Journal of Autism and Developmental Disorders

, Volume 41, Issue 12, pp 1706–1716 | Cite as

Handwriting Difficulties in Children with Autism Spectrum Disorders: A Scoping Review

  • Azadeh Kushki
  • Tom Chau
  • Evdokia Anagnostou
Original Paper


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.


Handwriting Autism Fine motor control Visual perception Visual-motor integration Kinesthesia 



This work is support by the Ontario Ministry of Research and Innovation, Canada Research Chairs Program, and the Holland Bloorview Kids Rehabilitation Hospital Foundation.


  1. Amundson, S. (1995). Evaluation tool of children’s handwriting. Homer, AK: OT Kids.Google Scholar
  2. Amundson, S., & Weil, M. (1996). Prewriting and handwriting skills. In J. Case-Smith, A. Allen, & P. Pratt (Eds.), Occupational therapy for children (pp. 524–541). St Louis, MO: Mosby.Google Scholar
  3. Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19–32.CrossRefGoogle Scholar
  4. Ayres, A. (1989). Sensory integration and praxis tests (SIPT). Los Angeles: Western Psychological Services.Google Scholar
  5. Beery, K., & Buktenica, N. (1989). Developmental test of visual motor integration. Cleveland: Modern Curriculum Press.Google Scholar
  6. Beversdorf, D., Anderson, J., Manning, S., Anderson, S., Nordgren, R., Felopulos, G., et al. (2001). Brief report: Macrographia in high-functioning adults with autism spectrum disorder. Journal of Autism and Developmental Disorders, 31(1), 97–101.PubMedCrossRefGoogle Scholar
  7. Bishop, D. (1994). Annotation: Autism, executive functions, and theory of mind: A neuropsychological perspective. Annual Progress in Child Psychiatry and Child Development (pp. 359–376).Google Scholar
  8. Cahill, S. (2009). Where Does Handwriting Fit in? Strategies to Support Academic Achievement. Intervention in School and Clinic, 44(4), 223–229.CrossRefGoogle Scholar
  9. Cartmill, L., Boccthy, M., Rodger, S., & Medst, B. (2009). Handwriting of eight-year-old children with autistic spectrum disorder: An exploration. Journal of Occupational Therapy, Schools & Early Intervention, 2(2), 103–118.CrossRefGoogle Scholar
  10. Chang, S., & Yu, N. (2009). Characterization of motor control in handwriting difficulties in children with or without developmental coordination disorder. Developmental Medicine and Child Neurology, 52(3), 244–250.CrossRefGoogle Scholar
  11. Chau, T., Ji, J., Tam, C., & Schwellnus, H. (2006). A novel instrument for quantifying grip activity during handwriting. Archives of Physical Medicine and Rehabilitation, 87(11), 1542–1547.PubMedCrossRefGoogle Scholar
  12. Cornhill, H., & Case-Smith, J. (1996). Factors that relate to good and poor Handwriting. American Journal of Occupational Therapy, 50, 732–739.PubMedGoogle Scholar
  13. Dakin, S., & Frith, U. (2005). Vagaries of visual perception in autism. Neuron, 48(3), 497–507.PubMedCrossRefGoogle Scholar
  14. Daly, C., Kelley, G., & Krauss, A. (2003). Relationship between visual-motor integration and handwriting skills of children in kindergarten: A modified replication study. American Journal of Occupational Therapy, 57(4), 459–462.PubMedCrossRefGoogle Scholar
  15. David, F., Baranek, G., Giuliani, C., Mercer, V., Poe, M., & Thorpe, D. (2009). A pilot study: Coordination of precision grip in children and adolescents with high functioning Autism. Pediatric Physical Therapy, 21(2), 205–211.PubMedCrossRefGoogle Scholar
  16. Denckla, M. (1974). Development of motor co-ordination in normal children. Developmental Medicine and Child Neurology, 16(6), 729–741.PubMedCrossRefGoogle Scholar
  17. Dowell, L., Mahone, E., & Mostofsky, S. (2009). Associations of postural knowledge and basic motor skill with dyspraxia in autism: Implication for abnormalities in distributed connectivity and motor learning. Neuropsychology, 23(5), 563–570.PubMedCrossRefGoogle Scholar
  18. Dziuk, M., Larson, J., Apostu, A., Mahone, E., Denckla, M., & Mostofsky, S. (2007). Dyspraxia in autism: Association with motor, social, and communicative deficits. Developmental Medicine and Child Neurology, 49(10), 734–739.PubMedCrossRefGoogle Scholar
  19. Exner, C. (2001). Development of hand skills. In J. Case-Smith, A. Allen, & P. Pratt (Eds.), Occupational therapy for children (pp. 289–328).Google Scholar
  20. Feder, K., & Majnemer, A. (2003). Children’s handwriting evaluation tools and their psychometric properties. Physical & Occupational Therapy in Pediatrics, 23(3), 65–84.CrossRefGoogle Scholar
  21. Feder, K., & Majnemer, A. (2007). Handwriting development, competency, and intervention. Developmental Medicine and Child Neurology, 49(4), 312–317.PubMedCrossRefGoogle Scholar
  22. Feder, K., Majnemer, A., & Synnes, A. (2000). Handwriting: Current trends in occupational therapy practice. Canadian journal of occupational therapy. Revue canadienne d’ergothérapie, 67(3), 197–204.PubMedGoogle Scholar
  23. Frith, U. (1991). Autistic psychopathy. In U. Frith (Ed.), Autism and Asperger syndrome (U. Frith, Trans. and Annotated) (pp. 37–92).Google Scholar
  24. Fuentes, C., Mostofsky, S., & Bastian, A. (2009). Children with autism show specific handwriting impairments. Neurology, 73(19), 1532–1537.PubMedCrossRefGoogle Scholar
  25. Fuentes, C., Mostofsky, S., & Bastian, A. (2010). Perceptual reasoning predicts handwriting impairments in adolescents with autism. Neurology, 75(20), 1825.PubMedCrossRefGoogle Scholar
  26. Gardner, M. F. (1996). Test of visual perceptual skills (non-motor)Revised (TVPS-R): Manual. Novato, CA: Academic Therapy Publications.Google Scholar
  27. Ghaziuddin, M., & Butler, E. (1998). Clumsiness in autism and Asperger syndrome: A further report. Journal of Intellectual Disability Research, 42(1), 43–48.PubMedCrossRefGoogle Scholar
  28. Ghaziuddin, M., & Mountain-Kimchi, K. (2004). Defining the intellectual profile of Asperger Syndrome: Comparison with high-functioning autism. Journal of Autism and Developmental Disorders, 34(3), 279–284.PubMedCrossRefGoogle Scholar
  29. Gibbs, J., Appleton, J., & Appleton, R. (2007). Dyspraxia or developmental coordination disorder? Unravelling the enigma. Archives of Disease in Childhood, 92(6), 534–539.PubMedCrossRefGoogle Scholar
  30. Gilliam, J. (1995). Gilliam autism rating scale. Taskmaster Ltd.Google Scholar
  31. Glazebrook, C., Elliott, D., & Szatmari, P. (2008). How do individuals with autism plan their movements? Journal of Autism and Developmental Disorders, 38(1), 114–126.PubMedCrossRefGoogle Scholar
  32. Glazebrook, C., Gonzalez, D., Hansen, S., & Elliott, D. (2009). The role of vision for online control of manual aiming movements in persons with autism spectrum disorders. Autism, 13(4), 411–433.PubMedCrossRefGoogle Scholar
  33. Graham, S. (1999). The role of text production skills in writing development: A special issue: I. Learning Disability Quarterly, 22(2), 75–77.CrossRefGoogle Scholar
  34. Graham, S., Berninger, V., Abbott, R., Abbott, S., & Whitaker, D. (1997). Role of mechanics in composing of elementary school students: A new methodological approach. Journal of Educational Psychology, 89(1), 170–182.CrossRefGoogle Scholar
  35. Graham, S., Harris, K., & Fink, B. (2000). Is handwriting causally related to learning to write? Treatment of handwriting problems in beginning writers. Journal of Educational Psychology, 92(4), 620–633.CrossRefGoogle Scholar
  36. Graham, S., & Weintraub, N. (1996). A review of handwriting research: Progress and prospects from 1980 to 1994. Educational Psychology Review, 8(1), 7–87.CrossRefGoogle Scholar
  37. Green, D., Baird, G., Barnett, A., Henderson, L., Huber, J., & Henderson, S. (2002). The severity and nature of motor impairment in Asperger’s syndrome: A comparison with specific developmental disorder of motor function. Journal of Child Psychology and Psychiatry, 43(5), 655–668.PubMedCrossRefGoogle Scholar
  38. Green, D., Charman, T., Pickles, A., Chandler, S., Loucas, T., Simonoff, E., et al. (2009). Impairment in movement skills of children with autistic spectrum disorders. Developmental Medicine and Child Neurology, 51, 311–316.PubMedCrossRefGoogle Scholar
  39. Hamstra-Bletz, L., & Blote, A. (1993). A longitudinal study on dysgraphic handwriting in primary school. Journal of Learning Disabilities, 26(10), 689–699.PubMedCrossRefGoogle Scholar
  40. Happé, F., & Frith, U. (2006). The weak coherence account: Detail-focused cognitive style in autism spectrum disorders. Journal of Autism and Developmental Disorders, 36(1), 5–25.PubMedCrossRefGoogle Scholar
  41. Hardan, A., Kilpatrick, M., Keshavan, M., & Minshew, N. (2003). Motor performance and anatomic magnetic resonance imaging (MRI) of the basal ganglia in autism. Journal of Child Neurology, 18(5), 317–324.PubMedCrossRefGoogle Scholar
  42. Harvey, C., & Henderson, S. (1997). Childrens handwriting in the first three years of school: Consistency over time and its relationship to academic achievement. Handwriting Review, 11, 8–25.Google Scholar
  43. Haswell, C., Izawa, J., Dowell, L., Mostofsky, S., & Shadmehr, R. (2009). Representation of internal models of action in the autistic brain. Nature Neuroscience, 12(8), 970–972.PubMedCrossRefGoogle Scholar
  44. Henderson, S., & Green, D. (2001). Handwriting problems in children with asperger syndrome. Handwriting Today, 2, 65–79.Google Scholar
  45. Hughes, C. (1996). Brief report: Planning problems in autism at the level of motor control. Journal of Autism and Developmental Disorders, 26(1), 99–107.PubMedCrossRefGoogle Scholar
  46. Jansiewicz, E., Goldberg, M., Newschaffer, C., Denckla, M., Landa, R., & Mostofsky, S. (2006). Motor signs distinguish children with high functioning autism and Aspergers syndrome from controls. Journal of Autism and Developmental Disorders, 36(5), 613–621.PubMedCrossRefGoogle Scholar
  47. Jones, D., & Christensen, C. (1999). Relationship between automaticity in handwriting and students’ ability to generate written text. Journal of Educational Psychology, 91(1), 44–49.CrossRefGoogle Scholar
  48. Jongmans, M., Linthorst-Bakker, E., Westenberg, Y., & Smits-Engelsman, B. (2003). Use of a task-oriented self-instruction method to support children in primary school with poor handwriting quality and speed. Human Movement Science, 22(4–5), 549–566.PubMedCrossRefGoogle Scholar
  49. Larsen, S., & Hammill, D. (1989). Test of legible handwriting.Google Scholar
  50. Laszlo, J., & Bairstow, P. (1984). Handwriting: Difficulties and possible solutions. School Psychology International, 5(4), 207–213.CrossRefGoogle Scholar
  51. Levine, M. (1987). Developmental variation and learning disorders. Cambridge, MA: Educators Pub Service.Google Scholar
  52. Lord, C., Cook, E., Leventhal, B., & Amaral, D. (2000). Autism spectrum disorders. Neuron, 28(2), 355–363.PubMedCrossRefGoogle Scholar
  53. Lord, C., Rutter, M., & Couteur, A. (1994). Autism diagnostic interview-revised: A revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. Journal of Autism and Developmental Disorders, 24(5), 659–685.PubMedCrossRefGoogle Scholar
  54. Malloy-Miller, T. (1995). Handwriting error patterns of children with mild motor difficulties. Canadian Journal of Occupational Therapy, 62(5), 258–267.Google Scholar
  55. Masterton, B., & Biederman, G. (1983). Proprioceptive versus visual control in autistic children. Journal of Autism and Developmental Disorders, 13(2), 141–152.PubMedCrossRefGoogle Scholar
  56. Maurer, R., & Damasio, A. (1982). Childhood autism from the point of view of behavioral neurology. Journal of Autism and Developmental Disorders, 12(2), 195–205.PubMedCrossRefGoogle Scholar
  57. Mayes, S., & Calhoun, S. (2003a). Ability profiles in children with autism: Influence of age and IQ. Autism, 7(1), 65–80.PubMedCrossRefGoogle Scholar
  58. Mayes, S., & Calhoun, S. (2003b). Analysis of WISC-III, Stanford-Binet: IV, and academic achievement test scores in children with autism. Journal of Autism and Developmental Disorders, 33(3), 329–341.PubMedCrossRefGoogle Scholar
  59. Mayes, S., & Calhoun, S. (2006). Frequency of reading, math, and writing disabilities in children with clinical disorders. Learning and Individual Differences, 16(2), 145–157.CrossRefGoogle Scholar
  60. Mayes, S., & Calhoun, S. (2007). Learning, attention, writing, and processing speed in typical children and children with ADHD, autism, anxiety, depression, and oppositional-defiant disorder. Child Neuropsychology (Neuropsychology, Development and Cognition: Section C), 13(6), 469–493.Google Scholar
  61. Mayes, S., & Calhoun, S. (2008). WISC-IV and WIAT-II profiles in children with high-functioning autism. Journal of Autism and Developmental Disorders, 38(3), 428–439.PubMedCrossRefGoogle Scholar
  62. Miller, L., Missiuna, C., Macnab, J., Malloy-Miller, T., & Polatajko, H. (2001). Clinical description of children with developmental coordination disorder. Canadian Journal of Occupational Therapy. Revue canadienne d’ergothérapie, 68(1), 5–15.PubMedGoogle Scholar
  63. Ming, X., Brimacombe, M., & Wagner, G. (2007). Prevalence of motor impairment in autism spectrum disorders. Brain and Development, 29(9), 565–570.PubMedCrossRefGoogle Scholar
  64. Minshew, N., Goldstein, G., & Siegel, D. (1997). Neuropsychologic functioning in autism: Profile of a complex information processing disorder. Journal of the International Neuropsychological Society, 3(04), 303–316.PubMedGoogle Scholar
  65. Mostofsky, S., Dubey, P., Jerath, V., Jansiewicz, E., Goldberg, M., & Denckla, M. (2006). Developmental dyspraxia is not limited to imitation in children with autism spectrum disorders. Journal of the International Neuropsychological Society, 12(03), 314–326.PubMedCrossRefGoogle Scholar
  66. Mottron, L., Dawson, M., Soulieres, I., Hubert, B., & Burack, J. (2006). Enhanced perceptual functioning in autism: An update, and eight principles of autistic perception. Journal of Autism and Developmental Disorders, 36(1), 27–43.PubMedCrossRefGoogle Scholar
  67. Myles, B., Huggins, A., Rome-Lake, M., Hagiwara, T., Barnhill, G., & Griswold, D. (2003). Written Language Profile of Children and Youth with Asperger Syndrome: From Research to Practice. Education and Training in Developmental Disabilities, 38(4), 362–369.Google Scholar
  68. Noterdaeme, M., Mildenberger, K., Minow, F., & Amorosa, H. (2002). Evaluation of neuromotor deficits in children with autism and children with a specific speech and language disorder. European Child and Adolescent Psychiatry, 11(5), 219–225.PubMedCrossRefGoogle Scholar
  69. Ozonoff, S., Pennington, B., & Rogers, S. (1991). Executive function deficits in high-functioning autistic individuals: Relationship to theory of mind. Journal of Child Psychology and Psychiatry, 32(7), 1081–1105.PubMedCrossRefGoogle Scholar
  70. Racine, M., Majnemer, A., Shevell, M., & Snider, L. (2008). Handwriting performance in children with attention deficit hyperactivity disorder (ADHD). Journal of Child Neurology, 23(4), 399–406.PubMedCrossRefGoogle Scholar
  71. Reisman, J. (1993). Development and reliability of the research version of the Minnesota Handwriting Test. Physical & Occupational Therapy in Pediatrics, 13(2), 41–55.CrossRefGoogle Scholar
  72. Rinehart, N., Bellgrove, M., Tonge, B., Brereton, A., Howells-Rankin, D., & Bradshaw, J. (2006). An examination of movement kinematics in young people with high-functioning autism and Aspergers disorder: Further evidence for a motor planning deficit. Journal of Autism and Developmental Disorders, 36(6), 757–767.PubMedCrossRefGoogle Scholar
  73. Rinehart, N., Bradshaw, J., Brereton, A., & Tonge, B. (2001). Movement preparation in high-functioning autism and Asperger disorder: A serial choice reaction time task involving motor reprogramming. Journal of Autism and Developmental Disorders, 31(1), 79–88.PubMedCrossRefGoogle Scholar
  74. Rosenblum, S., Epsztein, L., & Josman, N. (2008). Handwriting performance of children with attention deficit hyperactive disorders: A pilot study. Physical & Occupational Therapy in Pediatrics, 28(3), 219–234.CrossRefGoogle Scholar
  75. Rosenblum, S., & Livneh-Zirinski, M. (2008). Handwriting process and product characteristics of children diagnosed with developmental coordination disorder. Human Movement Science, 27(2), 200–214.PubMedCrossRefGoogle Scholar
  76. Rosenblum, S., Weiss, P., & Parush, S. (2003). Product and process evaluation of handwriting difficulties. Educational Psychology Review, 15(1), 41–81.CrossRefGoogle Scholar
  77. Rumsey, J., & Hamburger, S. (1990). Neuropsychological divergence of high-level autism and severe dyslexia. Journal of Autism and Developmental Disorders, 20(2), 155–168.PubMedCrossRefGoogle Scholar
  78. Sassoon, R. (1997). Dealing with adult handwriting problems. Handwriting Review, 11, 69–74.Google Scholar
  79. Schmitz, C., Martineau, J., Barthélémy, C., & Assaiante, C. (2003). Motor control and children with autism: Deficit of anticipatory function? Neuroscience Letters, 348(1), 17–20.PubMedCrossRefGoogle Scholar
  80. Siegel, D., Minshew, N., & Goldstein, G. (1996). Wechsler IQ profiles in diagnosis of high-functioning autism. Journal of Autism and Developmental Disorders, 26(4), 389–406.PubMedCrossRefGoogle Scholar
  81. Smits-Engelsman, B., & Van Galen, G. (1997). Dysgraphia in children: Lasting psychomotor deficiency or transient developmental delay? Journal of Experimental Child Psychology, 67(2), 164–184.PubMedCrossRefGoogle Scholar
  82. Smyth, M. (1989). Visual control of movement patterns and the grammar of action. Acta Psychologica, 70(3), 253–265.PubMedCrossRefGoogle Scholar
  83. Smyth, M., & Silvers, G. (1987). Functions of vision in the control of handwriting. Acta Psychologica, 65(1), 47–64.CrossRefGoogle Scholar
  84. Szatmari, P., Tuff, L., et al. (1990). Asperger’s syndrome and autism: Neurocognitive aspects. Journal of American Academy of Child & Adolescent Psychiatry, 29(1), 709–720.CrossRefGoogle Scholar
  85. Tseng, M., & Cermak, S. (1993). The influence of ergonomic factors and perceptual-motor abilities on handwriting performance. American Journal of Occupational Therapy, 47(10), 919–926.PubMedGoogle Scholar
  86. Tseng, M., & Chow, S. (2000). Perceptual-motor function of school-age children with slow handwriting speed. American Journal of Occupational Therapy, 54(1), 83–88.PubMedCrossRefGoogle Scholar
  87. Tseng, M., & Murray, E. (1994). Differences in perceptual-motor measures in children with good and poor handwriting. Occupational Therapy Journal of Research, 14(1), 19–36.Google Scholar
  88. van Doorn, R., & Keuss, P. (1992). The role of vision in the temporal and spatial control of handwriting. Acta Psychologica, 81(3), 269–286.PubMedCrossRefGoogle Scholar
  89. Van Galen, G., Portier, S., Smits-Engelsman, B., & Schomaker, L. (1993). Neuromotor noise and poor handwriting in children. Acta Psychologica, 82(1–3), 161–178.PubMedCrossRefGoogle Scholar
  90. Volman, M., Van Schendel, B., & Jongmans, M. (2006). Handwriting difficulties in primary school children: A search for underlying mechanisms. The American Journal of Occupational Therapy, 60(4), 451–460.PubMedCrossRefGoogle Scholar
  91. Wann, J., & Jones, J. (1986). Space-time invariance in handwriting: Contrasts between primary school children displaying advanced or retarded handwriting acquisition. Human Movement Science, 5(3), 275–296.CrossRefGoogle Scholar
  92. Wechsler, D. (1974). Manual for the Wechsler intelligence scale for children. New York: The Psychological Corporation.Google Scholar
  93. Wechsler, D. (1999). Wechsler abbreviated scale of intelligence. Psychological Corp.Google Scholar
  94. Weintraub, N., & Graham, S. (2000). The contribution of gender, orthographic, finger function, and visual-motor processes to the prediction of handwriting status. Occupational Therapy Journal of Research, 20(2), 121–140.Google Scholar
  95. Ziviani, J., & Elkins, J. (1986). Effect of pencil grip on handwriting speed and legibility. Educational Review, 38(3), 247–257.CrossRefGoogle Scholar
  96. Ziviani, J., & Wallen, M. (2006). The development of graphomotor skills. In A. Henderson & C. Pehoski (Eds.), Hand function in the child: Foundations for remediation (pp. 217–236). St. Louis: Mosby.CrossRefGoogle Scholar

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© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Bloorview Research InstituteHolland Bloorview Kids Rehabilitation HospitalTorontoCanada

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