Tori: A Case Study of Executive Dysgraphia

Children spend nearly 60% of their school day engaged in written expression or some type of fine-motor activity (Feder & Majnemer, 2007). Whether students are taking notes, writing a story, responding to math problems, or simply jotting down their homework assignment for that evening, writing skills are critical to school success. However, approximately 7-15% of school-aged children exhibit some kind of developmental writing deficit (Dohla and Heim, 2016).

The following case shows how one student was given the Feifer Assessment of Writing (FAW) to get to the root of her writing issues—and how her school was able to use this test data to help provide the support needed to help them succeed.

The concern

Tori is a 12-year-old student in 7th grade enrolled in a middle school in Indianapolis. Tori was diagnosed with Turner syndrome at birth. Individuals with Turner syndrome may have physical abnormalities such as short stature, cardiovascular malformations, and specific cognitive deficits. Tori, like others with Turner syndrome, has slightly lower cognitive abilities, extremely poor visual–spatial processing deficits, and inconsistent memory and attention skills.

Background from teachers and family

Tori was referred to her school psychologist after her teachers voiced concerns regarding her overall written language skills and periodic lapses with her memory. Tori’s parents were concerned about her inconsistent educational progress and were worried that she was not meeting grade-level standards in many of her classes.

Tori’s teachers reported that she was struggling in her language arts and mathematics classes—her last report card was mainly Cs and Ds.

Tori’s language arts teacher said she was struggling to organize her thoughts and ideas into organized paragraphs when writing essays in class and seemed to have difficulty retaining new information.

Her teachers in other subjects voiced concerns about Tori’s ability to sustain and focus her attention during lectures and noted that she frequently made careless mistakes in her daily schoolwork.

Test results

Tori was administered the FAW to assess the concerns with her writing abilities. She received a FAW Total Index score in the below average range, scoring in the 13th percentile compared with peers. Upon further investigation of her FAW results, there was significant variability among her index and subtest scores, which provided more insight into her specific strengths and weaknesses.

• Tori scored in the average range on the Graphomotor Index. Students who have lower scores on the Graphomotor Index often demonstrate difficulty with the physical act of penmanship. However, Tori’s fine-motor dexterity and coordination was appropriate, and her writing speed also appeared to be a strength. Yet, Tori had difficulty judging how large or small to make her letters given the amount of space on the page. Motor planning can be a concern for students with attention inconsistencies, an impulsive response style, and/or weaker visual/spatial skills.
• Tori’s Dyslexic Index score was in the average range. Students who have lower scores on the Dyslexic Index may have difficulty with spelling skills, which often manifests from an underlying learning disability in reading. However, Tori displayed good spelling skills when asked to spell words read aloud by the examiner. Yet, she had difficulty when asked to recognize the correct spelling of a phonologically irregular word from among four choices. This suggests that Tori has difficulty conjuring a visual–spatial image of a printed word form when spelling.
• On the Executive Index, Tori’s scores were in the moderately below average range. Lower scores on this index suggest difficulty on a wide range of written-language skills including weaknesses with planning, organizing, retrieving, and/or sequencing thoughts and ideas to produce a written response. These scores may indicate executive dysgraphia. Tori demonstrated a relative strength with her overall verbal retrieval skills when determining relationships between words, but she struggled to express her thoughts and ideas on a structured writing task. Tori also had problems self-generating her own thoughts and ideas, elaborating on her work, and organizing her writing in a logical flow. This may reflect weaknesses with the working memory and executive functioning demands of the writing process.
• When comparing Tori’s Compositional Writing Index to her peers, her scores fell into the below average range. These lower scores suggest difficulty with foundational written language skills and the ability to self-check her own work for grammar. Although Tori did well on an isolated task of copy editing, she made many grammatical errors when engaged in writing tasks.

Overall, Tori’s scores suggest that as the demands of the writing process increase, she becomes more susceptible to making careless mistakes on her work.

Recommendations and interventions

The school psychologist reviewed Tori’s FAW results with an occupational therapist in the district to ensure they were creating interventions that would have the most impact.

Tori performed significantly better on tasks that allowed her to anchor her writing on evenly spaced horizontal lines than on tasks that required her to determine spacing. Although Tori sometimes worked in a slightly hurried and impulsive manner, her FAW scores bring to light that many of her challenges reflect more visual–spatial concerns than attention issues. To help Tori with this, the occupational therapist recommended that she begin using raised lined paper in class assignments or graph paper when working on math equations. They also encouraged Tori to type on a keyboard for longer writing assignments.

Tori was able to spell words aloud easier than identifying words spelled correctly in print. Her FAW scores indicate that she may be having issues creating a cognitive template of the printed word form. The team determined Tori would benefit from using a spell check device or creating a word bank of phonologically inconsistent words that she can reference when she is working on longer writing assignments.

Overall, Tori presented with the profile of an individual with a learning disability in written language, specifically with executive dysgraphia. Her particular issues revolve around difficulty with working memory and the executive functioning demands of the writing process. Generally, when too many demands are placed on Tori’s working memory during the writing process, she becomes more vulnerable to making careless errors.

Tori’s team recommended that she begin using pre-writing activities like graphic organizers to help lessen the demand on working memory when she begins the writing process. They also loaded educational software onto her school-issued device that will help organize her thoughts before she begins writing. Additionally, they added a typing skills app to her school device to help speed up her motor output and reduce the pressure on her working memory to retain information over longer periods of time.

The outcome

After putting these interventions into place, Tori was able to strengthen her writing skills. Her typing speed has increased, and she’s more proficient in writing longer essays and adding additional details to her work. Her grades are improving in her language arts class and Tori reports enjoying class more than ever.

Last week, Tori entered a young authors writing contest hosted by her school librarian. She will be reassessed with select subtests of the FAW later this school year to monitor her progress.

References

Dohla, D., & Heim, S. (2016). Developmental dyslexia and dysgraphia: What can we learn from the one about the other? Frontiers in Psychology, 6, article 2045. https://doi.org/10.3389/fpsyg.2015.02045

Feder, K. P., & Majnemer, A. (2007). Handwriting development, competency, and intervention. Developmental Medicine & Child Neurology, 49, 312–317. http://doi.org/fc2sbc