Do children with ASD have difficulty handwriting under time pressure?

https://doi.org/10.1016/j.rasd.2017.02.001Get rights and content

Highlights

  • Children with ASD appear to have some capacity to compensate for underlying motor impairment when completing a well-practiced writing task.

  • There were no group differences in regard to handwriting errors and/or spacing between words in either condition.

  • The relationship between intellectual skills and handwriting performance is highly complex.

Abstract

Background

Children with autism spectrum disorder (ASD) often experience significant handwriting impairment, however the influence of time pressure on overall performance is unclear. The aim of the current study was to characterise the handwriting profile of children with ASD across both non-speeded and speeded conditions, with particular focus given to spacing difficulties and handwriting errors. A further aim was to explore the relationships between handwriting and both intellectual and motor skills under different task conditions.

Method

Boys with ASD (n = 23) and matched controls (n = 20) aged 8–12 years completed a modified version of the speed subtest of the Handwriting Performance Test, which allowed for both an ecologically valid and relatively simple motoric task. Participants wrote a simple phrase (cat and dog) five times in each condition.

Results

No significant group differences were identified for handwriting errors or spacing between words in either condition, however the ASD group demonstrated greater variability relative to controls, particularly in the speeded condition. Significant negative associations were identified between motor proficiency and handwriting errors in the non-speeded condition.

Conclusions

While motor processes are shown to have a significant role in overall handwriting proficiency, it appears that motor ability may influence the handwriting process to different degrees, depending on the nature of the task employed. A lack of group differences with respect to handwriting errors and spacing between words may suggest that children with ASD have the ability to compensate for underlying motor impairment when completing a well-practiced writing task.

Introduction

Motor impairment is considered to be a characteristic feature of autism spectrum disorder (ASD) alongside core ASD symptoms, specifically social-communication impairment and repetitive behaviours (Fournier, Hass, Naik, Lodha, & Cauraugh, 2010; American Psychiatric Association, 2013). While not all children with ASD will necessarily encounter motor difficulties, clinical data in Australia suggests that a large proportion of these children will require occupational therapy intervention for fine motor control, specifically handwriting remediation (Cartmill, Rodger, & Ziviani, 2009; Rodger & Polatajko, 2014). In 2011, a scoping review of seven handwriting studies in ASD identified poor legibility, specifically letter formation, as the most consistent feature of handwriting impairment in individuals with ASD (Kushki, Chau, & Anagnostou, 2011). Since this time, researchers have continued to identify significant differences in handwriting performance between children with ASD and age-matched peers (Rosenblum, Ben Simhon, & Gal, 2015; Johnson, Papadopoulos, & Fielding 2013; Johnson et al., 2015). In school-aged children, handwriting represents an everyday motor task that typically becomes an automated skill by age eight (Cartmill et al., 2009, Smits-Engelsman and Van Galen, 1997). Handwriting is important for classroom participation and academic achievement, as well as psychological factors, such as self-esteem (Feder and Majnemer, 2007, Rodger and Polatajko, 2014). Characterising and understanding handwriting problems is essential for tailoring handwriting remediation programs to children with ASD.

Several studies have explored the influence of different writing conditions on handwriting performance in children with ASD, with equivocal findings reported. In many cases, handwriting has been assessed under speeded conditions, whereby participants are instructed to write as quickly as possible. Greater writing speed puts more pressure on the motor system and is known to be associated with less control and consistency of movement, resulting in greater errors (specifically spatial inaccuracy) and poorer legibility (Smits-Engelsman & Van Galen, 1997). Indeed, in academic settings it is not uncommon for writing tasks to be completed under time constraints.

The speed subtest of the Handwriting Performance Test (HPT) is employed as a measure of handwriting proficiency under time pressure and requires an individual to copy the phrase cat and dog as many times as possible within a two minute period (Ziviani & Watson-Will, 1998). In a study by Cartmill et al. (2009), a significant negative correlation between consistency of letter formation and handwriting speed (indexed by the speed subtest of the HPT) was identified in eight year-old children with ASD (n = 28). This suggests that children with ASD may either sacrifice accuracy for speed when writing quickly or may not have the same ability to focus on accurate letter formation when writing quickly (Cartmill et al., 2009). Importantly, this was not found in the typically developing (TD) group, suggesting that a unique handwriting profile may emerge in children with ASD under speeded writing conditions.

Other studies using the speed subtest of the HPT in ASD populations have identified poorer spatial arrangement of words in cognitively able boys with ASD aged 7 to 14 years (n = 14) relative to age-matched controls (n = 21) (Johnson et al., 2013a). Interestingly, no group differences were identified in regard to handwriting errors (i.e., formation errors, stroke additions, letter transpositions and corrections). While this is unexpected in the context of Cartmill et al’s (2009) previously described findings, this study did not measure consistency per se, but rather total handwriting errors that were identified by the examiner. The production of smaller and less consistent spacing between words was suggested to reflect a piecemeal planning approach, whereby each letter is planned individually, rather than as part of an overall word and/or sentence (Johnson et al., 2013b). This is in contrast to the global planning approach in TD children who have been shown to plan their writing sequences in advance using syllables as functional units (Kandel, Alvarez, & Vallée, 2006; Kandel, Soler, Valdois, & Gros, 2006). Further research is needed to identify whether spacing difficulties are a consistent feature of handwriting performance in children with ASD, or whether this planning style is unique to specific writing conditions (e.g., speeded tasks).

ASD is a heterogeneous disorder, meaning that children will present with a varied range of motor and/or cognitive presentations. As such, there is considerable value in identifying which children are vulnerable to developing handwriting difficulties based on their overall clinical presentations. In the TD population, poor handwriting has been found to be associated with impaired motor functioning, as well as reduced cognitive, visual-motor integration and visual-perceptual skills (Feder and Majnemer, 2007, Hellinckx et al., 2013; Volman, Van Schendel, & Jongmans, 2006). This is less well-defined in ASD and different mechanisms are proposed. In the previously described study by Johnson et al. (2013b), perceptual reasoning and motor skills were reported to be predictive of handwriting spacing and errors in cognitively able boys with ASD, whereas verbal intellectual skills were reported to be predictive of handwriting speed (Johnson et al., 2013b). This is partially consistent with a previous predictor study of children with ASD (n = 69, aged 7 to 12 years) during a five minute speeded copy task (Hellinckx et al., 2013). Of particular relevance, alongside other cognitive and demographic variables, visuomotor integration was identified as a significant predictor of handwriting quality whereas reading abilities and fine motor coordination were found to impact handwriting speed (Hellinckx et al., 2013). In studies using non-speeded handwriting tasks, perceptual reasoning has been identified as the main predictor of handwriting performance in adolescents with ASD (n = 24, aged 12–16 years) (Fuentes, Mostofsky, & Bastian, 2010), whereas motor skills have been identified as the main predictor of handwriting performance in children with ASD (n = 28, 8–13 years) (Fuentes, Mostofsky, & Bastian, 2009). In light of these equivocal findings, further research is needed to clarify which factors are associated with handwriting performance in ASD and whether these may change as a product of different writing conditions.

At present, further research is needed to understand how different factors impact handwriting in order to characterise the motor profile of children with ASD and identify the most appropriate targets for handwriting intervention. As such, the aim of the current study was to characterise the handwriting profile of children with ASD across both non-speeded and speeded conditions. Particular focus was given to spacing difficulties and handwriting errors (letter transpositions, letter corrections, letter omissions, capitalisation and stroke additions), as both of these factors have been shown to be vulnerable in children with ASD during a speeded writing task and can impede the interpretability of text (Cartmill et al., 2009, Johnson et al., 2013b). A modified version of the speed subtest of the HPT was employed which allowed for both an ecologically valid and relatively simple motoric task (i.e., without confounding cognitive loading). Consistent with previous research, we anticipated that the ASD group would present with a) equivalent errors in the non-speeded condition (Johnson et al., 2013b) but significantly greater errors in the speeded condition (Cartmill et al., 2009), and b) significantly smaller spacing between words across both conditions (Johnson et al., 2013b). Specific attention was given to whether the degree of motor impairment in the ASD group influenced the presence of between group differences. This was achieved by further categorising children with ASD into groups (low or high), based on their level of motor proficiency. We also examined the relationship between motor proficiency and intellectual functioning with handwriting proficiency. Specific attention was given to whether these relationships would change as a function of the different task conditions.

Section snippets

Participants

The current study was part of a larger study approved by the Human Research Ethics Committee of Monash University and Deakin University, Melbourne, Australia, the methods of which are also reported in Grace et al. (2017). All participants in the current study were included in the sample outlined in the study of Grace et al. (2017). All parents of participants provided written consent prior to taking part in the study. Twenty-three boys with ASD were recruited from community organisations,

Results

Data were analysed using SPSS Version 23 for Windows. In order to minimise contrasts, data were collapsed across all included sentences in each condition to produce an average value for a given variable. Independent samples t tests were conducted to assess group differences where possible, however if the assumption of normality or homogeneity of variance was violated, non-parametric Mann-Whitney U tests were used instead, and alpha levels were adjusted using simple Bonferroni corrections. Group

Discussion

The purpose of this study was to characterise the handwriting profile of children with ASD across both non-speeded and speeded conditions, with particular attention to spacing difficulties and handwriting errors. We further aimed to examine the relationship between motor proficiency and intellectual functioning with these handwriting variables. Specific attention was given to whether these relationships would change as a function of the different task conditions.

In regard to handwriting errors,

Implications

While it is not surprising that motor proficiency was found to be significantly associated with overall handwriting proficiency, it is notable that motor abilities appear to influence the handwriting process differently, depending on the nature of the task employed. Further research is also still needed to clarify both when and how handwriting impairments manifest in ASD. This is particularly important given that there is a paucity of randomised-controlled studies evaluating handwriting

Ethical statement

All procedures performed in this study were in accordance with the ethical standards of the Human Research Ethics Committee of Monash and Deakin Universities, Melbourne, Australia. Informed consent was obtained from all participants included in the study.

Conflict of interest

The authors declare that they have no conflicts of interest

Acknowledgements

Peter G Enticott is supported by a Career Development Fellowship from the National Health and Medical Research Council (Australia). Beth P Johnson is supported by a Peter Doherty—Australian Biomedical Fellowship from National Health and Medical Research Council(Australia). Nicole J Rinehart is a recipient of project grants (#1004387 and #436609) from the National Health and Medical Research Council (Australia).

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