One of the roles of a speech-language pathologist is to help adults regain the ability to write after some type of brain injury. This article shares the results of a recent systematic review (Biddau et al. 2023), along with specific details on how to administer the different treatment protocols.
Free DIRECT downloads: Helping adults regain the ability to write (cheat sheet), CART worksheet 5 words per page and CART worksheet larger spaces. (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- What is an acquired writing impairment?
- About the systematic review on acquired central dysgraphia.
- Lexical writing treatments.
- Phonological treatment.
- Interactive treatment.
- Clinical considerations.
- Limitations of the systematic review.
- Related Eat, Speak, & Think posts.
- Key references.
What is an acquired writing impairment?
An “acquired” writing impairment means someone has learned how to write, but then loses the ability due to some type of injury or illness. This article focuses on writing impairments that may be caused by a head injury, stroke, a tumor, an infection, or a neurodegenerative disease. An adult who acquires a writing disorder usually will have difficulty with other areas of language, as well.
The acquired writing disorder may be labeled “agraphia” or “dysgraphia.” Agraphia is the inability to write, while dysgraphia is difficulty writing. Check out the NIH’s StatPearls article on this distinction.
Types of writing impairments
Here are some of the different types of dysgraphia that a person may experience, according to Biddau et al. (2023):
- Surface dysgraphia (left parietal lobe) – generally able to spell regular words and nonwords, but difficulty spelling irregular words.
- Phonological dysgraphia (left perisylvian cortical area) – difficulty writing non-words and unfamiliar words.
- Deep dysgraphia (supramarginal gyrus and the insula) – difficulty writing nonwords, unfamiliar words, and abstract words. May see semantic paragraphias (ex. writing “table” instead of “chair”).
- Graphemic buffer disorders (left parietal cortex) – difficulty with working memory during writing. Able to write short words better than longer words.
- Peripheral dysgraphia (left temporo-parieto-occipital cortex) – difficulty in “selecting the appropriate motor sequences to write letters”
According to Beeson & Rapcsak (2002), there are clinical reasons to focus on writing (or at least to include writing therapy in the plan of care). They argue that writing may be easier to recover than verbal speech, and writing can also serve as an effective compensatory strategy for verbal communication.
About the systematic review on acquired central dysgraphia
This article focuses on Biddau and colleague’s 2023 systematic review titled “Speech and Language Therapy for Acquired Central Dysgraphia in Neurological Patients: A Systematic Review to Describe and Identify Trainings for Clinical Practice.”
Biddau et al. (2023) included 11 studies with 43 patients (two patients participated in two unrelated studies). The systematic review excludes peripheral dysgraphias, which are writing impairments that include a motor or visual-spatial component.
The eleven studies were single-subject multiple-baseline design, two of which had a cross-over design. The studies were published in English, took place in the UK or the US, and were published between 2002 and 2019.
Eight studies used lexical writing treatments, one used a phonological treatment, and two studies looked at interactive treatments. The interactive treatments combined lexical and phonological exercises and trained problem-solving strategies, using an electronic speller. One of these studies included multiple oral reading.
While all of the studies reported improvements, greater success was reported for more patients undergoing lexical treatments than for the others. Biddau et al. (2023) identified the lexical treatments as being more widely used, seem to bring greater improvement, and are more flexible in clinical practice. In addition, the lexical treatments showed greater generalization and maintenance of effects.
Lexical writing treatments
The systematic review covers three lexical treatments, which were used in eight of 11 research articles. Nearly all participants showed improvement across the eight studies (33 out of 35). The treatment protocols were:
- Copy and Recall Treatment (CART).
- Spell-study-spell treatment.
- Oral repetition + CART.
Biddau et al. (2023) also report on intervention variations regarding:
- Errorful versus errorless teaching approaches.
- Unimodal versus multimodal intervention.
In general, participants showed improvement in spelling of trained words and some showed significant improvement in spelling of untrained words. I’ll go into more detail under the relevant section below, but read the systematic review for a full description.
As an aside, I’m aware of two other lexical treatments which weren’t included in the review. Perhaps the relevant research articles were considered but didn’t meet some criterion. The other two treatments are ACT (anagram and copy therapy) and ACRT (anagram, copy, and recall treatment), which is identified as a combination of ACT and CART. You can read a comparison of ACT and CART.
Copy and Recall Treatment (CART)
Two of the studies on Copy and Recall Treatment (CART) that were included in the systematic review were Beeson et al. (2003) and Clausen & Beeson (2003). Raymor et al. (2010) used a variation of CART. Not all of the CART studies looked at generalization.
- Identify a set of 5 meaningful words.
- Each word is to be copied at least 20 times a day, 6 days a week.
- Following the copying task, the patient completes a self-test for recall of the practiced words.
- A set is “mastered” when the patient can write at least 4 words across two consecutive sessions. Mastered words are still included in the daily practice.
- Choose a new set of 5 words.
Beeson et al. (2003) added additional semantic training or additional treatment sessions, as needed.
Spell-study-spell treatment
Rapp (2005) and Rapp & Kane (2002) reported on a spell-study-spell treatment protocol. All the participants showed improvement in spelling trained words. Only those participants with a deficit in the graphemic buffer showed generalization to untrained words.
Here is the general procedure, from the systematic review:
- Create 3 lists of words, 30 words per list. The lists are the “treated” words, the “repeated” words, and the “control” list.
- Treated list: Use at each session. Say the word. Your patient repeats it, then tries to spell it. If they are incorrect, show them the printed word and spell it aloud. Your patient studies it for as long as they like. Have them spell it again after a delay.
- Repeated list: Use for a spell-to-dictation task, conducted at each session.
- Control list: Only use for initial and final sessions. (In clinical practice, may omit this.)
Oral repetition + CART
Beeson & Egnor (2006) report on a protocol that combined an oral repetition task with CART. Their participants showed substantial improvement on naming and writing trained words, without generalization to untrained words. They also found significant improvement in speech in two patients (anomic and conduction aphasias).
Instead of describing their procedure, I’m presenting how I would modify it for clinical use. Be sure to select useful words for each individual patient!
- Select 10 – 20 meaningful words that your patient has trouble naming verbally and in writing.
- In the study, they used proper and common nouns. I would consider including verbs.
- Since only trained words are likely to improve, I would include any picturable word they want to re-learn.
- Each session: probe all 10 – 20 words, review the homework, then target 5 – 10 words for treatment.
- Probe all 10-20 words: Show a picture for each word, ask your patient to orally name it and then write it.
- Training part 1: Select 5 – 10 words for each session. Repeat this process 3 times per word.
- Show a picture for each word, ask your patient to orally name it and then write it.
- If using a device for the home exercise program (below), have your patient play that word, then repeat the model and try to write it again. If your patient can’t say the word, facilitate their production as needed. If they’re unable to write the word, point out the errors, then have them copy the correct word several times.
- Training part 2: Try to write each word from memory. Repeat 3 times per word.
- Ask your patient to verbally name each word in the list, then find it on their device, play the recording, and repeat it again.
- Next they will attempt to write the word without a written model if they correctly wrote the word earlier during the recall task, otherwise provide a model for them to copy.
- Daily home exercise program: 30-60 minutes. Provide a worksheet with spaces for 20 copies plus a self-test.
- The study used an AAC device to present the participant with a picture and spoken label. If our patient has a smartphone or tablet, we could potentially make short video clips or use an AAC app to do something similar.
- If we use a device, the therapy protocol trains them to do the home exercise program.
Variations in lexical treatments
As mentioned above, a few of the studies investigated intervention variations. Two studies compared errorless versus errorful teaching methods. Both approaches resulted in significant improvements in the 8 participants. One study suggested a possible advantage of errorful teaching, while the other didn’t find a significant difference.
A third study compared unimodal versus multimodal intervention. “Unimodal” therapy asked the participant to copy a word, then write it from memory and then proceed to the next word. The “multimodal” treatment required the participant to perform semantic, phonological, and orthographic tasks before saying the word and copying the word. All 8 participants in the study showed improvement. The authors didn’t find a significant difference between the two treatments.
Phonological treatment
Kiran (2005) reported that two out of three participants improved in almost all measures for treated and untreated words. The tasks were writing to dictation and written naming tasks. In addition, two out of three participants showed improvement in some oral spelling words that were trained. One participant did not significantly improve. They modified the protocol twice for one participant, and the third patient developed health issues and dropped out. Of three participants, only one achieved criterion.
Refer to Kiran (2005) for full details. I’m presenting a slight modification for clinical use.
- Select 10 picturable words that your patient can’t write, spell, or name. Print in 18 pt font on individual cards. Print a color picture for each word.
- Treatment: Present each word orally and ask the patient to write it. If correct, go on to the next word. If incorrect, follow these training steps:
- Have your patient copy the word and read it aloud.
- Present the letter tiles + an equal number of distractor tiles (see below). Ask them to select the letters and write the sounds of each letter in the correct sequence. Example “cup”: pick the ‘c’, ‘u’, ‘p’ tiles and write ‘kuh’, ‘uh’ ‘puh’. Assist as needed.
- Present each sound from the target word in random order. After hearing each sound, have your patient write the associated letter. Example: you make the ‘buh’ sound and your patient writes ‘b’. Assist as needed.
- Rearrange the letter tiles with the distractors and have them write the word.
- Say the word again and ask your patient to write it.
- Use pre-made letter tiles or make your own using card stock or index cards.
- Can provide the written alphabet for your patient to refer to.
Interactive treatment
Beeson et al. (2010) and Kim et al. (2015) report on a total of five participants who participated in interactive treatment protocols. The interactive treatments included training participants to use an electronic spell checker. Kim et al. (2015) used the Franklin Speaking Language Master* but stated that any similar device would suffice. If your patient isn’t able to use their smart phone or a voice assistant to check spelling, another option may be Webster’s Spelling Corrector*. Participants improved on spelling both trained and untrained words.
*This is an Amazon affiliate link. As an Amazon associate, I may earn a small commission on qualifying purchases. There is no extra charge to you, and it will help keep Eat, Speak, & Think sustainable.
Training grapheme-phoneme correspondence + electronic speller
Refer to Beeson et al. (2010) for more detail of their protocol. The study included 2 participants. Both of their participants improved spelling untrained regular and irregular words when using an electronic speller. One participant also improved without using the device.
Here is a description according to Biddau et al. (2023):
- Use a cueing hierarchy to train the grapheme-phoneme correspondence for 20 consonants and 12 vowels.
- Train the spelling of sets of 20 regular words and 20 nonwords, presented verbally.
- Use an electronic aid to check and correctly spell words.
- Criterion: Able to say and write each set with 80% accuracy across two sessions.
Reading treatment + spelling treatment with electronic speller
Kim et al. (2015) included three participants with alexia and agraphia, characterized by “relatively accurate but slow single-word reading with significant word length effects and surface agraphia” (p. 1527). All 3 participants improved on both trained and untrained words. They also improved their speed of reading trained passages, as well as single-word speed reading. They participated in two one-hour sessions per week.
Refer to Kim et al. (2015) for more details of their protocol.
- Reading treatment (30 minutes)
- Select a passage from a novel and obtain baseline measures for reading rate and accuracy.
- Have your patient read the passage aloud repeatedly. Provide corrections/assistance as needed.
- Assign a new reading passage every 4th session.
- Spelling treatment (30 minutes)
- Goal: Teach patients how to use residual (or retrained) phonology and orthographic skills to improve detection and correction of spelling errors. Use an electronic spell checker, such as the Franklin Speaking Language Master or the American Wordspeller.
- Select irregularly spelled words for treatment and homework.
- Train your patient to follow these steps for each word you present verbally:
- Write the word as best as you can.
- Look at the word. Does it look correct?
- Try to spell the word again by sounding out any parts that are difficult.
- If the spelling still doesn’t look correct, try to spell it again.
- Type the best spelling attempt into the spell checker.
- Scroll through the options to find the correct spelling.
- Copy the correct spelling.
- If your patient can write at the sentence level, you can include therapy tasks such as writing sentences to dictation and generating written sentences.
- Home exercise program.
- Reading: Read the same passage used for treatment aloud for at least 30 minutes a day.
- Spelling: Use a recordable device to record 5-10 irregular words per homework day. Patient is to follow the same steps to write and check their spelling. As able, have them use the word in a sentence or a paragraph.
Clinical considerations
These types of writing therapy programs may be best suited to highly motivated adults. Biddau et al. (2023) point out that some articles reported that their participants had previously shown success with other types of language therapy. Some of the articles explicitly suggested that their research subjects showed good results with therapy because they were highly motivated.
The dosage of therapy doesn’t need to be high. The studies featured individual sessions of 1 to 2 hours, and they met 1 to 3 times a week. Two of the studies included weekly group sessions for oral language skills. Most research protocols included daily writing assignments. Treatment lasted 4 to 14 weeks.
We don’t have to stick with a single treatment protocol. Two studies used a cross-over design to train two different protocols with each participant. In two other studies, the participants received two different protocols in each session.
We can certainly modify whichever protocol we choose to meet our patient’s needs. Four of the studies reported doing so. Some of the modifications included adding additional treatment sessions, adding homework assignments, providing additional tools, and repeating training.
Limitations of the systematic review
Biddau et al. (2023) list a number of limitations and possible confounding effects. I’ll list some of the highlights here, but please refer to the paper for a full discussion.
Limitations include:
- Small sample size.
- Wide variability in participant characteristics.
- Lack of disclosure on inclusion/exclusion criterion and other details.
- Many studies did not clearly state the type of dysgraphia.
- No study assessed the actual use of written language in daily life.
Possible confounding factors include:
- Age.
- Time since onset.
- Severity and extent of the lesion.
- Aphasia type and severity.
- Perceptual and spatial abilities.
- Cognitive abilities.
Related Eat, Speak, & Think posts
This is the first post I’ve made on writing! But if you found this post helpful, you may enjoy taking a look at these:
- Free multimedia resources for the SLP.
- Attentive Reading and Constrained Summarization tutorial.
- Improve aphasia outcomes by creating intensive home exercise programs.
Key references
- Beeson, P. M., & Egnor, H. (2006). Combining treatment for written and spoken naming. Journal of the International Neuropsychological Society : JINS, 12(6), 816–827. https://pubmed.ncbi.nlm.nih.gov/17064445/
- Biddau, F., Brisotto, C., Innocenti, T., Ranaldi, S., Meneghello, F., D’Imperio, D., & Nordio, S. (2023). Speech and Language Therapy for Acquired Central Dysgraphia in Neurological Patients: A Systematic Review to Describe and Identify Trainings for Clinical Practice. American journal of speech-language pathology, 32(2), 762–785. https://doi.org/10.1044/2022_AJSLP-22-00042
- Kim, E. S., Rising, K., Rapcsak, S. Z., & Beeson, P. M. (2015). Treatment for Alexia With Agraphia Following Left Ventral Occipito-Temporal Damage: Strengthening Orthographic Representations Common to Reading and Spelling. Journal of speech, language, and hearing research : JSLHR, 58(5), 1521–1537. https://doi.org/10.1044/2015_JSLHR-L-14-0286
- Kiran, S. (2005). Training phoneme to grapheme conversion for patients with written and oral production deficits: A model‐based approach. Aphasiology, 19(1), 53–76. https://doi.org/10.1080/02687030444000633
- Thiel, L., Sage, K., & Conroy, P. (2016). Comparing uni-modal and multi-modal therapies for improving writing in acquired dysgraphia after stroke. Neuropsychological rehabilitation, 26(3), 345–373. https://doi.org/10.1080/09602011.2015.1026357
Free DIRECT downloads: Helping adults regain the ability to write (cheat sheet), CART worksheet 5 words per page and CART worksheet larger spaces. (Email subscribers get free access to all the resources in the Free Subscription Library.)
Featured image by Nuchylee on Canva.com.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
Be First to Comment