A Challenge Even For the “Handwriting Experts.”

Handwriting difficulties are the most common reason for referral to school-based occupational therapy (OT). “They can’t write, so they must need OT.” However, school-based therapists often question how to provide effective and appropriate support for written expression difficulties in students with ADHD.

The most frequently asked questions I hear from other therapists are most likely ones you may have asked yourself many times.

Even the “ experts” need a better understanding of the complexity of the writing process for students with ADHD.

ADHD’s Impact on Handwriting and Written Expression

High-quality writing depends on handwriting , spelling, working memory, and executive function, which are often challenging for children with ADHD. Evidence supports that children with ADHD often have specific difficulties in written expression that include :

• Poor overall legibility 
• Poor organization of written material within the space available
• Poor spacing within and between words
• Inconsistent letter size and shape
• Poor margin alignment
• Frequent erasures
• Pressured writing 
• Difficulty spelling
• Lack of capitals and punctuation
• Frequent omissions of letters or words
• Difficulties in planning/organizing ( idea generation, what they want to write) 
• Problems organizing thoughts, prioritizing, and sequencing 
• Poor speed of output 

The “Anything But Simple View of Writing” 

Written language is a complex skill that integrates multiple components, each with its developmental sequence. Berninger et al. 2006 refer to handwriting as “language by hand.”

Evidence supports that writing is the simultaneous integration of letter forms (orthographic codes), (letter names and sounds( phonological codes), and written shapes (graphomotor codes). Researchers describe this process as orthographic motor integration.

Handwriting is not just a motor skill; as illustrated in The “Simple View of Writing” Model (Beringer et al. 2006) pictured above. Writing is a complex process that requires the integration of transcription skills ( handwriting, spelling) with executive function skills ( planning, organization, and self-regulation) to enable text generation (outcome as words, sentences, composition ). Berninger et al. 2006 emphasizes that all processes are guided and constrained by working memory.

Unfortunately, working memory is a limited resource and an area of significant weakness in children with ADHD. The more working memory resources required for any individual component of the writing process, the fewer resources are available to manage other elements of writing process. Students with age-appropriate fine and visual motor skills can produce short legible copy samples but will have difficulty with generalization into the classroom due to working memory deficits. A student who needs to actively think about how to form a letter or spell a word will use up the limited working memory space that is needed to hold the thought they are writing.

Automaticity in handwriting and spelling transcription processes is the foundation for written expression. Therefore, writers must learn to execute these skills fluently and automatically, with little or no thought.

Poor Automaticity in Handwriting 

Working memory impacts the development of handwriting automaticity.

Immature writers guide movements with visual and kinesthetic feedback as they learn the letter formation sequences. However, as the typically developing student matures, they develop automated motor patterns called motor engrams. To reach automaticity in handwriting, the learner must have access to these engrams of the learned letter and the corresponding motor plans associated with the letters little or no cognitive demand.

Students with ADHD and other neurodevelopmental conditions often have developmental delays in the foundational visual, motor, and somatosensory systems needed to learn writing and develop the motor engrams . Students with ADHD may be able to write letters in isolation or copy short words with legibility but may struggle to get more complex thoughts on paper due to working memory overload.

Poor Automaticy in Spelling Skills

Spelling places a high demand on working memory.

Spelling is the process of translating a sound (phonemes) to a letter or combination of letters that make up the sound(grapheme). Research indicates that students with ADHD often demonstrate “graphemic buffer errors”. The graphemic buffer is the working memory component of the spelling system that temporarily stores the sequence of graphemes while each grapheme is written. It is responsible for the active maintenance of letter identities and their order. Without automaticity, students with poor spelling skills hesitate when writing words, leading to less fluent writing (Berninger et al., 2008). 

So “What do we do with this ever-increasing population of ADHD students who are not writing?”

Regardless of the age, stage, and comorbidities, of the learner with ADHD, the most effective evidence-based strategies the school-based OT can use to improve performance in written expression is to support and reduce working memory demands needed for the writing task. This allows the learner to dedicate more working memory resources for text production.

Students with ADHD need support where they are currently, in the point of performance, in the classroom. Using the restorative model alone to improve the underlying performance components needed for handwriting is not supported by evidence to effectively improve handwriting. Therapists require interventions to use within the classroom context.

The following evidenced-based interventions will improve occupational performance in the classroom by supporting working memory, scaffolding executive functions and promoting automaticity of handwriting skills.

Evidenced Based Handwriting Interventions for Students with ADHD 

Integrated Therapy At the Point of Performance in and with actual classroom assignments. All of the below interventions can be done during the actual writing assignment. Many classrooms have “morning work” or ” writers journal” time where the OT will be able to intervene at the point of performance .

Reduce Environmental Distractions– reduce distractions or friction to decrease the external processing requirements during the writing task. 

• Consider how much more working memory is required for far point copying than near point. Sticky notes are gold here.

• I have used a wipe off marker and just written right on the students desk. The “pure insanity” of that maneuver was the just right engagement factor needed to get that student going. (hand sanitizer cleans it off) .

Use Procedural Feedback: Monitor and provide feedback for the process, not the product, and prevents incorrect repetitive practice. Provide models in between letters. Have the student write one line of text and then check before going on. Prevent having the student with ADHD to have to ” redo” large amounts of work by providing frequent monitoring.

Facilitate Frequent Self Evaluation – circle the best-formed letter on that line, provide a self-check rubric, so the student can stop and monitor and self-correct 

Adapt Writing Materials: The therapist can bring in select paper and writing materials that reduce working memory load. Papers can contain externalized working memory supports, explicit visual supports, directions, increased space for writing, color for engagement, and less visual information on the page. Using just a green, blue and brown colored pencil or a highlighter can make a dramatic difference for the learner.

Reduce Perceived Workload /Quantity

Therapist can reduces demands on working memory and other EF skills by reducing the “perceived” work load.

• Using graphic organizers
• Present only one part of the writing task at a time will reduce the perceived work load .
• You can fold the assignment in half.
• Cover it with another sheet or use a chunking folder.
• I use a ” to do list” wipe off sheet and list the parts of the assignment for them , going as detailed as the student needs.

Whole class or small group supports can be added to the classroom program or small group instruction.

Use Explicit Scaffolded Instruction– Use explicit handwriting instruction with scaffolds geared towards automaticity. 

• Can you write this letter with your eyes shut?

Gradual Faded Visual Prompts – provide all the external boundaries needed for immediate success, then gradually fade visual boundaries. See example below .

• Give the students a visual starting point .
• Use enlarged or colored baseline.
• Provide size and height boundaries with box dot prompts.

Use Video Modeling– video models help create motor engrams of letter formation sequences. They use verbal and visual supports simultaneously and allow the teacher to provide procedural feedback for students as they write. 

Structured Instruction Sequence– sequence of letters should be grouped by similarities to strengthen motor engram development.

My Top Ten Tools for Integrated OT Sessions

There are so many available resources to put in your “push in” bag. These are always in mine and used every day. Some include affiliate links for purchasing.  

1. Blue/Green/Brown colored pencils to shade writing areas. Colored pencil accept pencil writing better than markers or crayons.
2. Highlighters
3. Legiliner and Legiliner Worm Line
4. Alternate Ruled Notebooks Grade 3 /Alternate Rule Notebook Grade 4
5. Post Its
6. To Do List Wipe Off Board (Visual Schedule)
7. SHARP PENCILS with erasers: (don’t even get me started on the dull pencil problem )
8. Sound Blocking Headphones– Amazon has affordable pairs
9. Love pen – This is just a red marker or pen that I “heart” letters or words or lines with. I also encourage students to find and heart their own.
10. Wipe off marker.

Click here for a 15% off coupon for Legi-liner.

Key Takeaway

Written expression is the complex process of orthographic integration that is governed and managed by working memory, an area of significant weakness in children with ADHD. 

Contrary to limiting beliefs, our scope is not limited to just the motor components of school based occupations. School-based therapists can provide effective and appropriate support for written expression difficulties in students with ADHD who score age appropriate in “fine and visual motor skills”. We need to work in the classrooms to promote generalization of skills and provide ongoing support to these kids because as the writing demands increase from word, to sentence to paragraph, so do the demands on executive functions.

Providing a variety of working memory supports in the classroom will improve occupational performance in written expression for students with ADHD. Reducing differentiation demands upon the classroom teacher is always a welcomed relief for your colleague. 😉

Download this free one-page PDF to help explain to teachers and parents why your students are having difficulty with written expression and what to do to support it.

References

1. Rebecca A. Langmaid, Nicole Papadopoulos, Beth P. Johnson, James G. Phillips, Nicole J. Rinehart. Handwriting in Children With ADHD. Journal of Attention Disorders. https://doi.org/10.1177/1087054711434154. Original Research.
2. Berninger, V. W. (1999). Coordinating transcription and text generation in working memory during composing: Automatic and constructive processes. Learning Disability Quarterly, 22(2), 99-112.https://doi.org/10.1007/s11881-011-0054-0
3. Agnese Capodieci, Simona Lachina, Cesare Cornoldi,Handwriting difficulties in children with attention deficit hyperactivity disorder (ADHD),Research in Developmental Disabilities,Volume 74,2018, Pages 41-49, ISSN 0891-4222, https://doi.org/10.1016/j.ridd.2018.01.003. (https://www.sciencedirect.com/science/article/pii/S089142221830009X)
4. Kaiser ML, Schoemaker MM, Albaret JM, Geuze RH. What is the evidence of impaired motor skills and motor control among children with attention deficit hyperactivity disorder (ADHD)? Systematic review of the literature. Res Dev Disabil. 2015 Jan;36C:338-357. doi: 10.1016/j.ridd.2014.09.023. Epub 2014 Nov 6. PMID: 25462494.
5. Liat Hen-Herbst; Handwriting Measures and Executive Functions Among Adolescents Referred to OT. Am J Occup Ther August 2021, Vol. 75(Supplement_2), 7512505220p1. Doi: https://doi.org/10.5014/ajot.2021.75S2-RP220
6. Berninger V. W., Lee Y. L., Abbott R. D., & Breznitz Z. (2013). Teaching children with dyslexia to spell in a reading-writers’ workshop. Annals of Dyslexia, 63, 1–24. https://doi.org/10.1007/s11881-011-0054-0 [Google Scholar]
7. Marie Brossard-Racine, Michael Shevell, Laurie Snider, Stacey Ageronioti Bélanger, Marilyse Julien, Annette Majnemer. Persistent Handwriting Difficulties in Children With ADHD After Treatment With Stimulant Medication. Journal of Attention Disorders. https://doi.org/10.1177/1087054712461936. Original Research
8. Javier Fenollar-Cortes, Ana Gallego-Martinez, Luis J. Fuentes. The Role of Inattention and Hyperactivity/Impulsivity in the Fine Motor Coordination in Children with ADHD. Research in Developmental Disabilities. https://doi.org/10.1016/j.ridd.2017.08.003. Original Research.
9. https://sites.nd.edu/biomechanics-in-the-wild/2021/04/07/attention-deficit-handwriting-details-the-effects-of-adhd-on-handwriting/Source: Handwriting Performance in Children With Attention Deficit Hyperactivity Disorder (ADHD) – Marie Brossard Racine, Annette Majnemer, Michael Shevell, Laurie Snider, 2008
10. Agnese Capodieci, Simona Lachina, Cesare Cornoldi,Handwriting difficulties in children with attention deficit hyperactivity disorder (ADHD),Research in Developmental Disabilities,Volume 74,2018, Pages 41-49, ISSN 0891-4222, https://doi.org/10.1016/j.ridd.2018.01.003. (https://www.sciencedirect.com/science/article/pii/S089142221830009X)
11. Mayes SD, Breaux RP, Calhoun SL, Frye SS. High Prevalence of Dysgraphia in Elementary Through High School Students With ADHD and Autism. Journal of Attention Disorders. 2019;23(8):787-796. doi:10.1177/1087054717720721