ADHD and Handwriting: What's the Connection?

[theadhdwarrior]

• The link between ADHD and Poor Handwriting (Dysgraphia): It has been well-known for years that individuals with ADHD are often more prone to problems with penmanship, that is, they have trouble producing legible handwriting. But why is this the case? There are several theories out there, and multiple studies showing how effective ADHD treatments can also result in major improvements with a person's handwriting. I will review some of the current findings on the topic:
  
  

1. A group in Israel sought to investigate whether the problem with handwriting in ADHD children was due more to underlying language problems (i.e. spelling, formulating sentences, etc.) or more due to the mechanical problem of the physical writing process. While they concluded both were at play, the results of their study seemed to indicate that underlying language difficulties played only a secondary role to the writing difficulties and that the primary cause was due to "non-linguistic deficits". Interestingly, the group did find specific patterns to the frequent mis-spellings of words, instead of a host of random, unrelated errors. This blogger personally found the conclusion of the article's summary to be particularly amusing, as it recommended a "judicious use of psychostimulants".
2. Continuing on with the "judicious use of psychostimulants" theme, we must investigate the effectiveness of one of the most common types of stimulants for ADHD, methylphenidate (Ritalin, Concerta, Metadate). This drug has elicited a number of positive effects as far as improving both the cognitive and physical aspects of handwriting, as concentration or attentional lapses subside, allowing the thought process and physical act of writing to be performed simultaneously. However, another study found that even medication with methylphenidate had its limits, and that handwriting gradually deteriorated as the child continued with the writing process. This suggests that for long essays or standardized tests (such as the writing portion of the SAT's, or A.P. exams), medication with methylphenidate or other stimulants may only be useful early on.
   
   
3. Specific Genetic Factors may underlie both ADHD and handwriting problems: There was an interesting study done by a Dutch group which suggests that there may be some sort of genetic factor that inhibits fine motor movements (such as those required for writing) which then make their way over to ADHD. In other words, this study seems to suggest that ADHD is a secondary problem to fine motor problems such as dysgraphia (typically, it's the other way around, where ADHD is considered the primary disorder). This study discovered that non-ADHD siblings (who, by definition, share half of the ADHD child's genes, provided they are not identical twins) of the ADHD children also had difficulties with more complex forms of the writing process, compared to the general population. In other words, these siblings had some degree of impairments with the writing process, but not to the degree of their ADHD siblings. This suggests that these non-ADHD siblings may have enough genetic "impairments" to share some of the comorbid writing problems as their ADHD counterparts but not enough to manifest an outright diagnosis of ADHD themselves. In other words, the comorbidity (co-occurrence of) ADHD and dysgraphia is apparently not an all-or-nothing phenomena.
   
   
4. Differences in hand-eye coordination and motor control problems are more pronounced in the left hand for ADHD vs. non-ADHD children: We have previously investigated key brain regions commonly associated with ADHD, including differences in relative brain region size, use of brain regions, bloodflow patterns, brain electrical activity patterns, sense of smell, the relationship to alcoholism, brainwave patterns, and genetic differences targeting specific brain areas. However, it is worth noting that these brain regional differences are often not laterally symmetric, that is they may only be on the left side or right half of a particular brain region. This lopsidedness may play a role in manual dexterity and motor coordination differences between ADHD and non-ADHD individuals, which appear to be even greater in the left hand (which, in most cases the non-dominant one).
   
   The article which found this discrepancy between the different sides of the body goes on to suggest that testing for fine motor coordination in ADHD kids would be better suited for the left hand, since the effects are more pronounced. This leads to this potentially intriguing question: If handwriting is done with the dominant hand, does it stands to reason that handwriting difficulties are just the tip of the iceberg with regards to immensely greater fine motor difficulties? In other words, if an ADHD child is having trouble writing with his or her dominant right hand, how bad would the fine motor deficits be if they needed to use their left hand for something like catching a baseball, or shooting a left-handed layup in basketball?
   
   Based on this finding, it appears that poor handwriting may be just one aspect of a much larger fine motor disability. Another possibility, however, is that using one's non-dominant hand requires a higher order cognitive process than utilizing one's dominant hand for a routine task. This possibility may actually carry some weight, as we have seen in previous posts how discrepancies between ADHD and non-ADHD individuals begin to balloon as the cognitive processes become increasingly more difficult.
   
   This also seems to jive with the underlying genetic component of these disorders proposed by the ADHD sibling study in the previous point, in which the non-ADHD siblings had trouble only with the higher-order writing processes and not the more automatic ones (such as doing a simple task with one's dominant right hand). Unlike the Israeli study, this seems to favor more of an underlying cognitive discrepancy as the main culprit of poor handwriting in ADHD, as opposed to a more "mechanical" one.
   
   
5. The genetic discrepancies in ADHD and fine motor impairments may be one of motor timing: Going back to the genetic aspects of ADHD and motor impairments such as dysgraphia for a moment, it is worth mentioning another finding by a group investigating difficulties in timing fine motor applications in ADHD children. This study utilized tests such as pressing a button on self-determined one second intervals (and measuring how close the child's perceived timing matched up with "real" one-second intervals), tapping one's finger as many times as possible within a given time limit (a relatively common test for individuals with ADHD and related disorders) and tests which measured reaction timing to moving objects and visible changes (which may have direct implications as to how well a child would perform in a sport involving reacting to moving objects, such as baseball, lacrosse, or tennis). Based on these tests, the authors concluded that the motor impairments in the ADHD children were more likely due to timing issues as opposed to generalized motor problems. As a blogger's note, this might explain some of the difficulties in the handwriting mechanics, such as crossing "t's" and dotting "i's", which essentially involves hitting a "target" on the paper, or keeping up with a teacher while taking notes (which is a very time-dependent process which often requires a fast execution of handwriting numbers, letters, diagrams, and symbols).
   
   A number of books on the subject of ADHD and writing disorders show actual handwriting samples of children on and off medication for ADHD. The differences are astounding. Additionally, differences in complexity and eloquence in creating stories are often extremely pronounced depending on the mode of expression. For example, actual cases involving gifted children with ADHD have highlighted how a child can concoct an thorough, detailed, and well-rounded story orally, but when asked to write out the same story, he or she is scarcely able to construct even a single, legible, coherent paragraph.
   
   This brings up the important issue as to whether children with ADHD should be afforded opportunities to use different modes of communication for their assignments, such as dictating or typing as opposed to handwriting. It appears that for many, the actual process demanded of ADHD children for actually writing may rob or ferret away the majority of their cognitive capacity, resulting in a barren landscape of creativity or eloquence.
   
   Given the fact that many children with ADHD respond positively to alternative learning or expressive styles such as predominantly auditory (dictating) or kinesthetic (typing) means of expression, numerous questions surrounding the degree of accommodation for these ADHD children must be addressed. It is my personal hope that the findings of some of these studies will shed some light onto the mechanical and cognitive impairments of the physical writing process for children with ADHD will help shape an educational environment to help these children to flourish.
   
   Please note: This blog was originally posted on May 1, 2009 at: ADHD Treatments

[Clarissa Kelly]

What a great topic, I've read about this recently, lots of great input in the comments!

GARY, I totally relate to what you are saying: "Obviously, for me, the problem isn't fine motor control, it's just frustration and boredom. " In school I got top marks in many things, but my penmanship was awful. i always thought that I just couldn't write fast enough to keep up with my thoughts, too! I type fairly fast, so this form of writing is much better for me, too. It comes in very handy when I need to write letters, etc. I can write nicely if I want to, like on greeting cards or something I decide should look nice, but it has taken years for my handwriting to get to a decent level.

I also have excellent spelling, used to win spelling B's. I can spell when writing or speaking, no difference.

My brother has ADD and his handwriting is simply AWFUL. His looks as if someone around 7 years old has been writing and he is 33. He also only writes in normal block letters, never cursive, I've never seen his cursive. Mine is better than his, but I always think I have been able to work harder at things than he has. His ADD has been compounded by PTSD and some health issues.

So glad there are lots of studies going on and lots of research into the various aspects of ADHD. Gives me hope that I can make some sort of sense of it all someday. :)

[Debbie George]

My two boys have exactly the same handwriting, absolutely an undetectable difference! One is more hyperactive, one is more inattentive. They even have a hard time reading it days later, like trying to read notes or decipher a written essay for a teacher who needs to grade it. Even though they are four years apart, their handwriting has always looked like the same kid did it. I am more hyperactive and my handwriting has always been very good, even since childhood. My sons have excellent fine motor skills and have been able to use the tiniest lego pieces with ease since they were too young to have them (choking hazard). They are both incredibly fast on the computer keyboard since second grade. Who knows if their spelling skills improve, they use the spellcheck. They are excellent oral spellers, but look like second graders when they write. I often will read something they have written and ask them to spell all the wrongly written words and they know the correct spelling every time. They don't even know why this shuts down when they need to write. I rarely misspell a word - even when I write quickly. This looks like a neurological brain issue for us - I must carry some kind of recessive gene, my brothers all have terrible penmanship and spelling, my ADD sister has handwriting like me. We always thought it was a gender thing. Looks like its shaping up this way here, too. Though my sons are musically talented (seem to have a good sense of timing), they do have a problem with clumsiness and spacial orientation.

[theadhdwarrior]

Some great comments, thanks for everyone's input. From the kids I work with at school, I definitely do see a number of cases where the penmanship is beyond bad, it's completely unreadable. Fortunately my school has a pretty open-minded policy about letting kids with poor penmanship type. It seems like in addition to providing the obviously more legible forms of communication, they actually have a better time getting their thoughts out and organizing them. In general their whole writing improves. And to answer DANA's question, yes, it seems like the hyperactive subtypes of the disorder are often more affected by the "penmanship curse" of ADHD.

[Glenna]

My son struggles with his handwriting. There is definitely a tremendous difference in how legible his writing is when he is on his medication and when he is off his medication.

[frederick j haiss]

I find in myself that my handwriting has improved since I was put on a good medication,straterra wasn't any good for me but at 58 my Dr. was hesitant to put me on a stimulant.First I grew up in an era where being left handed was deviant behavior or at least the school system I was in.So I had to re-learn with the right(lol the right hand)this never helped my penmanship at all?I'm getting off track but I often find my mind racing faster than my hand can write.However since I was put on vyvanse it has improved and no-one out there cannot tell me that my ADD is not a gift:)it is difficult learning the right coping skills that fit your special needs:)when all is said life is good,life is fine,all is well and I will never regret being pro-active in the right treatment for my-self or any other adder be pro active-be honest and be well the world is ours

[Gary]

For me the answer is simple. Handwriting is far too slow and the attempt to keep up with my thoughts eventually causes the letters to be perilously close to slightly wiggly lines that even I can't read.

While I write I'm considering alternatives and that slows what comes out of my fingers to around 80-90 wpm. There's simply no way that I could do that with a pen. Fortunately I pouted until my high school allowed me to take typing in grade 9 -- I was in the science track and typing was only available to the business track (i.e. future secretaries). At the time computer nerds didn't need to know how to type -- that's what the punch card operators were for.

When I was in the SCA I did calligraphy and that wasn't a problem because the point was to copy text beautifully, not to actually get my thoughts on paper.

Obviously, for me, the problem isn't fine motor control, it's just frustration and boredom.

[Bryan Hutchinson]

Hrmmmm, this is very interesting information. I used to have very bad penmanship; however, my penmanship has gotten much better after being treated with therapy. Very interesting, indeed. Even so, I have always had excellent hand-eye coordination. Actually, I know many folks with ADHD who have excellent hand-eye coordination, but, it would be interesting to note if that is only with their dominant side? Interesting article.

PS: I like how you have included the various research. I was a bit worried all the links were from your site, which I have asked folks not to, and therefore was pleased to find the links went to actual research on your topic - great!

[Mel Taylor]

Hi Dana,

I have the primary inattentive subtype of ADHD, and I have to say that my penmanship is really lousy unless I can go slowly, concentrate, and take very frequent breaks. Hyperactivity has never been a problem for me, but I was diagnosed with dysgraphia at the same time that my ADHD was diagnosed. Both my brothers (one of whom we suspect has undiagnosed ADHD, and the other has OCD) and my father (who has severe dyslexia) have similar writing to my own. I can say with confidence that this doesn't come from picking up Dad's writing style, since he didn't really become literate until we were all in high school or older. Also, the three of us kids have superior reading and oral spelling skills. Most of our spelling and grammar mistakes on paper are actually due to sloppy writing rather than actual poor spelling. This makes me think the writing trouble comes from something other than dyslexia and my dad is just blessed with both.

... Heh, sorry for the rambling. I guess what I really wanted to say is that while hyperactivity might make it even harder (!) to learn to write, I don't think it necessarily is the major contributing factor to this interesting link between ADHD and dysgraphia.

[DANA]

Another very interesting topic! My ADHD teenage son has always written so tiny and messy that most teachers have complained through the years. My 10 year old ADHD daughter also does not have very neat penmanship. However, my 13 year old inattentive ADD daughter who is NOT hyperactive has BEAUTIFUL penmanship.

Do you think hyperactivity has a huge bearing on handwriting???