Gifted Issues Discussion homepage Forums Twice Exceptional What are the criteria for a dysgraphia diagnosis?

Hi

We had our DS8.5 in for psycho-educational assessment this week, and got some preliminary feedback today. Previous to today he had already been diagnosed with DCD and convergence insufficiency (almost ready to be discharged from VT). The school recommended having him assessed due to some behavior issues last year and also because to get him assistive technology we need a letter from a psychologist (so they said).

DS's handwriting is poor, slow and laborious, so I was thinking they might come back with dysgraphia. But the psychologist said that his written output was age appropriate (although she conceded it was very slow and there is a gap between cognitive ability and writing). But she told us that because he's not below grade level she can't give a LD diagnosis.

I don't have the testing summary (will take a couple of weeks for them to write everything up and send it to us), but I think the writing sample she showed us was from the WIAT? She said it was un-timed - but noted that one of the sentences took him over 10 minutes to write. She also noted that he mixed upper and lower case letters in his sentences and had to go back to put in the punctuation. He also did not complete all of the sentences - maybe 5 out of 8?

On the other hand, the spelling portion took him up into the 10th grade level, so I know he doesn't have issues with spelling.

Does anyone know what the specific criteria are for dysgraphia? Do you need to be below grade level? Is there another test she should have used?

Can2K, I'm on my phone and don't have time to reply in detail, but an LD diagnosis is a diagnosis for services at school, hence the comment about grades (which also isn't correct)... Is this a school psychologist who did the eval or was the eval specifically for school?

Whether or not your ds qualifies for services thru school, it sounds like he may be dysgraphic - and that's something that impacts his life. Parenting a child with a challenge is a bit like having two challenges to approach - how to remediate/accommodate for life, and how to get what is needed thru school.

Hope that makes sense!

polarbear

It is not clear to me what the criteria are for a dysgraphia diagnosis in a child with DCD, but I do have a friend with a child in early elementary who has been assessed as having writing difficulties due to DCD, but not dysgraphia (maybe a motor issue without an automaticity issue?). Her DC does qualify for AT with this set of diagnoses. Can you advocate for services based on the DCD diagnosis?

It's a rather lengthy piece but might be worth a look:

http://dyslexia.yale.edu/CommentsDSM5ColkerShaywitzSimon.pdf

P.13 discusses the issue of having to be "well below," which must be met to be given the SLD diagnosis.

Anyway, given that your DS already has the DCD diagnosis, that should qualify him for SPED and related services under OHI if the eligibility team agrees that the services are needed for him to receive FAPE.

I'm going to copy the quote I cited in another thread recently, which indicates the standard federal special education law says schools should use. (OCR is Office of Civil Rights. You do not want to mess with them, if you are a school.):

From this: http://www2.ed.gov/about/offices/list/ocr/letters/colleague-201607-504-adhd.pdf

(emphasis mine):

"Someone with ADHD may achieve a high level of academic success but may nevertheless be substantially limited in a major life activity due to his or her impairment because of the additional time or effort he or she must spend to read, write, or learn compared to others.44 In OCR’s investigative experience, school districts sometimes rely on a student’s average, or better-than- average, grade point average (GPA) and make inappropriate decisions."

Substitute dysgraphia (or, more properly, in the school context, Specific Learning Disability in written expression) for ADHD.

BTW, it might interest the reader to know that, despite all the hype about DSM-5, Medicare/Medicaid do not use it for diagnosis, in part due to the controversy regarding a great many disorders. They use ICD-10-CM instead. (https://www.cms.gov/Medicare/Coding/ICD10/index.html)

Dyslexia in the ICD-10 more closely resembles Shaywitz's recommendations (and the DSM-IV):

http://www.icd10data.com/ICD10CM/Codes/F01-F99/F80-F89/F81-/F81.0

So if a clinician says DSM-5 doesn't allow them to give a dyslexia or dysgraphia diagnosis, you may wish to ask them to consider ICD-10 diagnostic criteria.

It's a private psychology clinic (they also provide educational services) and we did request the eval. in order to get recommendations for school.

This was recommended by our (Canadian public) school, even though he does have a DCD diagnosis. They told us they need something from a psychologist to access AT.

The psych we met with seemed to brush aside the DCD diagnosis - told us they don't deal with gross motor. She did do the Beery with him but it didn't show a problem. (As far as I can recall, Visual-Motor Integration was ~30th percentile, Visual Perception 90th percentile, Motor Coordination~30th percentile). Perhaps the VT has brought up his scores since we had the OT eval. last year.

Just as a preliminary finding she was tending towards an ADHD diagnosis. As far as I can tell this was based purely on Connor questionnaire results (ours and teacher's), and her interaction with him over a few hours.

Perhaps it doesn't matter which diagnosis they put so long as he gets the accommodations. However, DH is concerned there may be stigma attached to an ADHD diagnosis.

Thanks - the school did accept the DCD diagnosis, and he has an IEP with some accommodations - but for some reason they wanted a letter from a psychologist to access AT.

Does your school allow a kid to bring/use their own device? Are all kids set up with google accounts?

DS didn't get his school chromebook until the end of grade 4. Until then we sent in an old laptop so he could use it whenever he wanted. He now officially has AT and received some training through the school on various tools but they were all things that were available on his school google account and had been using for years anyway.

Do you agree with ADHD? Our teacher's Connor results were very different than ours. In our case the tester saw more of the side that we see and he didn't come out with a diagnosis. He's since moved into a gifted class and is a model student with no signs of ADHD (shocking!!).

Thanks aeh - we're in Canada, so I'm not sure how much of that would apply, or if that is used up here.

It sounds like what they psychologist told us (about using grade-level for writing assessment) is not best practices, but also not uncommon.

I just wondered if there was another test that would show his writing issues more clearly. I mean if a kid can write at grade level, but it takes a long time and a lot of concentration to do that (10 minutes to write one sentence) - surely that shows a problem??

Also, if he is able to focus on writing one sentence for 10 minutes - how does he have ADHD?

Yes we probably can send in a device for him. DH is now saying the testing was a waste of money and we should have just done that. But without the recommendation on his IEP, it may be hit or miss whether the teachers allow him to use it day to day.

I still can't decide whether I agree with the ADHD suggestion. The psych thought that he had enough symptoms that it wasn't just him being bored in class. He does have problems with executive function (loses things a lot, needs reminders to do basic things). And he is very active and fidgety - but I always thought that was sensory; the behaviours decrease when we look after sensory needs.

They psych also suggested the gifted class may work better for him (partly because with FI he has to move from French to English partway through the day). But he doesn't want to move at the moment - enjoys his school and his friends.

Can2K, my ds was diagnosed 8 years ago, so some of what went into his diagnosis may be out-of-date, but this is what went into his diagnosis. The first note - he wasn't diagnosed with "dysgraphia", but instead with "Disorder of Written Expression" per DSM-IV. I'd never heard of dysgraphia until I did some googling to learn about DOWE. I then asked his neuropsych if he had dysgraphia, and she said yes, but that DOWE was the diagnosis recognized by schools (at that time).

The things that the neuropsych used to make the diagnosis:

* Review of handwriting samples from his classwork
* Discrepancy between ability measured by WISC-IV and WJ-III Achievement test
* Scatter in WJ-III Achievement subtests (scatter occurred between tests that required oral vs handwritten response)
* Scatter in WISC-IV subtests (difference of greater than 1.5 standard deviation between processing speed subtests and subtests that went into the GAI)

In addition to the above testing/review that correlated with a dysgraphia diagnosis, the neuropsych refined the diagnosis to show that the dysgraphia was related to fine motor issues rather than visual with these two tests:

* Scatter between subtest in the Beery VMI
* Low scores on a subset of the NEPSY (finger-tapping test)

I'm sure you've already done this, but googling types of dysgraphia might be helpful for you when trying to determine what's up with your ds. It sounds like his dysgraphia (if he's dysgraphic) may have had a visual component, and there is one type of dysgraphia in which spelling isn't impaired (I suspect it's the visual dysgraphia, but I haven't looked at the definitions recently enough to remember. If you're having a tough time finding those definitions let me know and I'll find a link for you).

My ds has also been given the TOWL twice (once through school for IEP eligibility and once later on privately). Although it isn't a direct test for dysgraphia, it can be extremely helpful in determining specific areas of challenge with written expression.

When my ds was diagnosed with DCD and DOWE, he'd landed at the neuropsych because his teacher was convinced he had ADHD. There are many overlaps in behaviors and symptoms between DCD, ADHD, and ASD (my neuropsych has a chart showing this - I wish I could find it online somewhere!). Teachers will often make a guess or in some cases an assumption based on what they has seen in the past - and if your area is like ours was 8 years ago, most teachers will have had students with ADHD in their classrooms but won't be familiar with dysgraphia. DS' neuropsych eval included behavior screens filled out by both parents and teacher, as well as a computer test that screened for ADHD. The neuropsych asked for us to have the behavior screens filled out by *any* adults who spent a significant amount of time with ds during the day, not just his primary teacher - unfortunately that one other person for our ds was a student teacher, and his primary teacher vetoed letting her fill it out (picture me knocking my head against the wall). When the results came in, ds' teacher was seeing a very different child than we saw at home, but that didn't line up with ADHD according to the neuropsych's observations of ds or the screening test. Combining that with the results of the neurospych testing supporting dysgraphia led the neuropsych to conclude that the behaviors of concern to the teacher were more likely due to a combination of DCD/DOWE and anxiety resulting from the impact of those disabilities in the classroom.

I hope some of that helps - again, it was just our experience, and it's very outdated at this point in time. DS has had semi-recent testing to support accommodations for SAT/ACT, but those evals were much less thorough and were designed to show current impact in a student who already had a recognized diagnosis. FWIW, the diagnosis he uses for accommodations (at school and for standardized testing) is DCD, not dysgraphia.

Best wishes,

polarbear

Two notes on this Can2K:

My ds with DCD has challenges related to EF and organization that are attributed to his DCD - this is a common part of DCD for many people. The challenges had a huge impact in elementary and middle school, but by middle school I was able to work with him in a way that was meaningful and helped tremendously. He still has these types of challenges in high school but he's much better equipped now to deal with them thanks to a combination of maturity, increased self-awareness, and years of practice.

I have a dd who had vision issues that were remediated through vision therapy. She *looked* like she had ADHD when she was young, before VT, because she never sat still, was extremely fidgety, and had a sensory diagnosis. All of those things improved tremendously with vision therapy, so I wonder if it might be that your ds is still dealing with vision issues. FWIW, vision therapy made a huge improvement in my dd's vision, but she still works hard at keeping her eyes tracking etc. and has been through one necessary "redo" of vision therapy, again, successful, but not a "cure-all".

Best wishes,

polarbear

We've been through this too - but keep in mind our provincial education system doesn't actually care about clinical diagnosis, per se, they care about functional impairment in the classroom. So you don't need a diagnosis of LD from your psych (although it often simplifies things, your board may also just reject/ ignore the diagnosis, because they "Identify" using educational, not clinical, criteria). What you do need, and your psych can provide without a diagnosis, is a letter from the psych stating that your child cannot access their education without [specify the AT required]. Your son's slow writing speed alone is more than enough to justify the letter, as is the DCD diagnosis. Your board is likely to have specific wording they want to see in that letter in order to make what is called a "SEA application", so ask them for their required wording, and provide it to your psych to use in her letter.

Our own psych did not think our DS was clinically LD (but that's a whole different problem for another day), but she did note a significant discrepancy in writing ability, and recommended AT based on that. She provided the specific letter on request, and a board SEA laptop was approved. DS has no clinical diagnosis, nor LD identified on his IEP. If handwriting is a barrier to your DS demonstrating his knowledge and participating in his education, then he is entitled to accommodations, period. And yes, for the long term, even if you are providing your own laptop, it's important to have that SEA approval on his IEP, to ensure it's seen as his right, and not a special privilege some teachers may choose to grant.


This bothers me. A lot. You can't talk about LDs and ignore dyspraxia, which goes way beyond gross motor. Honestly, if it's remotely feasible, you may want to consider taking your pile of results to another psych (thoroughly pre-interviewed!) who has a less limited view of their role, and more experience in this area. If nothing else, I cannot imagine concluding "no LD in writing" without doing any timed testing of writing fluency. The question is not "can he?" It's: can he form letters/ words/ sentences in an appropriate amount of time, with appropriate accuracy, and - the million dollar question - with appropriate levels of automaticity?

It sounds like you may need a bit of further testing to figure out if the problem actually is dysgraphia or (and) something else. The physical problems associated with DCD may actually be all that is slowing down the writing. If he produces ability-appropriate written output when he bypasses the physical constraints via typing (if that doesn't also hurt) or voice recognition, then the problem is probably just DCD. Which still fully warrants AT and other appropriate accommodations.

If, like mine, taking away the pencil removes the physical pain and takes writing from impossible to merely excruciating, then there are probably other things going on, too. Dysgraphia is a cognitive processing deficit, not a physical one: it's specifically about lacking automaticity in letter formation. Each letter has to be carefully thought out, how to produce it, every time it's written. The whole brain is sucked up with this, and no other thinking or listening may be possible while he's writing letters.

ADHD can have huge impact on the ability to organize thoughts and plan out writing. (note: people with ADHD may be able to focus for long periods; the problem is that they cannot choose/ control where to focus, rather than that they can't focus at all). I'd suggest reading a range of descriptions from reputable sources, and see if they resonate with you. ADHD can be a very helpful label - as long as it is the correct label. And as he gets older, it will matter more and more that teachers recognize critical skills gaps as "can't", not "can't be bothered". If he's ADHD, he may need a lot of extra support, explicit and repetitive training in basic executive function skills, and scaffolding and accommodations where skills are lagging or missing entirely. But if ADHD doesn't feel right, or like the whole answer to you, or your psych seems determined to go there without carefully considering other potential explanations, be cautious. Unsupported LD creates huge anxiety in the classroom, and anxiety can look an awful lot like ADHD. If you and the teachers are seeing similar issues in academic AND non-academic tasks, ADHD may be part of the puzzle. If the issues are only being seen around school work, unrecognized LD and anxiety could well be making the child unable to take in what's being said to him, and to shut down or act up when faced daily with tasks he can't handle without extreme effort.

Just to muddy the waters though, I should note that work that is way too easy can have the same effects.... our psych, for example, wasn't willing to assess for ADHD as long as DS was not in a gifted classroom, as being in an inappropriate environment (whether too hard, too easy, or both) can cause similar anxiety and behaviour. An amazing number of kids in our board's primary gifted program are referred to psychs for ADHD assessment, not giftedness - and for most, the ADHD behaviours disappear in a gifted classroom.

And just to throw it in there, another possibility is expressive language deficits, which can make it really hard to access and organize words and ideas. For what it's worth, in our case, I suspect my DS's writing problems are a mix of fine motor issues (hypermobility), extreme inattentive ADHD and expressive language - pretty much everything but dysgraphia. Still trying to find a psych who can untangle this...

Thanks a lot Platypus! It makes sense that the school would mostly care about his needs/deficits - if he is slow at writing and needs AT, surely it doesn't really matter why.

Although now I am puzzled that our school resource teacher was insisting on having a diagnosis (at least for the DCD she really wanted a letter from our doctor - wouldn't accept the OT report alone).

I think the psych could clearly see that DS would benefit from AT, so I'm pretty sure that will end up in the recommendations (which we don't have yet - so far just preliminary finding).

She also commented that he kept dropping his pencil and then would have a hard time picking it up - to me this is clearly the DCD, not ADHD. And thinking about it, he gets quite distracted when these things happen, so some of the symptoms are clearly DCD-related.

After doing some reading, I see that writing problems can be generated from DCD alone - clearly he has trouble with motor planning. But to me it looks like he has trouble with automaticity - I can almost see the wheels turning in his head when he is printing each letter.

The thing is, currently his typing is also pretty slow. And he's not too interested in typing tutors or learning to type faster. So right now, having him type will likely not speed up his writing by much. And he also has trouble either deciding what to write, or coming up with the words. I do a lot of scaffolding on written homework. Again - is this dysgraphia, ADHD, or both? Or does it really matter which one, if we get the right accommodations in place?

ADHD - some of the symptoms fit - he loses things, has trouble organizing himself, is often inattentive at home. And apparently 50% of DCD kids also have ADHD - so I guess not too surprising?

I hear you on finding that one person who can explain it all - DH even suggested getting the psych, the OT and vision therapist all in a room together so they can come up with an answer. But I'm not convinced that would work either - they all look at DS through their own lens/experience. I wish there was one professional who would look at the big picture - but that seems to be up to us, the parents.

Thanks a lot Polarbear! Sounds like there is a lot more testing that the psych could have done - I am not at all sure we got value for our money, but we'll have to see what the final report looks like.

There does seem to be a lot of overlap among all these diagnoses - it is really confusing and hard to sort out. The DCD symptoms make sense to me and really fit what I see with DS, but a lot of those are also in the lists for ADHD and dysgraphia - as you said, a chart would be helpful.

I did find sheets with recommended accommodations for DCD and also ADHD - the ADHD chart had most of the DCD accommodations plus a lot more - some of which might apply to DS and some not.

This is interesting - DS's fidgeting has decreased over the last year, and I think it is partly due to VT (probably also partly just getting older). I can tell when the optometrist examines him that his eye tracking is better - but he still doesn't have the stamina. I'm hoping they can keep working with him on that because, while his reading has improved, he still will read not longer than a few minutes at a time (although he does OK with comics/graphic novels).

So Platypus - am I right in thinking that given we already have an IEP with both gifted and DCD diagnosis listed on it, that all we need is a formal recommendation for AT from the psychologist (as well as whatever other accommodations they suggest).

There shouldn't really be a need to list ADHD or dysgraphia unless we want to?

Yes, in terms of getting the AT, the letter should be all you need (just make sure it uses the right wording for your board). In terms of adding other diagnoses, they are probably not necessary at this time, as long as the accommodations provided for the first two are adequate to cover all his needs.

Speaking from experience, though, as he moves towards middle school you may want his challenges more specifically diagnosed and documented, so that you can ensure appropriate supports are added as time goes on. Come grade 6, we found DS's (undocumented) ADHD suddenly shifted from being a source of frustration to his teachers, to being a source of his losing a whole lot of marks.

Thanks Platypus - it's very helpful to hear from other parents who have been there!

Just got off the phone with a psychologist where we had the testing done - they are diagnosing ADHD. She refused to consider simply documenting his deficits and recommending accommodations based on that - said that would not be professional.

Also, she seemed to not be impressed with his previous diagnosis of DCD, given that he scored at the 30th percentile on the Beery.
Still waiting for the full report...

I'm curious about the ADHD diagnosis - once you have the full report, I'd be interested in knowing what she used as basis for the diagnosis. Did you and/or your ds' teacher have to fill out any type of behavioral survey?

I also understand why she wouldn't want to document deficits and make accommodations recommendations without a diagnosis.



I can't find my ds' Beery report at the moment, but I'm fairly certain he didn't have any scores that were super-low. When you get the report, look to see if the subtest scores are listed, because that's where the information that's useful really is. There are three subtests: Visual Motor Integration, Visual Perception, and Motor Coordination. If there is a discrepancy in scores between subtests, it can help you figure out where the challenge is that's driving the handwriting issue.

I think you've mentioned other things that clearly line up with DCD that aren't in the realm of ADHD symptoms at all - I'm sorry I can't remember exactly what those things were, but how is his ability to do things such as tie shoes, button shirts, throw or kick a ball, do a jumping jack etc? Does he walk fast or slow? Every person with DCD is impacted differently, so it's not possible to make a determination based on comparing behaviors, but fwiw, my ds walked extremely slowly when he was your ds' age. Still does... but otoh so do a lot of teens lol. He had a really tough time learning how to tie his shoes - wasn't able to until he was in 4th grade and then forgot how to after not wearing tie-shoes for a week during spring break.

It is really confusing as symptoms and behaviors overlap between ADHD and DCD, but there are also symptoms that don't - and looking for those can be helpful in figuring out what's really going on. And of course, it's possible to have both - but if you accommodate for the DCD and the ADHD-like symptoms go away, it's much more likely that what you were seeing was DCD.

Did the psych tell you when you'd have her report?

Best wishes,

polarbear

Hi Polarbear - as far as I can recall, the Beery subtests were:

Visual Motor Integration - ~30th percentile
Visual Perception ~90th percentile
Motor Coordination ~30th percentile

Psych said that 25-75 is in the normal range, which is why they don't see a fine motor issue. But it looks like a lot of scatter to me.

For his motor skills, he just does almost everything very slowly (putting on velcro shoes, getting out of the car, putting on his jacket) - he doesn't walk slowly (sometimes runs), but kind of all over the place - ie not in a straight line. He has learned to swim, but it's not very efficient. I can see his swim teachers struggle when trying to teach him different strokes. His ball skills have improved, but he gets frustrated easily when the ball doesn't go where he wants.

He can do buttons, sometimes has a hard time with zippers. I haven't tried teaching him to tie shoes yet. He still hates to use cutlery at the table, but will do if I insist.

Also, the psychologist said that he kept dropping his pencil during testing and had a hard time picking it up - this is very familiar to me! To me it sounds like poor motor planning/coordination - she didn't say he deliberately dropped it, or was throwing it around the room.

ADHD was based on Connor questionnaire scores from myself and DH and DS's teachers, as well as observations by the psychologist and some other test she didn't name which involved moving beads around on a peg-board (but she told me had minimal motor skill involvement).

I agree that some of his behaviours are not DCD-related - he zones out when I talk to him, forgets things, loses things. I'm sure he has EF issues. So, not totally against the idea of ADHD, although DH has concerns about stigma.

It's in what's called "normal" range, but it's also on the very low end of "normal". 25th percentile is a cut-off that's used a lot in US schools as a guideline for SPED eligibility (or at least it's used in our school district). A kid who doesn't quite fall under that bar can still be incredibly challenged. I'm going to try to find my ds' Beery results this weekend if I can - I'm fairly certain he didn't fall below 25th percentile, but he definitely (and obviously) has DCD. I see the Beery as more of a tool to use to understand how a person is impacted rather than determining that they do or don't have a challenge.


Our ds had a lot of those types of issues when he was your ds' age - still has some of those issues in high school. When he was your ds' age he had a mild ADHD diagnosis, but as he matured his neuropsych felt that it wasn't really ADHD and the symptoms that looked like ADHD were due to DCD. Most of what I've read about people's experiences with DCD/dyspraxia indicate that these types of challenges are common with DCD. The tricky thing about DCD is that it can be so different in how it impacts each individual. DS is 16 now, and he attributes his inability to see his lost pencil on the floor next to his shoe completely to his DCD - not flippantly but just as what he thinks it is. As he matured, it started becoming more obvious to me that his organizational challenges were coordination-related.

I really *really* have no problem or worries about an ADHD diagnosis, but I do feel that it's important to understand what the real diagnosis is (or multiple diagnoses), because once you have a diagnosis you typically follow a specific direction in dealing with it. Sometimes that direction overlaps with exactly where you would have gone with the actual diagnosis, sometimes not. ADHD is something that is becoming somewhat common in schools, DCD not so widespread. I wouldn't worry about having an ADHD diagnosis, but I'd worry about what you might miss in terms of missing a DCD diagnosis when it's present. Aside from the practicalities of making appropriate accommodations and remediation where possible, I think that having an appropriate diagnosis early helped my ds tremendously in developing self-confidence and learning how to accept his challenges for what they are - challenges, nothing more. Prior to his diagnosis he struggled tremendously with anxiety and self-confidence.

Sorry for the long ramble - hope some of it helped!

polarbear

Thanks Polarbear - I guess part of what is bugging me is that the psychologists didn't seem to take the DCD seriously. Didn't even mention that often kids have both (which is right on the CanChild website, and would seem to be an argument in favor of their diagnosis), or that there are overlapping symptoms.

Makes me wonder if we've seen the right clinic. However, maybe I just need to be patient and it will all be in the written report.
Also curious what they will recommend as treatment ...