Children with Autism Show Specific Handwriting Impairments

Background: Handwriting skills, which are crucial for success in school, communication, and building children’s self-esteem, are frequently poor in individuals with autism. Despite the importance of these skills and the frequency with which individuals with autism are found to be impaired, the only study specifically examining handwriting in this population focused on letter size in adults. No study has explored handwriting in children with autism, and no study has tried to tease apart the multiple aspects of handwriting that may differentially contribute to impairments in autism. As a result, the specific aspects of handwriting in which individuals with autism demonstrate difficulty remain unknown.

Objectives: We asked whether, consistent with common observations, children with high-functioning autism (HFA) show overall handwriting impairments. If so, we wanted to further assess whether these impairments are in specific qualitative categories that can be differentially addressed during training and whether the impairments can be accounted for by factors such as age, intelligence, visuospatial abilities, and motor abilities.

Methods: We studied handwriting samples from children between the ages of 8 and 12 with and without HFA by using the Minnesota Handwriting Assessment. Samples were scored by two experimenters on an individual letter basis, with each letter receiving a score in five qualitative categories: legibility, form, alignment, size, and spacing. Most qualitative scoring was based on ruler measurements, and additionally an overall rate score was obtained. Subjects were also tested on the Wechsler Intelligence Scale for Children IV (WISC-IV) and the Physical and Neurological Examination for Subtle (Motor) Signs (PANESS).

Results: We demonstrated that children with HFA do indeed show overall worse performance on a handwriting task than do age- and IQ-matched controls. More specifically, children with HFA show worse quality of forming letters but do not show differences in their ability to correctly size, align, and space their letters. Among all subjects, PANESS scores were significantly predictive of legibility and form scores, whereas age and IQ (full-scale and sub-scores) were not.

Conclusions: We have provided the first systematic demonstration that children with HFA show overall worse handwriting performance relative to controls. Rather than showing random impairments, handwriting performance was specifically worse in the quality of form of letters while performance in other qualitative categories was comparable to controls. General motor abilities were a strong predictor of handwriting performance, as opposed to age, intelligence, and visuospatial abilities. These results suggest that training targeting letter formation, potentially in combination with compensatory motor strategies, may be the best direction for improving handwriting performance in children with autism.