From Our 2009 Archives

Kids With Autism Need Handwriting Help

As Kids Overcome Autism, Handwriting Thwarts Progress

By Daniel J. DeNoon
WebMD Health News

Reviewed By Louise Chang, MD

Nov. 9, 2009 -- Kids battling autism face an extra hurdle: handwriting.

The problem seems to be something parents have long suspected, but that researchers are only beginning to define.

It's long been obvious to Jennifer Toney. Her son, Alex, has autism. Alex, age 9, is at least as intelligent as his fourth-grade classmates who don't have autism. But in addition to overcoming the relational and developmental challenges of autism, Alex also battles subtle motor-control issues.

"He's always had a bit of minor gross motor delay," Toney tells WebMD. "For example, he doesn't know how to ride his bike without training wheels. And he's always had balance issues, like walking up stairs one foot at a time."

None of this has kept Alex from being placed in a regular classroom with other kids his age. But his difficulty writing numbers and letters means he has to work harder than others do -- and, frustratingly, he sometimes gets lower grades than he deserves.

"His writing is very hard to read. The letters are really big and spaced funny and malformed and misshaped and the circles are not really circles," Toney says. "Because of that, he has trouble completing work. And in math, he often gets questions marked incorrectly even though the numbers really are there. ... His problem isn't getting the knowledge -- it's getting it on paper to demonstrate he's getting the knowledge."

Things may soon change for kids like Alex. A new study -- in which Alex participated -- shows that high-achieving kids with autism very often have trouble with handwriting.

It should come as no surprise. Hans Asperger, the first to describe relatively high functioning people with autism, noted that "the pen did not obey" one of his original patients. But research failed to show exactly what was wrong.

Now Amy J. Bastian, PhD, PT, and colleagues at Baltimore's Kennedy Krieger Institute, have identified a central clue. Using a test that dissects five separate aspects of handwriting, they showed that normal-intelligence kids with autism can align, size, and space their letters as well as normal kids.

The problem is that they have great difficulty forming their letters -- suggesting that the problem relates to motor control. That's new, because motor signs are not classically associated with autism.

"Where they broke down was in the fine motor control when they had to form actual letters," Bastian tells WebMD. "Their letter 'D' might have a gap at the top, or they are unable to make the curve match up with the line on a lower-case 'd.' A letter might have a piece falling out, or have sharp protrusions rather than clearly curving features. Clearly they have this problem with fine motor control."

It's not just writing that's a problem, as Toney and other parents already know. These high-achieving kids also have other problems, such as holding and using eating utensils in a normal way.

There's no one-size-fits-all solution. But there's a lot of hope. Some of the kids in the Bastian study had more legible handwriting than some of the "normal" kids, although it took a lot of effort. Two of the kids with the best handwriting had been taught by physical therapists to steady their writing hand with their other hand.

"Physical therapists are very clever," Bastian says. "We can teach kids to change their grip on the pen, give fatter or weighted pencils -- or maybe motor practice can be effective. Many of the parents we have interacted with are happy to know this is a purely motor problem, because it is a bit more straightforward to work on such things than to work on behavioral issues."

Some kids may do better typing on a computer keyboard than writing with pencil and paper.

Bastian warns that poor handwriting can't be used to diagnose autism. There are lots of reasons why a child doesn't write well; but an autism diagnosis is based on an entirely different set of criteria.

"Parents of children with autism may want to talk to the administration about whether their child qualifies for physical or occupational therapy, or ask their doctor if they can have some occupational therapy prescribed," Bastian says. "These kids really should be looked at. Because if you are trying to listen to your teacher and trying to understand her and also having to work as hard as you can on your writing, it can be very bad for self-esteem and academic success."

Bastian and colleagues report their findings in the Nov. 10 issue of Neurology.

SOURCES: Fuentes, C.T. Neurology, Nov. 10, 2009; vol 73: pp 1532-1537.

Amy Bastian, PhD, PT, director, motion analysis laboratory, Kennedy Krieger Institute, Baltimore.

Jennifer Toney, Ellicott City, Md.

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