Autism notes: handwriting

Latest 2017
Grace N, Enticott PG, Johnson BP, Rinehart NJ. Do Handwriting Difficulties Correlate with Core Symptomology, Motor Proficiency and Attentional Behaviours? J Autism Dev Disord. 2017 Apr;47(4):1006-1017.
Handwriting is commonly identified as an area of weakness in children with autism spectrum disorder (ASD), but precise deficits have not been fully characterised. Boys with ASD (n = 23) and matched controls (n = 20) aged 8-12 years completed a simple, digitised task to objectively assess handwriting performance using advanced descriptive measures. Moderate to large associations were identified between handwriting performance and attention, ASD symptoms and motor proficiency. The ASD group demonstrated significantly less smooth movements and significantly greater sizing variability and peak velocity relative to controls. These findings provide a clearer indication of the specific nature of handwriting impairments in children with ASD, and suggest a relationship with core clinical symptom severity, attention and motor behaviours



Alaniz ML, Galit E, Necesito CI, Rosario ER. Hand Strength, Handwriting, and Functional Skills in Children With Autism. Am J Occup Ther. 2015 Jul-Aug;69(4):6904220030p1-9. doi: 10.5014/ajot.2015.016022. PubMed PMID:
26114459.

OBJECTIVE:  To establish hand strength development trends in children with autism and to investigate correlations between grip and pinch strength, components of handwriting, and functional activities in children with and without autism.
METHOD: Fifty-one children were divided into two groups: typically developing children and children on theautism spectrum. Each child completed testing for pinch and grip strength, handwriting legibility, pencil control, and independence in functional activities.
RESULTS: The children with autism followed the same strength development trends as the typically developing children. Grip strength correlated with pencil control in both groups and with handwriting legibility in the typically developing children but not in the children with autism. Grip and pinch strength correlated with independence with functional activities in both groups.
CONCLUSION: This study provides evidence that grip and pinch strength are important components in developing pencil control, handwriting legibility, and independence with functional fine motor tasks.


Fuentes, C. T., Mostofsky, S. H., & Bastian, A. J. (2009). Children with autism show specific handwriting impairments. Neurology, 73(19), 1532–1537. http://doi.org/10.1212/WNL.0b013e3181c0d48c

Background: Handwriting skills, which are crucial for success in school, communication, and building children’s self-esteem, have been observed to be poor in individuals with autism. Little information exists on the handwriting of children with autism, without delineation of specific features that can contribute to impairments. As a result, the specific aspects of handwriting in which individuals with autism demonstrate difficulty remain unknown.

Methods: A case-control study of handwriting samples from children with and without autism spectrum disorders (ASD) was performed using the Minnesota Handwriting Assessment. Samples were scored on an individual letter basis in 5 categories: legibility, form, alignment, size, and spacing. Subjects were also tested on the Wechsler Intelligence Scale for Children–IV and the Physical and Neurological Examination for Subtle (Motor) Signs. 

Results: We found that children with ASD do indeed show overall worse performance on a handwriting task than do age- and intelligence-matched controls. More specifically, children with ASD show worse quality of forming letters but do not show differences in their ability to correctly size, align, and space their letters. Within the ASD group, motor skills were significantly predictive of handwriting performance, whereas age, gender, IQ, and visuospatial abilities were not.

Conclusions: We addressed how different elements of handwriting contribute to impairments observed in children with autism. Our results suggest that training targeting letter formation, in combination with general training of fine motor control, may be the best direction for improving handwriting performance in children with autism.


Fuentes, C. T., Mostofsky, S. H., & Bastian, A. J. (2010). Perceptual reasoning predicts handwriting impairments in adolescents with autism. Neurology,75(20), 1825–1829. http://doi.org/10.1212/WNL.0b013e3181fd633d

We have previously shown that children with autism spectrum disorder (ASD) have specific handwriting deficits consisting of poor form, and that these deficits are predicted by their motor abilities. It is not known whether the same handwriting impairments persist into adolescence and whether they remain linked to motor deficits.

Methods: A case-control study of handwriting samples from adolescents with and without ASD was performed using the Minnesota Handwriting Assessment. Samples were scored on an individual letter basis in 5 categories: legibility, form, alignment, size, and spacing. Subjects were also administered an intelligence test and the Physical and Neurological Examination for Subtle (Motor) Signs (PANESS).

Results: We found that adolescents with ASD, like children, show overall worse performance on a handwriting task than do age- and intelligence-matched controls. Also comparable to children, adolescents with ASD showed motor impairments relative to controls. However, adolescents with ASD differ from children in that Perceptual Reasoning Indices were significantly predictive of handwriting performance whereas measures of motor skills were not.

Conclusions: Like children with ASD, adolescents with ASD have poor handwriting quality relative to controls. Despite still demonstrating motor impairments, in adolescents perceptual reasoning is the main predictor of handwriting performance, perhaps reflecting subjects' varied abilities to learn strategies to compensate for their motor impairments.


Johnson BP, Phillips JG, Papadopoulos N, Fielding J, Tonge B, Rinehart NJ. Understanding macrographia in children with autism spectrum disorders. Res Dev Disabil. 2013 Sep;34(9):2917-26. doi: 10.1016/j.ridd.2013.06.003. Epub 2013 Jun 29. PubMed PMID: 23816627.

It has been consistently reported that children with autism spectrum disorders (ASD) show considerablehandwriting difficulties, specifically relating to accurate and consistent letter formation, and maintaining appropriate letter size. The aim of this study was to investigate the underlying factors that contribute to these difficulties, specifically relating to motor control. We examined the integrity of fundamental handwritingmovements and contributions of neuromotor noise in 26 children with ASD aged 8-13 years (IQ>75), and 17 typically developing controls. Children wrote a series of four cursive letter l's using a graphics tablet and stylus.

Children with ASD had significantly larger stroke height and width, more variable movement trajectory, and higher movement velocities. The absolute level of neuromotor noise in the velocity profiles, as measured by power spectral density analysis, was significantly higher in children with ASD; relatively higher neuromotor noise was found in bands >3 Hz.

Our findings suggest that significant instability of fundamental handwriting movements, in combination with atypical biomechanical strategies, contribute to larger and less consistent handwriting in children with ASD.


Kushki A, Chau T, Anagnostou E. Handwriting difficulties in children with autism spectrum disorders: a scoping review. J Autism Dev Disord. 2011 Dec;41(12):1706-16. doi: 10.1007/s10803-011-1206-0. Review. Erratum in: J Autism  Dev Disord. 2011 Dec;41(12):1717. PubMed PMID: 21350917.

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. This scoping review aimed to: (1) survey the existing evidence about potential contributions to compromised handwriting function in children with ASD, and (2) map out the existing studies documenting handwriting difficulties in children with ASD.

The current evidence implicates impairments in fine motor control and visual-motor integration as likely contributors to handwriting difficulties in children with ASD, though the role of the latter is not well-understood. Moreover, diminished overall legibility and compromised letter formation are emerging points of convergence among existing studies of handwriting quality in children with ASD.


Palsbo SE, Hood-Szivek P. Effect of robotic-assisted three-dimensional repetitive motion to improve hand motor function and control in children with handwriting deficits: a nonrandomized phase 2 device trial. Am J Occup Ther. 2012 Nov-Dec;66(6):682-90. doi: 10.5014/ajot.2012.004556. PubMed PMID: 23106988.

OBJECTIVE: We explored the efficacy of robotic technology in improving handwriting in children with impaired motor skills.

METHOD: Eighteen participants had impairments arising from cerebral palsy (CP), autism spectrum disorder(ASD), attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), or other disorders. The intervention was robotic-guided three-dimensional repetitive motion in 15-20 daily sessions of 25-30 min each over 4-8 wk.

RESULTS: Fine motor control improved for the children with learning disabilities and those ages 9 or older but not for those with CP or under age 9. All children with ASD or ADHD referred for slow writing speed were able to increase speed while maintaining legibility.

CONCLUSION:  Three-dimensional, robot-assisted, repetitive motion training improved handwriting fluidity in children with mild to moderate fine motor deficits associated with ASD or ADHD within 10 hr of training. This dosage may not be sufficient for children with CP.