According to the American Psychiatric Association, “The prevalence of Disorder of Written Expression is difficult to establish because most studies only focus on overall learning disabilities. Disorder of Written Expression is considered rare if the child does not have any other learning disabilities.” To help gain an understanding and an awareness of the Disorder of Written Expression I have interviewed Dr. John and Pamela McCaskill.
Tell me a little bit about who you both are.
“We are licensed clinical psychologists with specialized training/experiences in the areas of clinical child/developmental psychology, pediatric psychology, health psychology, and parent training/coaching. We both specialize in diagnostic evaluation and treatment/intervention planning for children, adolescents and adults with a variety of neurodevelopmental disorders (including specific learning disabilities, ADHD, developmental disabilities, autistic spectrum disorders), clinical evaluation and treatment of children, adolescents and adults with emotional/behavioral difficulties (including Oppositional-Defiant Disorder, anxiety, depression, and mood regulation disorders), as well as related parent training/coaching, and assessment of intellectual giftedness. We also conduct behavior management workshops for parents of strong-willed children (including children with ADHD and/or Oppositional-Defiant Disorder), as well as provide consultation and in-service training workshops to schools and community groups on a variety of topics, upon request.”
What is Disorder of Written Expression? What are the signs and symptoms of someone who has Disorder of Written Expression? What type of impact does Disorder of Written Expression have on a person’s life?
“Disorder of Written Expression (also often referred to as “Dysgraphia”) is a specific learning disability involving significant, neurologically-based difficulties with the mastery of writing skills and the production of written output, relative to typical expectations based on age, intellectual capability, and grade level. A specific learning disability reflects specific difficulties with the fluent, consistent learning and application of specific types of mental skills; however, this is a separate issue from general intelligence. Regardless of any specific functional difficulties stemming from their learning disability, children (and adults) with these conditions exist at all levels of global intelligence, ranging from low-average to average, above-average, superior and even into the gifted ranges of intelligence. For example, children (and adults) with a Disorder of Written Expression often can express themselves much better and more easily orally (even eloquently, at times); however, translating these same thoughts into written format usually is much more cumbersome and even impossible at times. So, a specific learning disability is not the same thing as “lack of intelligence.””
“While many people might experience some degree of difficulty with the process of writing, a specific learning disability in written expression is defined by standardized assessments of a child’s writing skills which are significantly lower than would typically be expected by other children of the same age and grade level in school, as well as substantially lower than might be expected based on the child’s intellectual capabilities and/or academic achievement in other areas. The definition of “significantly lower” can vary from one state to another, and from one school district to another (even within the same state); however, “clinical significance” generally is defined as being at least one standard deviation (i.e., 15 standard score points) below the mean (which translates into a standard score of 85 or lower on most standardized tests of written expression, since the mean standard score is 100) or, to put it another way, performing at or below the 16th percentile for age on standardized tests of written expression skills. However, a specific learning disability is not simply defined based on standardized test scores; other factors also have to be taken into consideration, along with test scores, in order to interpret a child’s abilities and difficulties within appropriate developmental and clinical context (e.g., the nature and extent of any more individualized and/or specialized tutoring or other forms of instruction in written expression skills that might already have been provided to a child; the child’s mastery of other types of academic skills, relative to the written expression difficulties; the child’s intellectual capabilities; the specific instructional modalities and/or performance expectations utilized within the child’s classroom; whether the child has repeated a grade). Therefore, there are many reasons why a child might experience difficulties with written expression; they may or may not represent a specific learning disability. However, by the same token, taking all factors into consideration within appropriate context, it also is possible for a child to have a specific learning disability in written expression, even though standardized achievement test scores may not meet the “one standard deviation below the mean” criteria (i.e., their scores on tests of written expression skills may fall less than 15 points below the mean). Therefore, any diagnosis of a specific learning disability should be based on careful consideration of multiple factors, rather than simply on test scores.”
“Because the process of producing written output in any form (from simple rote copying to more complex idea generation, essay composition and expository writing) requires the coordination and integration of many different types of mental and physical skills, there are many different reasons why a child (or adult, for that matter) might experience difficulties with written expression. Written output entails considerable demands for “mental multi-tasking.” More specifically, written expression requires the effective coordination of both cognitive information processing (e.g., mentally resisting distractions and “overcoming inertia” to get started on a task, idea development, concept formation, thinking, reasoning, fluent retrieval of information from memory, expression of information, attention to detail, task analysis and prioritization, planning and organization, appropriate sequencing of ideas and activities, concentration, understanding of language and appropriate communication rules/syntax, working memory or memory for specific instructions and/or steps required for completing activities, etc.) and motor skills (e.g., finger speed/dexterity, pencil control, visual-motor integration, arm/hand muscle strength/endurance, graphomotor fluency). Difficulties in any one of these various skill sets can disrupt the overall fluency (i.e., the quality, consistency and/or efficiency) of a child’s written output efforts. Unfortunately, most individuals with a Disorder of Written Expression experience significant weaknesses or deficits in multiple skill sets, not just one.”
“Just as there are many specific skill sets involved in the act of writing, there are many different reasons why a Disorder of Written Expression might exist. Specific learning disabilities affecting written expression typically do not exist in isolation; rather, they often co-occur with other conditions, as part of a larger clinical syndrome. Specific conditions frequently associated with a Disorder of Written Expression include language processing disorders/weaknesses (involving receptive language, or comprehension, as well as expressive language), reading disorders, ADHD, dyspraxia and other motor coordination/sequencing disorders. Most commonly, a Disorder of Written Expression reflects the outward manifestations of language processing weaknesses and/or broader language-based learning disabilities (e.g., Dyslexia). Quite often, the Disorder of Written Expression reflects fundamental weaknesses with phonological processing and fluent word/information retrieval that essentially represent the earliest, emerging signs of Dyslexia; however, because written output entails greater demands for mental multi-tasking and sustenance, specific writing weaknesses often become more apparent, more quickly and more obviously, than the reading weaknesses commonly associated with Dyslexia, particularly in very bright individuals with extensive home/school support.”
“The types of errors/difficulties observed in children with a Disorder of Written Expression can vary considerably, depending on which specific factors (discussed above) are affected in their situation, how severely and to what extent. Additionally, children often tend to naturally compensate for areas of weakness by avoiding them (whenever possible) and, instead, playing to their own inherent strengths (e.g., oral discussion, drawing pictures or other graphic reprentations, emphasizing “concepts” over technical details). However, difficulties often are observed in many of the following skill sets, to varying degrees: handwriting, spelling, sentence construction, punctuation, grammar, language syntax, idea generation and development, note-taking, rote copying, producing more complex written responses and/or communicating thoughts in written format, organization of written output, omitting relevant words or thoughts, incompletely writing words and/or producing fragmented sentences.”
“In most cases, a Disorder of Written Expression does not involve a complete lack of writing skills, or a complete inability to produce legible, or even decent quality written output; rather, the overall extent and severity of written expression difficulties can vary considerably from one child to another (ranging from very mild to very severe). Further, the nature and extent of a specific child’s written output difficulties also can vary considerably from one task to another, often depending on the specific nature of the task, performance demands or expectations, task complexity, time of day, and the child’s mental fatigue level, hunger, state of physical health and/or mood. The ease and/or quality of writing certainly can vary (from day to day, or from task to task) for many people, including those without specific learning disabilities; however, overall, people without learning disabilities affecting written expression can function effectively, the vast majority of the time. On the other hand, even though most people with a Disorder of Written Expression certainly are capable of producing adequate (even good) quality written output with a certain type of task, completed on a certain day and/or under certain types of performance conditions, overall, they have trouble fluently, reliably and consistently applying written output skills, the majority of the time, for purposes of effective written communication and expression (again, more often and/or more severely than typical same-age, grade-level peers). Additionally, for people with a Disorder of Written Expression, written output typically requires more conscious, deliberate mental effort, vigilance and concentration (e.g., in order to resist distractions and retrieve relevant information from memory, express information clearly and effectively, and even to remember the topic at hand and/or their own ideas long enough for their eyes and hands to translate mental information into written format), mental and physical energies than for most of their peers, even in order to perform simple rote copying or note-taking tasks. In other words, they simply have more trouble “turning their skills on and off” fluently, and using their skills reliably and consistently, than most people their age. Therefore, people with a Disorder of Written Expression often are more easily/quickly fatigued by writing tasks (even simple ones), and are more quickly/easily frustrated with writing tasks, than most of their peers. This type of performance variability, manifesting as inconsistencies across different performances, can give the impression that the person is “fully capable of doing the work, but simply doesn’t want to put forth the effort (or is ‘choosing not to do so’)”, giving the impression of laziness or willful non-compliance; however, nothing could be further from the truth. Rather, the moments of “on” performances reflect genuine motivations to comply and to succeed, as well as the person’s conscious, deliberate efforts to do so; however, they simply cannot sustain these levels of performance over the long haul, given the extensive amount of energy and effort required to do so, and still attend to all of the rest of life’s demands.”
“So, in addition to experiencing greater difficulty and frustration with written output demands, people with a Disorder of Written Expression quickly associate intensely negative experiences with the act of writing (e.g., frustration, anger, feelings of incompetence, self-criticism, stress associated with criticisms and/or pressures from others, teasing by peers, perceived disappointments to parents and teachers, shame, etc.); eventually, even the introduction of a writing assignment, or even the mere thought of the possibility of having to write, elicits the same types of negative emotionality, stress, and social/performance anxieties. This is why many people with a Disorder of Written Expression disdain writing tasks, produce minimalistic output, quit prematurely, shut down and/or avoid writing tasks altogether; not because of simply “not liking to write”, “not wanting to write”, “choosing not to write”, being unmotivated to perform, being obstinate or defiant, regardless of how it might seem on the surface. Rather, most individuals experience frustration reactions because they fundamentally are motivated to perform, to master skills/tasks, to succeed, to be liked/accepted by peers and/or to earn the approval and/or praise of their parents and teachers; if they were not motivated in these regards, they wouldn’t experience such intense frustration in the first place. However, their legitimate physical, neurological difficulties, their ever-increasing sense of ineptitude and incompetence, and associated social stressors, and their frustrated motivations (as listed above) all contribute to stress and anxiety associated with the process of writing. Before long, children begin to cope with this stress and anxiety in many different ways (e.g., task avoidance, “making excuses”, tantrums), all expressing emotional stress and frustration, and many reflecting their attempts at avoiding or minimizing stress, negative experiences, and the emotional pain that accompany them.”
What type of help is available for someone who has Disorder of Written Expression?
“Depending on the age of the child, the nature and extent of their difficulties, most treatment/intervention plans involve a combination of skill-building, weakness bypass and/or environmental/task accommodation strategies, to varying degrees. In general, any interventions or performance help should occur within a very supportive, patient, positive and encouraging context, keeping in mind some very simple, but almost universal truths — if a child can do something, they will, and if they’re not doing it, there’s typically a very legitimate reason. Regardless of how “lazy”, “unmotivated”, “oppositional-defiant”, “moody”, “whiny” or “lackadaisical” a child might appear on the surface, it’s important to realize that those features typically reflect reactions to frustration, defenses against insecurity and/or anxiety, or even features of the learning disability itself (e.g., information processing weaknesses often manifest as a “sluggish cognitive tempo”, dawdling or even unresponsiveness); children don’t typically “make bad choices” on purpose or otherwise “choose” to do things that essentially will make their lives even more difficult or frustrating, or otherwise “put themselves in harm’s way” socially and emotionally. So, significant, rather pervasive and on-going written output difficulties typically are not simply the result of a child’s “not liking” writing, “preferring not to write”, laziness, or lack of motivation or concern about their performances; occasional moodiness, or some other motivational fluke, might explain occasional performance difficulties, or temporary difficulties (e.g., during a time of heightened stress), but not on-going difficulties.”
“Likewise, it’s also important to realize that these types of written output difficulties reflect neurologically-based weaknesses that are very legitimate; in order words, the brain’s skill-set system is “wired differently” than for most same-age peers. Therefore, expecting the person with a specific learning disability to perform in the same way, under the same conditions, and within the same time parameters, as a person without a learning disability really is unfair in most cases, and often amounts to legal discrimination against a person with a legitimate disability. Interventions for addressing learning disabilities (including environmental accommodations and curriculum modifications) essentially attempt to “level the playing field” and allow the person to access the curriculum and/or demonstrate their true competence via a modality that is relatively unaffected by their disability (allowing them to play to their strengths). In this regard, said interventions do not provide the person with a disability with an “unfair advantage” over their peers, nor do they “compromise the integrity of the curriculum” or amount to “cheating”, “providing a crutch” or “enabling”, any more than glasses or contact lenses might do for a person with nearsightedness. Likewise, depriving a learning disabled person of the appropriate accommodations essentially would be like depriving the nearsighted person of their glasses/contacts (or the epileptic their anticonvulsant medication, or the diabetic their insulin, or the paraplegic their wheelchair), but then still expecting them to perform the same way, within the same parameters and using the same methods, as all of their non-disabled peers. Not only will these approaches yield unreliable and invalidly low assessments of the person’s capabilities, they also will yield more frustrations, emotional and behavioral difficulties, further complicating matters and contributing to the person’s under-achievement relative to their potential. By analogy, an intelligent near-sighted person will not function very efficiently without their glasses/contacts, and their performances likely will be sub-par (particularly over a longer period of time, following sustained difficulties); however, give them their glasses, and their performances will better reflect their capabilities, and will do so more efficiently. Non-disabled peers will not be hurt by the learning disabled students’ use of appropriate accommodations. We simply have to help other students, parents, and professionals understand the accommodations as legitimate tools for neutralizing the impact of a physical/neurological disability, and which function just like glasses/contacts, wheelchairs, etc. do for each of their respective disabilities.”
“The following strategies can be helpful to individuals with a Disorder of Written Expression:
1. “Scaffolding” and “mentoring” with regard to the writing process, with the adult assisting the child in basic task analysis, problem-solving, planning, organization, and item prioritization, breaking tasks down into even smaller/simpler steps or “chunks” (even smaller steps than might be required by most grade-level peers), and walking the child through the task one step at a time, essentially talking their way through it and making explicit all of the tiny steps/details that tend to occur more intuitively for most children (and which often get taken for granted as being “obvious” but which, to a child with a learning disability, aren’t so intuitively obvious).”
2. “Utilizing “Concept Mapping” or “Webbing” strategies in order to identify a topic and related ideas, visually illustrating their linkages via use of “bubble and line diagrams.” This tends to capitalize on visualization skills, in lieu of more complex language processing skills (which typically are weak in this type of learning disability), by providing concrete visual cues.”
3. “Utilizing graphic organizers in order to identify main topics, brainstorm related and/or supporting ideas, develop and organize an outline of the topic, and elaborate on specific ideas in “bullet point” format. Having done this, the points can be developed into complete sentences (either via handwriting or keyboarding), and then the task completed by walking through the outline already developed.”
4. “Maintain an emphasis on the main ideas or “big picture” while writing the first draft; emphasize content, disregarding spelling, punctuation, grammar, neatness, etc. (for the time being). Once the content is developed and produced, then the work can be proofed for mechanical and syntax issues. However, it’s generally best to emphasize only 1 or 2 primary skill sets at a time, in order to avoid overwhelming the child and further contributing to their frustrations; additional skill sets can be emphasized once the primary sets have been mastered, or at least are being utilized more readily, comfortably and reliably, without excessive frustration.”
5. “Try to emphasize “fun and games” types of tasks, or allow the child to write on a topic of their choosing, whenever possible, in order to maximize enjoyment of the written communication process (or at least minimize frustrations).”
6. “Minimize the sheer volume of written output required, particularly with regard to rote copying and/or note-taking tasks; provide the child with hard copies of classroom assignments and/or lecture notes, which they then can personalize as needed (thus allowing them to emphasize “active listening” and comprehension, in the course of classroom activities). Emphasize “quality” over “quantity of written output with more complex writing tasks.”
7. “Allow the child to tape record classroom lectures/lessons, so that they can engage in “active listening” without fear of missing anything (preventing them from feeling compelled to write down, rotely, every single thing that’s said); they often can’t effectively integrate information, discriminate relevant from relevant details, and write/copy notes quickly enough, all simultaneously.”
8. “Minimize mental multi-tasking demands whenever possible. Identify one main area of emphasis (e.g., content, original ideas, neatness, spelling, punctuation, etc.) and focus solely on that area, with regard to grading; the specific area of emphasis can change, depending on the nature of the task.”
9. “Allow additional time for completion of written tasks; during timed testing, emphasize content (rather than neatness of handwriting, spelling or other mechanics).”
10. “Teach them to take notes in abbreviated format, including the use of symbols, contractions, abbreviations, etc.”
11. “Allow alternative forms of presentation (e.g., oral expression, visual demonstrations, graphics, etc.).”
12. “Teach keyboarding skills and allow use of a word processor.”
13. “Use computer programs for teaching, organizing and strengthening writing skills (e.g., Kidspiration/Inspiration, SMART Ideas, Co-Writer).”
14. “Use oral dictation software or strategies (e.g., Write: Out Loud, Dragon Naturally Speaking).”
15. “Occupational therapy services can be helpful to younger children with specific fine motor, visual-motor integration and/or graphomotor weaknesses, in order to strengthen these specific skills. Likewise, use of specialized pencil grips and/or different sized pens/pencils also can augment graphomotor control.”
16. “Allow the child to mark answers within test booklets, rather than having to transfer their answers onto separate “bubble sheets.””
17. “Structure and organize tests by providing study guides ahead of time, using “previewing” strategies, allowing multiple-choice or fill-in-the-blank responses, or allowing “take home” tests.”
18. “Don’t penalize a child for failing to complete written work within standard time parameters by withholding recess, gym, PE, art, music, or other “special” activities. Again, modify the quantity of work required and/or the specific performance parameters. Don’t be overly concerned about “failing to hold the child accountable” or “teaching them responsibility” by holding them to the same types of consequences, based on performing under the same types of conditions, as their peers without learning disabilities; doing so simply would punish them for even having a learning disability in the first place, and likely will simply engender further frustration and resentment toward the learning process and schooling in general. Keep the overall performance climate positive and, as their brains develop further, their skills and abilities to effectively use “bypass” tools strengthen, the normal internal drives for autonomy and independence will continue to develop, and the child will gradually assume more responsibilities as they are able to do so successfully.”
What advice would you like to leave for someone who has Disorder of Written Expression?
“Simply having a learning disability — of any type — does not have to prevent you from achieving your educational or career goals. What is important is to recognize the learning disability for what it is — nothing more than a specific pattern of functional strengths and weaknesses — and to use this information to your advantage, as much as possible. Remember the old saying, “Know thyself, and to thine own self be true.” Learn as much as you can about your own strengths and weaknesses, and the reasons for the difficulties you experience, and understand that specific learning disabilities and intelligence are two separate things. While your performance difficulties may have left you feeling pretty inept, incapable or different from your peers, and maybe even “stupid” at times, specific learning disabilities actually have little or nothing to do with overall intelligence; rather, they simply reflect specific weaknesses with regard to how fluently, easily or reliably you use your intellectual skills in order to perform specific types of tasks, under specific types of conditions. However, it is important to remember that there are many areas in life where you have demonstrated competence and experienced success — even with regard to school and academic tasks — and those were not accidental. Your particular profile of strengths and weaknesses might be different from 80-85% of the general population, but that does not make your profile “wrong” or “incompetent.” Rather, it simply means that you might go about the processes of learning and/or performing (i.e., demonstrating your competence) in a slightly different manner, or under different time conditions. However, ultimately, life is about getting results, and there is “more than one way to skin a cat” so to speak; in the end, how you get results really does not matter (so long as you do so legally and ethically, and without hurting or disrupting others), so long as you get the results. There are many, many successful people out there with learning disabilities, of various types — Charles Schwab, Anderson Cooper, Jay Leno, Tom Cruise, Patrick Dempsey, just to name a few; all you have to do is search the various websites for examples of “famous people with…” and you’ll be astounded by how many very successful people essentially overcame, or worked around their learning disabilities, by playing to their strengths and neutralizing/minimizing the impact of their weaknesses. Yes, you can identify examples of people with learning disabilities who have failed as well — however, the same can be said for many, many people without any identifiable learning disabilities (as far as we know!).”
“So, it’s again important to remember that people are inherently programmed to master and succeed and that, if these things are not happening, there’s a legitimate reason why. Start by getting a comprehensive evaluation of your intellectual and functional skills, as well as your mastery of academic concepts/skills, with an appropriately credentialed professional who has the appropriate clinical training and expertise with regard to child development, cognition and learning skills — a Ph.D.-level clinical or educational psychologist, with specialized training and experiences in clinical child psychology, meets these criteria. This comprehensive evaluation will identify your strengths and weaknesses, as well as interpret everything within appropriate developmental, clinical and educational context, diagnose the specific reasons for your difficulties, and prescribe appropriate treatment and intervention plans. Intervention plans will be designed to capitalize on your strengths, identify appropriate strategies for strengthening and/or bypassing areas of weakness, identify appropriate environmental accommodations and technological resources for minimizing difficulties and maximizing fluency/effectiveness of your performances, and educate you regarding appropriate educational, legal and vocational resources for ensuring that you receive free and appropriate educational services, supports, and protections from discrimination (e.g., misunderstanding, mistreatment) under the law, with regard to current schooling, as well as future educational and/or career endeavors beyond the grade school years. The clinical professional also can refer you to appropriate websites, groups or other resources for further information regarding your condition and potentially helpful intervention tools/strategies, as well as provide educational and/or career advocacy services on your behalf, as you negotiate the process of securing appropriate accommodations within the school or workplace. In some cases, it will be necessary to hire a more specialized educational advocate and, if so, the evaluating clinician can refer you to the appropriate advocate. Again, information, self-advocacy, persistence, and “working smarter, not harder” (i.e., using your tools/resources effectively, to play to your strengths and minimize/neutralize the impact of your weaknesses) are primary ingredients in the recipe for success. As the saying goes, “Know the truth, and the truth will set you free.””
Thank you Dr. John and Pamela McCaskill for the interview. If you would like more information on Dr. John and Pamela McCaskill check out their website at http://www.drpam.org.