Handwriting problems in children with Asperger Syndrome.

Sheila E. Henderson and Dido Green Institute of Education, University of London

A few years ago hardly anyone had heard of the term (Asperger's Syndrome)...yet today almost every school seems to have a child with this new syndrome (Attwood, 1998).

Since Asperger, a Viennese paediatrician, first described the syndrome that was later to bear his name (Asperger, 1944), there has been a great deal of debate about its status, its particular characteristics and whether it can truly be distinguished from autism (see e.g. Frith, 1991; Howlin, 2000). Recently, however, Asperger Syndrome (AS) has gained formal recognition, through entries in the diagnostic manuals of the World Health Organization (ICD-10, 1992) and the American Psychiatric Association (DSM IV, 1994), although doubts continue to be expressed as to whether it describes a distinct clinical entity and how it relates to High Functioning Autism (HFA). Nevertheless, the inclusion of AS was an important development because of the impact of these bodies on research and practice. Since the manuals present an entire diagnostic system they tend to crystallize our thinking about the relationship between conditions and how these should be described and distinguished, thus providing a focus for remedial programmes. The manuals, albeit conceived within a rather medical framework, are increasingly widely used by professionals in education as well as health, whose task it is to ensure that appropriate criteria are applied before an individual is assigned a particular label.

Although most teachers and therapists will be familiar with the term Asperger Syndrome and many will have had direct experience of working with a child bearing such a label, not all will be familiar with the full scale of the problems such children can encounter in school. ICD-10 and DSM IV list similar sets of diagnostic features for Asperger Syndrome. They include examples of impaired social interaction and the obsessional pursuit of repetitive or idiosyncratic interests, while at the same time emphasizing normality of cognitive and early language development. In addition, both manuals mention 'clumsy' movement as a common feature but do not consider this to be a defining feature, i.e. one of a set of features that must be present for the diagnosis to be made.

Given the focus of this journal, it will not surprise our readers to discover that it is these movement difficulties to which we draw particular attention in this paper. More specifically, we want to ensure that practitioners are aware of the fact that many children with AS find handwriting a particularly difficult skill to acquire and are likely to need special help right from the start.

Although Asperger himself did not consider the question of whether motor difficulties were characteristic of all children with the other symptoms he described, he certainly attached considerable weight to 'clumsiness' in his clinical descriptions of the children with whom he worked. In the classic paper on the syndrome (Asperger, 1944 translated in Frith, 1991), we find four case histories each describing the child as poorly coordinated. The difficulties mentioned include absence of facial expression, poor fine motor coordination, a lack of fluency in locomotion and in all but once case, special problems with handwriting:

Of Fritz, V. Asperger notes: "Writing was an especially difficult subject, as we expected, because his motor clumsiness, in addition to his general problems, hampered him a great deal. In his tense fist, the pencil could not run smoothly. A whole page would suddenly become covered with big swirls, the exercise book would be drilled full of holes, if not torn up. In the end, it was possible to teach him to write only by making him trace letters and words written in red pencil. This was to guide him to make the right movements. However, his handwriting has so far been atrocious".

Of Harro L, Asperger writes: "All his movements eloquently expressed his problem. His facial expressions were sparse and rigid... clumsiness was particularly well demonstrated during PE lessons…His movements never unfolded naturally and spontaneously...from the proper coordination of the motor system as a whole. Instead, it seemed he could only manage to move those muscular parts to which he directed a conscious effort of will." (p. 57). Asperger continues: "His handwriting, as would be expected from his general clumsiness, was very poor. He carried on writing carelessly, and messily, crossing out words, lines going up and down, the slant changing. His spelling, however, was reasonably accurate. As long as his attention was focused on one word, he knew how to spell it. It was very significant then that he made more spelling errors when copying that at dictation. Really, one would expect that copying should not present any problems at all since the words were in front of him; but this very simple and straightforward task simply did not interest him".

Of Ernst K, Asperger notes: "His most blatant failure was in writing. ... this motorically clumsy child had atrocious handwriting... The pen did not obey him, it stuck and sputtered; he corrected without concern for appearance and would simply write new letters on top of old ones."

Finally, of Hellmuth, L. Asperger writes "...he was clumsy to an extraordinary degree... he stood in the middle of a group of playing children like a frozen giant. He could not possibly catch a ball however, easy one tried to make it for him...he was said to have been clumsy in all practical matters from infancy."

Since the English-speaking world was introduced to Asperger's work by Wing in 1981, many additional studies have been published which underline the importance of motor aspects. For example, ill-coordinated movements and odd posture are noted in research studies by Burgoyne and Wing, 1983; Gillberg, 1989; Manjiviona and Prior, 1995; Klin et al, 1995. Many of these comment on handwriting as a special problem.

In this short article, our objective is to provide concrete evidence of the handwriting problems experienced by children who have been properly diagnosed by very experienced paediatricians and psychiatrists as having Asperger's Syndrome. We present two contrasting case studies of children who currently attend mainstream schools in the U.K. Rather unusually one of these children is a girl (current estimates of the ratio of boys to girls with AS is 4:1). So that the handwriting difficulties of the two children can be compared, we provide examples of their performance on a test called the Evaluation Tool of Children's Handwriting (ETCH, Amundson, 1995). This is an American test, which one of us (DG) has found very useful in clinical practice and which we feel provides quite good information on different dimensions of a child's handwriting problems. For those not familiar with the content of the test, each child performs 7 tasks as follows:

(1) Writing the alphabet from memory in lower case then in upper case. The child is instructed not to join the letters together and erasing or striking out is only permitted once.
(2) Writing the numerals from 1-20 under the same conditions.
(3) Near-point copying. The child is shown the sentence "Spaceships quickly orbited the moon" and is required to copy it from a sample placed on the desk surface beside them.
(4) Far-point copying. The child is required to copy the sentence "Sixty cows jumped and gazed at them" from a distance of 6-8 feet raised 4 feet from the floor.
(5) Manuscript-to cursive transition. The child is shown the sentence "Astronauts waved to sixty cows below " in print form and is required to write it in joined up writing.
(6) Four non-words are dictated to the child and he/she is required to write them from memory - boizt, clagy, shrum and 58273.
(7) The child is asked to write a sentence containing no less than five words.

All tasks are timed but the child is NOT instructed to write as fast as possible (see manual for full details). Unfortunately, proper norms are not yet available for this test so age-related statements cannot be made. However, as most teachers and therapists will be aware the derivation of age norms for a complex, taught skill like handwriting is fraught with difficulties and such information would have to be interpreted with great caution.

Case A.

Background information. Mark was born in April 1988 and is now 13. He is a very bright boy who has attended mainstream school since he started at the age of 5. In order to confirm the diagnosis of AS, Mark was recently assessed on a test known as the Autistic Diagnostic Inventory (ADI: Rutter, Lord and LeCouteur, 1995). The ADI comprises three sections. These are concerned with Social Reciprocity, Communication, and Special Interests. Mark's scores placed him in the "impaired" category on all three.

When tested by an educational psychologist on the British Ability Scales (BAS), Mark obtained a verbal IQ of 145 and a performance IQ of 124. Although he experiences some very real difficulties in school, he reads well and is good at science and history. He does have a Statement of Special Educational Needs and is supported by the Special Educational Needs Coordinator. He now has a laptop computer and this has improved his written work tremendously. However, as with so many children with movement difficulties, this was not an over-night answer to all of his problems and key-boarding skills took some time to acquire.

Motor difficulties. Like most other children with AS, Mark is not well coordinated and has great difficulty in learning new (and especially) complex motor skills. He does not like P.E in school and still has some difficulty riding a bicycle. Recently, Mark was assessed on the Bruininks-Oseretsky test (Bruininks, 1978). This a standardised test, published in the USA, which assesses gross and fine motor control as well as attributes such as strength and endurance. At the age of 12 years 11 months, Mark obtained scores on running speed and agility that indicated performance at a level of the average 5.5 year old. On the balance tests, his age-equivalent score was 7.5, on fine motor control, 6.2 and on the tasks involving ball skills, 6.11. Overall, therefore, Mark's performance was well below that of his same-age peers. In her report, his therapist made special mention of his difficulties in executing a sequence of movements, as well as difficulty in learning things to a level where they could be performed fluently, without requiring constant monitoring and attention.

Mark's Handwriting

Figures 1 and 2 show aspects of Mark's performance on the ETCH test when he was 12 years 11 months. As most of our readers will agree, his difficulty with handwriting is very obvious. Surely we would expect a bright boy, nearly 13 years of age, to write more uniformly and legibly than this? A rough estimate of the legibility of his writing indicated that, overall, only 54% of his words were legible. However, this varied in an interesting way, from task to task. When the material was in front of him to copy, 80% of his letters were legible. When he had to generate his own sentence, however, letter legibility dropped to 50%. When the copying task required transformation of the material from print to cursive script, legibility fell even further - to 33%.

What about speed? Once again, the speed of Mark's writing fluctuated from task to task but a rough estimate suggested an overall rate of about 38 letters per minute. This is significantly slower than one would expect for a boy of his a age

Case B.

Background information. Molly was born in September 1992 and is now nine years old. Like Mark, Molly is a very bright child. She showed signs of AS from a very early age. In particular, she had obsessions about the colour of her clothing, all of which had to be a special colour on particular days. As time passed, other symptoms emerged and Molly was given a diagnosis of AS at the age of 5. At this time, she was also referred to occupational therapy following concerns about her coordination and her ability to organise herself at home or at school coordination. Although she had difficulty in school from the beginning and has required extra assistance, she has managed to remain in a mainstream school.

When tested by an educational psychologist on the Weschler Scales (WISC IIIR) at the age of nine, Molly was reported to be at the 97th percentile on the verbal scales and above the 81st percentile on the performance scales (this means that on verbal ability, for example, her score was equal to or better than 97% of children of the same age). The psychologist noted that she was advanced in her verbal reasoning skills and in social comprehension (a very surprising result given her autistic tendencies). On the practical tasks, in the performance section of the test, she did well when she could talk her way through the task and develop an overall strategy for performance. However, when she had to modify strategies as the task became more complex, she ran into difficulties. At school, Molly's teacher was pleased with her academic progress. She confirmed that she had good long term memory and retained information well. She was described as good at mathematical investigations. The only area of concern was her handwriting.

Motor competence. Molly's general motor competence proved quite different from that of Mark. Over the years, she has been tested on several tests, each devoted to different aspects of perceptuo-motor control and development. Yet, on all of these she scored rather well. At the age of five, she was assessed on a test called the SIPT (Ayres, 1989). This is intended to assess the child's visual and kinaesthetic perception, requiring them to complete tasks like finding a particular shape hidden among others or to recognize a shape by touch. It also assesses the ability to perform actions to command (e.g. put one hand on your foot and one hand on your head), to copy designs, and to copy facial movements. Balance is measured in various ways and other gross motor tasks are included. Although Molly had minor difficulties with some of these tasks and her therapist was slightly concerned about some aspects of her perceptuo-motor development, overall her scores fell within the normal range.

At the age of 7.5, Molly was tested on the Bruininks-Oseretsky. Unlike Mark, she obtained scores on this test that were considerably above her age level. When required to run at speed, she obtained an age-equivalent score of 8.8. On the tasks involving manual dexterity and upper limb control, her age equivalent score was 9.11. Overall, therefore, on motor tests which did not resemble handwriting, she seemed rather well coordinated.

Molly's handwriting. Figures 1 and 3 show examples of Mollys handwriting. Many aspects of her writing were striking, especially the variability exhibited in the free writing tasks shown in figure 3. From the ETCH test, we can see that Molly is uncertain about the formation of a number of letters, although sometimes it would seem that the problem has arisen because she has joined up all the lower case letters of the alphabet in spite of being asked not to. She seems shaky on a few of the capitals, too. In terms of legibility, overall only 53% of her words were legible and 74% of her letters. She was only able to produce between 16 and 25 letters per minute, depending on the task, a speed far below what would be expected of a child her age. In the testing situation, Molly's difficulties reduced her motivation and her cooperation to such an extent that she actually refused to complete some of the tasks on the ETCH. In addition, it was very difficult indeed to get her to produce any free writing for us - so the example shown in figure 3 must speak for itself.

Conclusions

Handwriting is a complex skill involving a wide range of cognitive, linguistic, perceptual and motor abilities. It is a skill that children rarely acquire spontaneously. Even with expert tuition, it usually takes some time to perfect. As the child progresses through school the requirement to write legibly and fluently, at speed, increases considerably and the cost of being unable to do so also increases. At secondary school, children are obliged to write almost constantly, taking notes to dictation, writing essays, and copying down the homework required for the next day. For the child who has learned to form letters without apparent deliberation or effort, such tasks are straightforward. In contrast, for the child who is still struggling with the basic elements of the skill then even copying down homework may present a problem.

These two case studies illustrate the very significant difficulties with handwriting that children with AS may experience. Although Asperger commented on the incidence of the problem among the children he studied, there has been no subsequent systematic research that further illuminates the problem.

The difficulties involved in generating a satisfactory explanation of the defective handwriting of children with AS is (dare we say) graphically illustrated by the two children we have described. Both are highly intelligent and verbally fluent. Both did very well on the verbal components of the IQ tests and less well, but still considerably better than average, on the performance components. Both read very well and neither seemed to have general problems with visual pattern recognition. Taken together, these strengths might seem to suggest that neither child should have problems learning the rules of handwriting. For example, knowing that the body of all letters should sit on the line or knowing that word boundaries are marked by a letter space in English script would not be expected to cause special difficulties for these children. If the children's general cognitive abilities allow us to exclude such difficulties, where else might the problem with handwriting reside? The two remaining domains of explanation would seem to be defective motor control or defective motivation.

Might it simply be that the children cannot control their hands and fingers adequately, for example repeatedly generating the calibrated force required to produce a series of shapes of a the same size? Certainly both children had difficulty in maintaining consistent size and slope when writing. However, here we are confronted with a fundamental difficulty posed by our data. Quite simply, it is that one child appears to be generally "clumsy", while the other does not. More specifically, one has balance difficulties that might in turn, lead to poor sitting posture, the other has not. The same child has generalised fine motor difficulties and cannot cut with scissors, use a ruler, etc., but, again, the other does not. Had they both been poorly coordinated then we might have been satisfied with the explanation that handwriting is just another movement skill, like catching a ball or cutting with scissors, which such children find hard to learn. In sum, whereas a fine motor control defect evident in the execution of writing seems to offer a plausible account of Mark's difficulties, it seems flatly inconsistent with Molly's apparent competence in a broad range of motor tasks outside of the domain of handwriting. Could it be that handwriting is a much more complex task than any contained in tests like the Bruininks-Oseretsky, and that Molly's difficulties only become evident when task difficulty lies close to that found in handwriting. We might argue that the sequences of movements required to form letters and the timing required to join them fluently is so demanding that it uncovers difficulties in children who otherwise seem quite well coordinated. The trouble with this hypothesis is that it is blatantly post hoc and will remain so until we can find another task with the type and level of difficulty that we believe characterises handwriting and show that it causes Molly peculiar difficulty. This possibility provides a salutary reminder that in the solution of this problem, an advance in our understanding of handwriting skills may be at least as important as a better understanding of Asperger Syndrome.

Finally, there is always the possibility, that the lack of interest in communicative skills that might be said to be a central characteristic of children with AS, may result in reduced motivation to acquire writing skills. However, that leaves unexplained the broad range of Mark's motor incompetence, which is arguably more typical than Molly's surprising competence.

Whatever the final answer, parents and teachers working with these children should ensure careful assessment of handwriting is undertaken as it cannot be assumed that even the most 'gifted' of these children will automatically acquire competence in this area. Obviously, consideration should also be given to early substitution of keyboarding skills. Many professionals in the field find that children with AS benefit greatly from
being introduced to a computer early on in their school career.

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Authors note:
As we have pointed out in this article, children with Asperger's Syndrome are a particularly challenging group to teach when it comes to handwriting. Some professionals feel that computers should be introduced very early on. Others feel that we should persevere with handwriting for a while. If YOU have a view on this, do please write to the editor of our journal so that experiences can be shared. Equally, if there is anything that you as a teacher or therapist find particularly helpful for children with AS, please share it with us

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