Handwriting Difficulties in Children with Autism Spectrum Disorders
– A Scoping Survey
Azadeh Kushki1, Tom Chau1,2, Evdokia Anagnostou1,2
1Bloorview Research Institute; 2 University of Toronto
Research question: What is the nature of handwriting difficulties in children with autism
spectrum disorders?
Target population: Children with autism spectrum disorders
Introduction: Handwriting is a functional skill that profoundly impacts children’s academic and
psychosocial development. Functional handwriting involves complex interactions among
physical, cognitive and sensory systems. Impairments in many aspects of these systems are
associated with Autism spectrum disorders (ASD), suggesting a heightened risk of handwriting
difficulties in children with ASD. Given this backdrop, this scoping review aimed to: (1) survey
the existing evidence about deficits of fine motor control, visual perception and visual motor
integration, and kinesthetic function in children with ASD, as potential contributions to
compromised handwriting function, and (2) map out the existing studies documenting handwriting difficulties in children with ASD and thereby identify gaps in evidence where future research
is needed.
Methods: We conducted a scoping review of the literature pertaining to handwriting difficulties
in autism spectrum disorders. We searched the literature for studies of handwriting difficulties in
children with ASD using electronic databases including PubMed, Scopus, ISI Web of Science,
and Google Scholar. We used various combinations of the terms ‘autism, Asperger, and
pervasive developmental disorders’ with ‘writing, handwriting, dygraphia, and graphomotor’. We
included all English-language studies that directly examined handwriting samples in children
with ASD between January 1943 and January 2010.
Results: The current evidence implicates impairments in fine motor control and visual
perception as likely contributors to handwriting difficulties in children with ASD. Only six studies
to date have specifically scrutinized handwriting in children with ASD, often with conflicting
descriptions of handwriting quality. Nonetheless, diminished overall legibility and compromised
letter formation are emerging points of convergence among these studies. The lack of
consensus about the quality of letter alignment, spacing and sizing and the absence of
biomechanical process descriptions of handwriting in children with ASD are identified as gaps in
evidence.
Conclusions: Children with ASD frequently have impairments in fine motor control and visual
perception, both of which are known to be correlated with poor handwriting quality. The
reviewed studies provides contrasting descriptions of handwriting quality in part due to their
consideration of heterogeneous samples of children, non-standardized writing tasks, and
varying quality measures, among other discrepant aspects of study design. The only convergent
conclusion seems to be that children with ASD exhibit poorer overall legibility than their typically
developing peers, with specific detriments in letter formation. Larger studies with more homogeneous samples, deploying standardized measurement tools and writing tasks are needed.