1. Dysgraphia Virginia W. Berninger, University of Washington
Presented to ESD Special Education Co-operative
4/25/17

2. Based on Dr. Berninger’s presentation to ESD 105 (August 9-10, 2016)
All slides and content are Dr. Berninger’s
Materials provided are from Dr. Berninger
Reading material is from the book
Dyslexia, Dysgraphia, OWL LD, and Dyscalculia: Lessons from Science and Teaching, Berninger & Wolf, 2016

3. Todays Goals:
To study deeper Dysgraphia, a sub set of Specific Learning Disabilities
To be introduced to the concept that SLD’s are a brain based hidden disability with roots in physical brain differences
To understand that, while SLD’s are physically based, recent research has studied and developed interventions specific to each sub set that have demonstrated changes in the physical brain response
To understand that with proper identification and intervention, AND ongoing progress monitoring with the appropriately identified assessments, students with such disabilities may grow and be successful in their school careers

4. Differential Diagnosis of Specific Learning Disabilities (SLDs)
Rule out Developmental Disabilities (Pervasive or Specific) in cognitive, language, sensory motor, social emotional, and/or attention executive function domains outside the normal range and/or, other neurogenetic disorders, injuries, toxins or typical language learner. Care about students with those disorders and their families and develop specialized instruction for them but don’t confuse them with SLDs.
Identify a student’s Learning Profile and Associated Working Memory Phenotype Profile in order to define SLDs, which are invisible disabilities inside the brain/mind that affect observable learning.
for Dysgraphia, Dyslexia, Oral and Written
Language Learning Disability (OWL LD), or Dyscalculia.
Compare to developmental , educational, medical, and family
histories

5. Phenotype:
how genetic and environmental influences come together to create an organism's physical appearance and behavior

6. Genotype
The total set of genes contained within an organisms cells. Organisms contain some genes that are expressed (you can consider the "expressed" to mean that the gene is active or being used) and some that are not. Regardless, all the genes an organism has are considered the genotype.

7. Orthography Dictionary.com definition:
1. the art of writing words with the proper letters, according to accepted usage; correct spelling.
2. the part of language study concerned with letters and spelling.
3. a method of spelling, as by the use of an alphabet or other system of symbols; spelling.
4. a system of such symbols Missionaries provided the first orthography of the language.

8. Does research show how to define dysgraphia
Does research show how to define dysgraphia? Are all writing problems dysgraphia?
YES, dysgraphia, which is a Greek word meaning impaired letter writing by hand, exists and can be defined. NO, not all handwriting problems are related to dysgraphia. Handwriting problems are also found in Developmental Motor Disorder. But different treatments are needed for that than for dysgraphia.
Learning Profile for Dysgraphia: Impaired legible and automatic alphabet letter writing (handwriting) ( which may interfere with learning to spell and compose, and legible and accurate numeral writing, which may interfere with written math.
Phenotype Profile for Dysgraphia: Impaired orthographic coding (mind’s eye), sequential finger planning, orthographic loop from letter coding in mind’s eye to sequential finger movements to produce letters, and executive functions for supervisory attention.
Has research shown there a brain basis for dysgraphia? yes

10. Working Memory Phenotype Profiles of 3 SLDs
Common Lower Level Executive Function Problems across all 3 SLDs (Supervisory Attention).
Orthographic Loop= Orthographic Coding of Letters/ Words and Sequential Finger Movements
Phonological Loop=Phonological Coding of Letters /Words and Sequential Mouth Movements
Coding=Storing and Processing Word Forms Syntax Buffer Stores and Processes Accumulating Words.
Morphological and Syntactic Coding and sometimes Word Finding
Phonological and
Orthographic Word Form Coding and
Phonological and Orthographic Loops
Orthographic
Word Form Coding
and Loop
 Dysgraphia (handwriting)
Dyslexia (spelling and
word decoding)
Oral and Written Language Learning
Disability (OWL LD)
(reading comprehension
and written expression)

11. Working Memory Constraints
Capacity Limitations (how much can be stored or processed)
Resource Limitations (what other processes can be accessed)
Timing Limitations (speed or rate or automaticity)
NO ONE WORKING MEMORY TEST CAN ASSESS ALL RELEVANT COMPONENTS IN WORKING MEMORY SYSTEM THAT SUPPORTS LANGUAGE OR MATH LEARNING!

12. Twice Exceptional – Language Strengths May Mask invisible SLD
Probands with dyslexia in waves 4 and 5 of the family genetics study with highest VIQ above 120 (superior) compared to the lowest VIQ 90 t0 99 (average)
Groups did differ significantly in word reading or spelling or morphology or syntax achievement
They did not differ significantly in the components of the verbal working memory (language learning) architecture—phonological and orthographic word storage and processing units, phonological and orthographic loops, or supervisory attention (inhibition, switching, sustaining, monitoring attention)

13. Experiences Can Alter Mediation of Behavioral Expression
Epigenetics (epi—Greek for above)
Changes to genes that do not involve sequencing of 4 base chemicals of DNA but do involve chemical mechanisms (e.g. methylation).
DNA sequencing did not account for whole human genome– much empty space that may account for the computational capability at the nano-level (neurons).
Some genotypes can be expressed differently depending on environmental influences.

14. Why SLDs are Disabilities Yet Responsive to Instruction
SLDs such as dysgraphia, dyslexia, and OWL LD are INVISIBLE DISABILITIES in the MULTI- COMPONENT WORKING MEMORY SYSTEM SUPPORTING LANGUAGE LEARNING.
Genetics research shows there are genetic bases for these, and research that identified the phenotype markers (behavioral expression of the underlying genetic bases) are useful in clinical assessment designed to identify specific SLDs.
However, instructional research has shown that behavioral expression can be modified through appropriate individually tailored instruction! Cutting-edge epi-genetics research is investigating how.
SLDs may be biologically based but there are educational solutions for teaching students with them effectively.

15. Brain Lesson 1--Dysgraphia Handwriting is Not Just a Motor Skill
Children with good handwriting (left) and with poor handwriting (right)
differed in efficiency of using brain resources in learning novel letters.

16. Brain Lesson 1--Dysgraphia Handwriting is Not Just a Motor Skill
Brain Lesson 1--Dysgraphia Handwriting is Not Just a Motor Skill. Handwriting is a Written Language skill.
Children with good handwriting (left) activated more than children with poor handwriting (right) in writing familiar letters only in left fusiform—a region associated with single written letters and letters in written words (written language at subword level)—not in the motor regions of the brain!

17. fMRI BOLD Activation on Contrast between Finger Tapping with and without Sequencing
Robust Differences in BOLD activation between 5th Graders with and without Dysgraphia (next slide)
Behavioral measures in handwriting (alphabet 15 seconds), dictated spelling, and composing correlated significantly with 5 brain regions (in temporal, parietal, and frontal), which may be writing center in brain, during sequential finger tapping.
Gender Differences only in Left Superior Parietal (Often Associated with Working Memory and Preparing Letters for Output), which correlated significantly with automatic legible letter writing on alphabet 15 task—the orthographic loop.
Following computerized handwriting lessons many improve significantly on alphabet 15—orthographic loop—at the behavioral level in recent studies.
Diffusion Tensor Imaging showed that the white matter integrity (related to myelination and structural connections) also changed following computerized handwriting instruction.

18. What Is Handwriting?
Handwriting is partly a motor skill but not only a motor skill
Letter forms stored and processed in working memory (temporary memory that supports language learning and use) also play a role
ORTHOGRAPHIC LOOP from
the MIND’S EYE (where letters and written words are stored and processed in working memory) to
the MOVING HAND/FINGERS

19. Read pages 29-32

20. Teaching Lesson 1--Dysgraphia Teach Handwriting as a Subword Letter Writing Skill
Teach plan for forming letter (numbered arrow cues for each stroke), name letter, close eye and see letter in “mind’s eye”, open eyes and write the letter from memory.
Practice each letter once daily as a warm-up before teaching the other levels of written language close in time (words, sentences, text).
Teach manuscript K to 2 Transfers to reading
Teach cursive grades 3 and 4 Transfers to spelling
Teach touch typing for keyboarding grades 4 or 5 and above
Once children master letter writing, provide weekly or monthly tune ups and have students exchange written work and give peer feedback about letters that are not legible and have writer fix them so they are.

22. Teaching Lesson 3
Use Multi-Modal (sensory and motor) methods to integrate word and sentence (language) skills with input and output during instruction: Name visual symbols (phonological loop) and Write visual symbols, Look at and Touch visual symbols Store Heard and Viewed Language Input (Ears and Eyes) in Working Memory (Mind’s Eye) Retrieve and Produce Stored or Recent Input in Writing Output (orthographic loop)

23. Teaching Lesson 4: Teach Strategies for Paying Attention To, Engaging In, and Self-Regulating Language Learning across the Multiple, Multi-Leveled Language Systems that interact with sensory and motor systems and cognitive, social emotional, and attention /executive function systems UW LD Center for OWLs copyrighted V. W. Berninger 2011
COGNITIONS SS
Language By Mouth:
Subword
Spoken Words
Multi-Word
Text--Multi-Utterances
Language By Hand:
Written Words
Mutli-Word
Text--Multi Sentences
Language By Eye:
Viewed Words
Text--Multi-Sentencess
Language By Ear :
Heard Words

24. Teaching to All Levels of Language Close in Time for Reading and Writing see Teaching Lesson 4 and Slide 63 T
each in a way to help students make connections
Across levels of language (subword, word, multi-word sentences, multi-sentence text)
Across language by ear (listening), by mouth (oral expression), by eye (reading), and by hand (writing)
Across language and thinking and self-regulating
Across social emotional and motivational functions

25. Specialized, Evidence-Based Instruction for Working Memory Architecture
Note: To overcome working memory problems teach
procedural knowledge: point to/touch letters, name letters and words and say corresponding phoneme close in time, that is, exercise the phonological loop, or write letters than correspond to sounds or name, that is, exercise the orthographic loop, rather than parrot declarative knowledge (e.g., phonics rules), but teach for transfer of procedural knowledge to words and text;
teach to all levels of language close in time;
avoid habituation by not doing the same activity for a long time— vary activities; and
teach reflection (linguistic awareness).

26. Research Lessons on Computerized Instruction
Don’t just use computers for accommodations—also use for explicit instruction in writing at all levels of language close it time.
Teach Touch Typing
SLDs in writing, reading, and oral language are treatable!

27. Handouts Writing lesson 1, Set 3, Tier 1
Source: PAL Handwriting lessons

28. Interventions for Dysgraphia

29. Teach Orthographic Coding and Loop
Skills Explicitly to Develop Handwriting
Orthographic
phonological
ORTHOGRAPHIC
LOOP, Executive
Functions and Finger
Sequencing
morphological
Specialized Instruction for Dysgraphia in White

30. Read Pages 33-37

31. Different Kinds of Handwriting Problems Require Different Kinds of Treatment
Those who do have developmental motor disorder have handwriting problems for other reasons, do qualify for OT services, and require treatment specialized for specific motor problems or developmental motor problems that occur alone (SDD in motor domain) or with other disorders such as PDD due to neurogenetic or acquired disorders.
Typically those with dysgraphia do not qualify for occupational therapy services and need special written language instruction from a teacher. Recall recent brain imaging showing DTI changes following specialized handwriting instruction.

32. Instruction for Dysgraphia PAL Reading and Writing Lessons Set 3 based on Berninger et al. 1997
Teach plan for letter formation (study numbered component strokes in model letter form) --overcomes sequential finger movement problem.
Cover letter and hold letter form in working memory (mind’s eye) for increasing duration.
Write letter from memory and compare to model. Revise if necessary.
Evaluate if letter is legible (recognizable by others) and automatic (requiring minimal working memory resources)

33. Instruction for Dysgraphia continued
Only practice each of 26 letters once in session “writers’ warm-up (avoid habituation, all letters equal opportunity to become automatic).
Always name letter at each stage (study, cover, see in mind’s eye in memory, write from memory, and compare to model)—facilitates retrieval fluency.
Always teach for transfer—follow letter writing practice with composing on a teacher-provided prompt and share writing with peers (communication of ideas).

34. Instruction for Dysgraphia continued
Teach for Letter Retrieval from long-term memory (Writing letters that come after and before other letters—transfers to longer compositions).
Teach self-monitoring and other-monitoring of letter legibility (recognizable out of word context) in written compositions.

35. Instruction for Dysgraphia (Berninger, Rutberg et al
Instruction for Dysgraphia (Berninger, Rutberg et al. 2006, Berninger, Winn et al. 2008)
Teach letter writing—do not just use keyboards as accommodation. Research showed that in grade 2 to 6 writing by pen results in longer texts, faster writing, and more idea expression than writing by keyboard.
Teach keyboarding explicitly (touch typing—look at monitor not the keys as in hunting and pecking) and how to use word processor for generating and revising texts before expecting students to use word processor for writing assignments.

36. Read pages 38-40

37. Monitoring Response to Instruction Letter Writing (by hand)
PAL2 Alphabet Writing*: Print the letters of the alphabet in order as accurately and quickly as you can without making a mistake. Use manuscript not cursive writing.
PAL2 Copy A*: Copy sentence with all the letters in the alphabet from a model (no memory requirements). Also DASH Copy Fast and Best
PAL2 Copy B: Copy paragraph—sustain handwriting over time in three 30 second intervals.
Independent Composing: PAL II
Scores: *Automatic legible letter writing (first 15 seconds)
Legible letter writing.
Legible letter writing speed (total time)

38. Review pages 40-51 Moving forward. . . . . Whole group discussion
What can be done immediately with this information?
Moving forward
How could this work be used within our region?
Would you be interested in studying this further next year?
How might we create a “study” of our own?