of motor impairment in referred children with anxiety disorders (AnxDs), compared with children with attention deficit/hyperactivity disorder (ADHD), children with comorbid AnxDs and ADHD, and nonreferred controls. All participants (n=141; 90 males, 51 females; mean age: 10years, 1month; range: 7-13years) had an IQ greater than 70. Diagnoses of mental disorders were established using the Schedule for Affective Disorders and Schizophrenia for School-Aged Children (Kiddie-SADS). Motor ability was assessed using the Movement Assessment Battery for Children (M-ABC). We found that children with AnxDs exhibited significantly higher total impairment scores on the M-ABC than controls, but were not significantly different from children with ADHD or children with comorbid AnxDs and ADHD. All clinical groups exhibited similar profiles of motor impairment. A total of 19 (46%) children with AnxDs scored below the 5th percentile on the M-ABC, indicating that motor function is impaired in many children with AnxDs to a degree that probably interferes with their activities of daily living. These results support the notion that assessment of motor function is important in understanding the daily challenges of children with AnxDs.     

Handwriting Difficulties in Children with Autism Spectrum Disorders: A Scoping Review

Functional handwriting involves complex interactions among physical, cognitive and sensory systems. Impairments in many aspects of these systems are associated with Autism spectrum disorders (ASD), suggesting a heightened risk of handwriting difficulties in children with ASD. This scoping review aimed to: (1) survey the existing evidence about potential contributions to compromised handwriting function in children with ASD, and (2) map out the existing studies documenting handwriting difficulties in children with ASD. The current evidence implicates impairments in fine motor control and visual-motor integration as likely contributors to handwriting difficulties in children with ASD, though the role of the latter is not well-understood. Moreover, diminished overall legibility and compromised letter formation are emerging points of convergence among existing studies of handwriting quality in children with ASD.     

Examining the relationship between motor assessments and handwriting consistency in children with and without probable Developmental Coordination Disorder

Children with Developmental Coordination Disorder (DCD) often experience difficulties in handwriting. The current study examined the relationships between three motor assessments and the spatial and temporal consistency of handwriting. Twelve children with probable DCD and 29 children from 7 to 12 years who were typically developing wrote the lowercase letters “e” and “l” in cursive and printed forms repetitively on a digitizing tablet. Three behavioral assessments, including the Beery–Buktenica Developmental Test of Visual-Motor Integration (VMI), the Minnesota Handwriting Assessment (MHA) and the Movement Assessment Battery for Children (MABC), were administered. Children with probable DCD had low scores on the VMI, MABC and MHA and showed high temporal, not spatial, variability in the letter-writing task. Their MABC scores related to temporal consistency in all handwriting conditions, and the Legibility scores in their MHA correlated with temporal consistency in cursive “e” and printed “l”. It appears that children with probable DCD have prominent difficulties on the temporal aspect of handwriting. While the MHA is a good product-oriented assessment for measuring handwriting deficits, the MABC shows promise as a good assessment for capturing the temporal process of handwriting in children with DCD.     

Motor skills of children newly diagnosed with Attention Deficit Hyperactivity Disorder prior to and following treatment with stimulant medication

Motor difficulties are common in children with Attention Deficit Hyperactivity Disorder (ADHD). Although preliminary evidence has suggested that methylphenidate can improve the motor skills in children with ADHD and Developmental Coordination Disorder (DCD), the effect of stimulant medication on motor performance in children newly diagnosed with ADHD with or without motor impairment remains unclear. A cohort study of 49 medication-naïve children (39 male; mean age 8.4 ± 1.3 years) with ADHD was conducted. Children were evaluated using the Movement Assessment Battery for Children and the developmental test of visual motor integration at diagnosis and again three months following daily treatment with a stimulant medication. Motor difficulties were highly present at baseline (73.5%) but resolved in a subset after treatment with stimulant medication, suggesting that their motor difficulties may be attributed in part to their attentional problems. Nevertheless, motor impairment persisted in 55.1% of the sample. The severity of the behavioural symptoms was significantly associated with balance skills in children without motor impairments (r² = 0.30, p < 0.01) and with visual motor integration skills in children with persisting motor difficulties (r² = 0.27, p < 0.01). Attentional difficulties negatively affect the motor skills of children with ADHD. Following the use of stimulant medication, an important subset continued to demonstrate motor difficulties. The improvement in behaviour was insufficient to resolve motor problems and these children should therefore be targeted for rehabilitation services.     

What is the evidence of impaired motor skills and motor control among children with attention deficit hyperactivity disorder (ADHD)? Systematic review of the literature

This article presents a review of the studies that have analysed the motor skills of ADHD children without medication and the influence of medication on their motor skills. The following two questions guided the study: What is the evidence of impairment of motor skills and aspects of motor control among children with ADHD aged between 6 and 16 years? What are the effects of ADHD medication on motor skills and motor control? The following keywords were introduced in the main databases: attention disorder and/or ADHD, motor skills and/or handwriting, children, medication. Of the 45 articles retrieved, 30 described motor skills of children with ADHD and 15 articles analysed the influence of ADHD medication on motor skills and motor control. More than half of the children with ADHD have difficulties with gross and fine motor skills. The children with ADHD inattentive subtype seem to present more impairment of fine motor skills, slow reaction time, and online motor control during complex tasks. The proportion of children with ADHD who improved their motor skills to the normal range by using medication varied from 28% to 67% between studies. The children who still show motor deficit while on medication might meet the diagnostic criteria of developmental coordination disorder (DCD). It is important to assess motor skills among children with ADHD because of the risk of reduced participation in activities of daily living that require motor coordination and attention.     

Megalographia in Children with Cerebellar Lesions and in Children with Attention-Deficit/Hyperactivity Disorder

Structural changes of the cerebellum have been reported in attention-deficit/hyperactivity disorder (ADHD) in several studies. The cerebellum is a structure essential for motor coordination and motor learning. Beside behavioral deficits, children with ADHD often show slight motor abnormalities. In the present study, handwriting was examined in both children with ADHD and children with cerebellar lesions. By writing the same sentence several times, letter height increased in the ADHD and cerebellar groups but not in controls. Comparable disorders of handwriting in cerebellar and ADHD children support previous studies, which suggest a contribution of cerebellar dysfunction to motor abnormalities in ADHD. However, an involvement of non-cerebellar dysfunctions in ADHD cannot be excluded.     

Movement Assessment Battery for Children (M-ABC): Establishing construct validity for Israeli children

The Movement Assessment Battery for Children (M-ABC) is one of the most accepted tools, both in clinical practice and in research, for the diagnosis of Developmental Coordination Disorders (DCDs) in children. The present study aimed to: (1) establish the construct validity of M-ABC in Israel by comparing the motor performance of typically developed children in four age groups (ranging from 6 to 12 years) and (2) examine the impact of socio-demographic parameters on children's motor performance.Participants were 249 typical children, between 4.1 and 12.08 years old, whose motor performance was evaluated by the M-ABC. The results showed that age, gender, mother's education level, and socioeconomic status had an impact on children's motor performance. Thus, the M-ABC may serve as a suitable tool for examining the motor performance of children in Israel. This examination should also refer to socio-demographic factors in order to shed light on the contribution of environmental disadvantages to children's motor performance.     

The effect of a computerized visual perception and visual-motor integration training program on improving Chinese handwriting of children with handwriting difficulties

This study aimed to investigate the effect of a computerized visual perception and visual-motor integration training program to enhance Chinese handwriting performance among children with learning difficulties, particularly those with handwriting problems. Participants were 26 primary-one children who were assessed by educational psychologists and occupational therapists to have handwriting difficulties. They were matched according to their age and then randomly assigned into either the control group or the experimental group. Subjects in the experimental group (n = 13) would receive eight sessions of computerized visual perception and visual-motor integration training together with a home training program while those in the control group (n = 13) would only receive conventional handwriting training by teachers, which focused mainly on remedial handwriting exercises. Results from repeated measure ANOVA revealed that children in the experimental group showed improvements in their visual perception skills as well as in their handwriting time. Both the “On Paper” time and “In Air” time of this group were improved when compared to the control group. However, no significant differences were found in visual-motor integration skill and handwriting legibility between the two groups after the intervention. This computerized training program focusing on visual perception and visual-motor integration training appeared to be effective in enhancing the handwriting time among children with handwriting difficulties. However, the training program did not seem to improve the legibility of children.     

Fine motor skills and effects of methylphenidate in children with attention-deficit-hyperactivity disorder and developmental coordination disorder

The aims of this study were to investigate fine motor skills of children with both attention-deficit-hyperactivity disorder (ADHD) and developmental coordination disorder (DCD) and those of a control group, and to examine the effects of methylphenidate on these skills. A group of 12 children with ADHD-DCD (11 males, one female; mean age 9y 8mo [SD 1y 7mo]) and 12 age- and sex-matched controls (mean age 9y 7mo [SD 1y 2 mo]) participated. The manual dexterity subtests of the Movement Assessment Battery for Children, the concise assessment method for children's handwriting, and a computerized graphomotor task were used. Results demonstrated that children with ADHD-DCD performed more poorly on the manual dexterity subtests, had poorer quality of handwriting, and drew more rapidly, more fluently, but less accurately than controls on the graphomotor task. On methylphenidate, manual dexterity and quality of handwriting improved, and strokes on the graphomotor task became less fluent but more accurate. ADHD is characterized by persistent symptoms of inattention, impulsivity, and hyperactivity, affecting 3 to 5% of school-age children. Up to 50% of children with ADHD also have motor coordination problems that are severe enough to meet criteria for DCD. In DCD, children demonstrate functional motor performance deficits not explained by the child's (chronological) age or intellect, or by other neurological or psychiatric disorders.     

Motor coordination and kinaesthesis in boys with attention deficit-hyperactivity disorder

In the current study, movement ability and underlying kinaesthetic processes of boys with attention deficit-hyperactivity disorder (ADHD) were compared with a group of control children. Two groups of 16 boys with either predominantly inattentive subtype ADHD (ADHD-PI) or combined subtype ADHD (ADHD-C) were compared with 16 control boys matched on age and verbal IQ. The findings demonstrated that the children with ADHD had significantly poorer movement ability than the control children. A high percentage of children with ADHD displayed movement difficulties consistent with developmental coordination disorder. In addition, the current study found that the type and degree of movement difficulty differed between subtypes. Children with ADHD-PI had significantly poorer fine motor skill while children with ADHD-C were found to experience significantly greater difficulty with gross motor skill. The severity of the children's inattentive symptomatology was found to be a significant predictor of motor coordination difficulties. Kinaesthetic sensitivity was not found to differ significantly between the groups.