Demystifying Dysgraphia: Assessment, Evaluation, and Identification of Dysgraphia
As mentioned in my Defining Dysgraphia post, Dysgraphia is a type of Specific Learning Disorder (SLD). According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a comprehensive evaluation is required. SLD can only be diagnosed once the child begins school and no single data source is sufficient for SLD identification. Rather, the SLD diagnosis is based on a synthesis of data from the individual’s medical, developmental, education, and family history; the history of the writing difficulty; the impact of the difficulty on academic, occupational, or social functioning; previous or current school reports; portfolios of work samples; curriculum-based measurements (CBMs); and previous or current standardized tests of academic achievement.
The DSM-5 goes on to indicate if an intellectual disability, sensory, motor, or neurological disorder is suspected, then the clinical assessment for those specific disorders should be included to rule them out. In other words, the only test one must administer for SLD identification (per the DSM-5) is an achievement measure. Intellectual (IQ) tests are not required for DSM-5 SLD identification. In addition, they separate out SLD from a neurological disorder (as previously mentioned). However, according to the National Institute of Neurological Disorders and Stroke (NIH), Dysgraphia is a neurological disorder characterized by writing disabilities. In order to assess Dysgraphia from a neuropsychological perspective, the following assessments have been proposed.
According to Steven Feifer and Philip Defina (2002), a Dysgraphia evaluation should include measures of intelligence, copying, working memory, executive functions, writing and spelling, phonological awareness, and retrieval fluency. In addition, a thorough family history should be conducted.
There are several comprehensive intelligence tests available (e.g., Woodcock-Johnson Test of Cognitive Abilities, Fourth Edition; WJ IV COG; Weschler Intelligence Scale for Children, Fifth Edition; WISC-V; Differential Ability Scales, Second Edition; DAS-II; Kaufman Assessment Battery for Children, Second Edition; KABC-II; Stanford-Binet Intelligence Scales, Fifth Edition; SB-5). Intelligence tests are particularly important to rule out the presence of an intellectual disability (i.e., IQ <70; <2nd percentile). However, many researchers also contest that intelligence tests are also important to identify an individual’s cognitive profile (e.g., acquired knowledge, short-term memory, long-term retrieval, fluid reasoning, visual spatial processing, auditory processing, and processing speed). The WJ IV COG and DAS-II are the only two of the aforementioned tests that assess all seven previously mentioned cognitive processes.
Copying tests (e.g., NEPSY-II Design Copying) assess motor and visual-perceptual skills associated with the ability to copy two and three-dimensional geometric figures. At the basic level, an inability to copy basic two-dimensional geometric figures may be indicative of Dysgraphia.
Working memory is an important skill for a vast majority of everyday tasks. Broadly put, it is our ability to hold information in our mind long enough to be able to do something with it. A great example of a working memory task is following auditory multi-step directions. That is, if someone tells you three things, likely you have to go back and do the first thing first and then remember to follow the next two steps. A simple working memory accommodation is writing the information down (which the majority of us naturally do). Working memory tests are found on the intelligence tests (e.g., WISC-V, WJ IV COG, KABC-II, etc.) and stand alone measures (e.g., Test of Memory and Learning, Second Edition; TOMAL-2).
Executive functions are a group of goal-oriented/directed skills. This includes concepts such as planning, task initiation, task completion, sustained attention, cognitive/mental flexibility, and reasoning. Executive Functions (EF) are vital in writing. In order to write well, you must plan what you are going to say. For some of us, the planning might take several seconds. However, when it comes to writing something you are not familiar with the planning demands significantly increase. So a child with an EF deficit in planning will undoubtedly struggle with writing on topics they know little about. They may also find writing laborious and a non-preferred task. Executive functions are indirectly assessed on our intelligence batteries. However, the Delis-Kaplan Executive Function System (D-KEFS) is a great stand-alone EF battery. In addition, particularly for children younger than 8 years old, the NEPSY-II is a great option.
Writing & Spelling
Of course, if you suspect one of a learning disorder in writing (Dysgraphia), you will want to actually measure writing. Fortunately, psychologists have several achievement tests at their disposal that measure writing well and somewhat differently. For instance, the Wechsler Individual Achievement Test, Third Edition (WIAT-III) has writing measures of combing sentences, generating sentences, essay composition, alphabet writing fluency, and spelling. Note: The WIAT-4 is now out and published in the fall of 2020. The WJ IV ACH does not require the examinee to compose any essays; rather, the measures focus on shorter sentence generation, fill in the blanks, spelling, and editing. The KTEA-3 takes a different approach in that examinees complete a workbook of several pages. The examinees are taken through a story in which they have to generate words and sentences, fill in the blank, and then compose an essay at the end.
Phonological awareness is particularly important in the spelling of words. Phonological awareness tests are represented on some of our intelligence batteries (e.g., WJ IV COG), and the WJ has a stand alone Oral Language Battery (WJ IV OL). In addition, the Comprehensive Test of Phonological Processing, Second Edition (CTOPP-2) is a great tool for measuring phonological awareness skills in children and young adults ages 4-24.
The ability to rapidly produce information is retrieval fluency. In writing, if one has difficulty with retrieval fluency, they will definitely struggle with sentence/essay composition, particularly when having to generate their own ideas. Retrieval fluency is found on the NEPSY-II (Word Generation), D-KEFS Verbal Fluency Test, and the WIAT-III.