|Look up dysgraphia/agraphia in Wiktionary, the free dictionary.|
|Classification and external resources|
|ICD-10||F81.1, R48.8, R27.8|
|ICD-9||315.2, 784.61, 784.69|
Dysgraphia is a deficiency in the ability to write primarily in terms of handwriting, but also in terms of coherence. Agraphia is a complete loss of ability to write and spell when writing. Persons with agraphia can not transform graphemes in written language. Both occur regardless of the ability to read and is not due to intellectual impairment. Dysgraphia is a transcription disability, meaning that it is a writing disorder associated with impaired handwriting, orthographic coding (orthography, the storing process of written words and processing the letters in those words), and finger sequencing (the movement of muscles required to write). It often overlaps with other learning disabilities such as speech impairment, attention deficit disorder, or developmental coordination disorder. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), dysgraphia is characterized as a learning disability in the category of written expression when one’s writing skills are below those expected given a person’s age measured through intelligence and age appropriate education. The DSM is not clear in whether or not writing refers only to the motor skills involved in writing, or if it also includes orthographic skills and spelling. The word dysgraphia comes from the Greek words dys meaning "impaired" and graphia meaning "making letter forms by hand".
There are two stages, at least, in the act of writing; a linguistic stage and a motor-expressive-praxic stage. The linguistic stage involves the encoding of auditory and visual information into symbols for letters and written words. This is mediated through the angular gyrus. The angular gyrus provides the linguistic rules which guide writing. The motor stage is where the expression of written words or graphemes is articulated. This stage is mediated by Exner’s writing area of the frontal lobe. Most patients with aphasia will suffer from some form of agraphia due to a disturbance in language processing which ultimately affects the ability to write. 
People with dysgraphia can often write on some level and may lack other fine motor skills, for example they may find tasks such as tying shoes difficult, but it does not affect all fine motor skills. People with dysgraphia often have unusual difficulty with handwriting and spelling which in turn can cause writing fatigue. They may lack basic grammar and spelling skills (for example, having difficulties with the letters p, q, b, and d), and often will write the wrong word when trying to formulate their thoughts on paper. The disorder generally emerges when the child is first introduced to writing. Adults, teenagers, and children alike are all subject to dysgraphia.
This impairment results most often from some type of damage to Wernicke's receptive speech area, Broca’s expressive speech area, and Exner’s writing area. Exner’s and Broca’s areas are implicated in the expressive aspects of writing, where as temporal and parietal areas are involved in comprehension of written words. Most often, agraphia is caused by a stroke or lesion to the left temporal or parietal lobe. The principle structures involved in this disorder include the left frontal lobe, the left temporal lobe, and the superior and inferior parietal lobe. It is hypothesized that the parietal lobe constructs written-word images via an interaction with Wernicke’s area which converts these images into graphemes. These motor-graphemes are then transmitted to Broca’s and Exner’s areas for conversion and motor expression into written language.
Dysgraphia is often, but not always, accompanied by other learning disabilities such as dyslexia or attention deficit disorder, and this can impact the type of dysgraphia a person might have. There are three principal subtypes of dysgraphia that are recognized. There is little information available about different types of dysgraphia and there are likely more subtypes than the ones listed below. Some children may have a combination of two or more of these, and individual symptoms may vary in presentation from what is described here. Most common presentation is a motor dysgraphia/agraphia resulting from damage to some part of the motor cortex in the parietal lobes.
People with dyslexic dysgraphia have illegible spontaneously written work. Their copied work is fairly good, but their spelling is usually poor. Their finger tapping speed (a method for identifying fine motor problems) is normal, indicating that the deficit does not likely stem from cerebellar damage.
However, lesions localized to the frontal lobe, particularly Exner’s and Broca’s areas most often result in disturbances in the basic motor aspects of writing. Grapheme (letter) formation becomes labored, uncoordinated, and takes on a very sloppy appearance. Cursive handwriting is more often disturbed than print handwriting. The ability to spell is also affected. Patients may not be able to spell correctly even when given block letters to use for demonstration. Grapheme selection is also altered and at times it may seem that the patient may have forgotten how to form certain letters. The wrong letter may be written, which may appear as though they have forgotten how to spell. Sometimes patients will even add unnecessary letters or write letters in an abnormal sequence when forming a written word. Patients with frontal agraphia, particularly when Broca’s area is damaged, are unable to write spontaneously or to dictation. Writing may be cluttered by perseverations (writing the same letter over and over) or the addition of additional strokes to a letter, particularly when writing in cursive. 
Motor dysgraphia is due to deficient fine motor skills, poor dexterity, poor muscle tone, or unspecified motor clumsiness. Letter formation may be acceptable in very short samples of writing, but this requires extreme effort and an unreasonable amount of time to accomplish, and it cannot be sustained for a significant length of time. Overall, their written work is poor to illegible even if copied by sight from another document, and drawing is difficult. Oral spelling for these individuals is normal, and their finger tapping speed is below normal. This shows that there are problems within the fine motor skills of these individuals. Writing is often slanted due to holding a pen or pencil incorrectly.
Pure agraphia is associated with frontal lobe lesions most commonly, but may also be caused by damage involving the superior and inferior parietal lobe. The inferior parietal lobe sites at the junction of all four cerebral lobes and functions as an integration location for complex auditory, visual, motor and tactile sensations to form a multi-modal concept which is important for language, particularly comprehension and expression. With damage to the inferior parietal lobe, individuals have difficulty programming movements necessary to form written words. Individuals with this type of agraphia often misspell words, and may insert the wrong letters or place them in the wrong order or sequence when attempting to write, this is similar to frontal lobe agraphia. In contrast the frontal lobe agraphia, the individual’s ability to read, speak and name objects or letters is generally intact.
Most commonly, this form of agraphia involves lesions in the superior and mid parietal regions of the left hemisphere, and/or the inferior parietal lobe. Individuals are unable to write because the area involving visual-letter organization is cut off from the region controlling motor (hand) movements in the frontal lobe. Motor programs for the perception and production of written language has been hypothesized to be located in the inferior parietal lobe of the left hemisphere. It is the individuals’ inability to access these motor programs that causes them to have a deficit in written ability. Writing samples provided by individuals with inferior parietal lobe damage often are characterized by misspellings, letter omissions, distortions, temporal-spatial misplacements and inversions.
Alexic-Agraphia is a disturbance involving the ability to read (alexia) and the ability to write (agraphia) or one altering the ability to decode and encode written language. In this type of agraphia, writing and reading are not equally affected. Some individuals may be able to recognize written letters, but are not able to form them. Some individuals can form the letters, but cannot read or identify them. Similar to alternate forms of agraphia, patients with alexic-agraphia also have difficulty with spelling, even when given blocks for demonstration.
Often alexic-agraphia is due a lesion involving the inferior parietal lobe in the left hemisphere and the angular gyrus (see: parietal lobe alexia). In this form of agraphia, there is a disturbance of motor control that separates this condition from pure alexia. 
A person with spatial dysgraphia has a defect in the understanding of space. They will have illegible spontaneously written work, illegible copied work, and problems with drawing abilities. They have normal spelling and normal finger tapping speed, suggesting that this subtype is not fine motor based.
Right cerebral injuries can disrupt writing skills as a consequence of generalized spatial and constructional deficits. In right hemisphere lesions, particularly temporal-parietal injuries, individuals cannot form words and letters correctly, due to a difficulty in aligning them on the page. Individuals may write words on a slant or at an abnormal angle on the page. Individuals may write illegibly, or may write only on one side of the paper, often they will ignore the left side of the page due to the lesion on the right side of the brain. Individuals may also introduce abnormal spaces between letters within words, particularly when writing in cursive.
Signs and symptoms 
The symptoms to dysgraphia are often overlooked or attributed to the student being lazy, unmotivated, not caring, or having delayed visual-motor processing. In order to be diagnosed with dysgraphia, one must have a cluster, but not necessarily all, of the following symptoms: 
- Cramping of fingers while writing short entries
- Odd wrist, arm, body, or paper orientations such as bending an arm into an L shape
- Excessive erasures
- Mixed upper case and lower case letters
- Inconsistent form and size of letters, or unfinished letters
- Misuse of lines and margins
- Inefficient speed of copying
- Inattentiveness over details when writing
- Frequent need of verbal cues
- Referring heavily on vision to write
- Poor legibility
- Handwriting abilities that may interfere with spelling and written composition
- Having a hard time translating ideas to writing, sometimes using the wrong words altogether
- May feel pain while writing
Dysgraphia may cause students emotional trauma often due to the fact that no one can read their writing, and they are aware that they are not performing to the same level as their peers. Emotional problems that may occur alongside dysgraphia include impaired self-esteem, lowered self-efficacy, heightened anxiety, and depression. They may put in extra efforts in order to have the same achievements as their peers, but often get frustrated because they feel that their hard work does not pay off.
Dysgraphia is a hard disorder to detect as it does not affect specific ages, gender, or intelligence. The main concern in trying to detect dysgraphia is that people hide their disability behind their verbal fluency because they are ashamed that they cannot achieve the same goals as their peers. Having dysgraphia is not related to a lack of cognitive ability, and it is not uncommon in intellectually gifted individuals, but due to dysgraphia their intellectual abilities are often not identified.
Dysgraphia is a biologically based disorder with genetic and brain bases. More specifically, it is a working memory problem. In dysgraphia, individuals fail to develop normal connections among different brain regions needed for writing. People with dysgraphia have difficulty in automatically remembering and mastering the sequence of motor movements required to write letters or numbers. Dysgraphia is also in part due to underlying problems in orthographic coding, the orthographic loop, and graphmotor output (the movements that result in writing) by one’s hands, fingers and executive functions involved in letter writing. The orthographic loop is when written words are stored in the mind’s eye, connected through sequential finger movement for motor output through the hand with feedback from the eye.
Treatment for dysgraphia varies and may include treatment for motor disorders to help control writing movements. The use of educational therapy can be effective in the classroom as long as teachers are well informed about dysgraphia. Other treatments may address impaired memory or other neurological problems. Some physicians recommend that individuals with dysgraphia use computers to avoid the problems of handwriting. Dysgraphia can be overcome with appropriate and conscious effort and training. The International Dyslexia Association suggests the use of kinesthetic memory through early training by having the child overlearn how to write letters and to later practice writing with their eyes closed or averted to reinforce the feel of the letters being written. They also suggest teaching the students cursive writing as it has fewer reversible letters and can help lessen spacing problems, at least within words, because cursive letters are generally attached within a word.
Currently treatment options for agraphia/dysgraphia are limited as the condition is considered to be rather rare. Researchers have been studying case examples in order to determine what may be a potentially effective treatment. In 2010, Beeson and colleagues examined two women who had persistent impairments of written language following damage to their left temporal-parietal regions. The researchers used a cuing hierarchy to ultimately retrain the women to learn phoneme-grapheme correspondences for letters as well as other phonological training tasks. The participants were also training on spelling and were challenged with words and nonwords. After the third session, both participants were able to correctly spell 80% of the real words that were given. Both participants improved phonological abilities in spelling and reading.
Diagnosing dysgraphia can be challenging but can be done at facilities specializing in learning disabilities.It is suggested that those who believe they may have dysgraphia seek a qualified clinician to be tested. Clinicians will have the client self-generate written sentences and paragraphs, and copy age-appropriate text. They will assess the output of writing, as well as observe the client's posture while writing, their grip on the writing instrument, and will ask the client to either tap their finger or turn their wrists repeatedly to assess fine motor skills.
In the classroom 
There is no special education category for students with dysgraphia; in the United States, The National Center for Learning Disabilities suggests that children with dysgraphia be handled in a case-by-case manner with an Individualized Education Program, or provided individual accommodation to provide alternative ways of submitting work and modify tasks to avoid the area of weakness. Students with dysgraphia often cannot complete written assignments that are legible, appropriate in length and content, or within given time. It is suggested that students with dysgraphia receive specialized instructions that are appropriate for them, this means that each set of instructions may be different for each child. Children will mostly benefit from explicit and comprehensive instructions, help translating across multiple levels of language, and review and revision of assignments or writing methods. Direct, explicit instruction on letter formation, and guided practice will help students achieve automatic handwriting performance before they use letters to write words, phrases, and sentences. Some older children may benefit from the use of a personal computer, or a laptop in class so that they do not have to deal with the frustration of falling behind their peers.
It is also suggested by Berninger that teachers with dysgraphic students decide if their focus will be on manuscript writing (printing), or keyboarding. In either case, it is beneficial that students are taught how to read cursive writing as it is used daily in classrooms by teachers. It may also be beneficial for the teacher to come up with other methods of assessing a child's knowledge other than written tests, an example would be oral testing. This causes less frustration for the child as they are able to get their knowledge across to the teacher without worrying how to write their thoughts.
The number of students with dysgraphia may increase from 4 percent of students in primary grades, due to the overall difficulty of handwriting, and up to 20 percent in middle school because written compositions become more complex. With this in mind, there are no exact numbers of how many individuals have dysgraphia due to its difficulty to diagnose. There are slight gender differences in association with written disabilities; overall it is found that males are more likely to be impaired with handwriting, composing, spelling, and orthographic abilities than females.
See also 
- Alexia without agraphia
- Learning disability
- Developmental dyspraxia
- Character amnesia
- Chivers, M. (1991). "Definition of Dysgraphia (Handwriting Difficulty)." Dyslexia A2Z. Retrieved from http://www.dyslexiaa2z.com/learning_difficulties/dysgraphia/dysgraphia_definition.html
- Berninger, V.W.; B.J. Wolf (2009). Teaching students with dyslexia and dysgraphia: Lessons from teaching and science. Baltimore, Maryland: Paul H. Brooks Publishing Co. pp. 1–240. ISBN 978-1-55766-934-6.
- Nicolson RI, Fawcett AJ (January 2011). "Dyslexia, dysgraphia, procedural learning and the cerebellum". Cortex 47 (1): 117–27. doi:10.1016/j.cortex.2009.08.016. PMID 19818437.
- Joseph, R. (2000). Neuropsychiatry, Neuropsychology, Clinical Neuroscience. New York, New York: Academic Press.
- NCLD Editorial Staff. (2010). "What is Dysgraphia?" National Center for Learning Disabilities. Retrieved from http://www.ncld.org/ld-basics/ld-aamp-language/writing/dysgraphia.
- Berninger VW, May MO (2011). "Evidence-based diagnosis and treatment for specific learning disabilities involving impairments in written and/or oral language". J Learn Disabil 44 (2): 167–83. doi:10.1177/0022219410391189. PMID 21383108.
- Beeson, P.M.; Rising, K., Kim, E.S., Rapcsak, S.Z. (2010). "A treatment sequence for phonological alexia/agraphia.". Journal of Speech, Language and Hearing Research 53: 450–468.
- Lorch, M.P. (1995). "Language and praxis in written production: a rehabilitation paradigm". Aphasiology 9 (3): 208–282.
- NINDS Dysgraphia Information Page
- An Online Spelling Correction Resource Assisting Dysgraphia & Dyslexia
- The National Center for Learning Disabilities
- Holistic Individualized Education