Handwriting in children with Attention Deficient Hyperactive Disorder: role of graphology

Handwriting difficulties are common in children with attention deficient hyperactive disorder (ADHD) and have been associated with lower academic achievement and self-esteem [1‐3]. Teachers report that the handwriting of both boys and girls with ADHD is immature, messy, and illegible. These findings may reflect poor motor skills and visual-motor integration, which are directly correlated with low handwriting legibility [2]. Furthermore, studies have shown that force, timing of agonist and antagonist muscles, and pen pressure are all weaker in children with ADHD [2, 4].

Tucha and Lange [5] studied the effect of methylphenidate on the quality and fluency of handwriting in children and adults with ADHD but did not evaluate changes in specific handwriting characteristics.

Graphology is an ancient discipline developed in China for purposes of analyzing the personality and behavior of individuals through the physical characteristics and patterns of their handwriting [6]. Following publication of the systematic theory of handwriting analysis by Ludwig Klages, a nineteenth century German philosopher and psychologist, the use of graphology for various purposes, including psychiatric research and evaluation, spread throughout Europe [7]. In 1942, the graphologist T.S. Lewiston and psychologist J. Zubin developed L-Z scales to objectively evaluate quantitative and qualitative handwriting elements, using statistical evidence to differentiate between handwriting of abnormal and normal personalities [8]. The scales made it possible for expert graphologists to identify relevant handwriting features in different languages and determine how they interact. Conclusions regarding either specifics or absolutes could not be reached on the basis of a single feature alone. It was the combination of several different features interacting in various ways that made it possible for clinicians to achieve a full and clear interpretation.

Since the mid-twentieth century, graphology has been applied in many settings: to find suitable employees, establish the authenticity of a signature or text, and establish the state of the author of a signature or a text, (e.g., drunk or anxious). It has also been used in court and during criminal investigations. Handwriting examinations are recognized clinical tools in psychiatry [7] for the diagnosis of suicide attempts [9] and severe major depressive disorder [10].

We hypothesized that children with ADHD might be distinguished by the types and number of abnormalities found in their handwriting. The aim of the present study was to use graphology to analyze the characteristics and patterns of handwriting in children diagnosed with ADHD compared to children without ADHD and to determine if graphology might serve as an objective auxiliary tool in the diagnosis of ADHD.

The total cohort included 22 boys (44.9%) and 27 girls (55.1%) of whom 14 boys (66.7%) and 7 girls (33.3%) had ADHD. Nine children (2 girls) had combined-type ADHD (43% of the total ADHD group). The subjects with and without a DSM IV/V diagnosis of ADHD were comparable in age distribution (mean ± SD, 15.53 ± 1.50 years vs. 14.87 ± 1.96 years, p = 0.204) and more likely to be male (66.7% vs. 25%, p = 0.002) .

The children with a DSM-IV/V diagnosis of ADHD had a significantly higher mean graphology score than the children without ADHD (9.61 + 3.49 vs. 5.79 + 4.01, p = 0.002; Table 1) Analysis by sex revealed that among the girls, graphology scores were below 9 in 80% of the subjects without ADHD (95% CI 59.2–92.8) and 9 or higher in 71.5% of the subjects with a DSM-IV/V diagnosis of ADHD (95% CI 35.2, 93.5). Among the boys, the corresponding values were 62.5% (95% CI 29.5, 88.1) specificity and 78.6% (95% CI 53.1, 93.6) sensitivity. The total sensitivity of graphology to detect ADHD was 75% (95% CI 57.1, 88.1), and the total specificity, 76.2% (95% CI 55.4, 90.3) (Table 2). The AUC of the graphology scores was 0.756 (95% CI 0.635, 0.877), with a positive LR of 3.05 (95% CI 1.54, 6.04) and a negative LR of 0.32 (95% CI 0.140, 0.70) (Fig. 1). In females, the AUC was 0.757 (95%CI 0.568, 0.946), with a positive LR of 3.57 (95% CI 1.32, 9.65) and negative LR of 0.36 (95% CI 0.11–1.18). In males, the AUC was 0.705 (95% CI 0.506, 0.905), with a positive LR of 2.10 (95% CI 0.82, 5.34) and a negative LR of 0.34 (95% CI 0.11, 1.07).

On separate evaluation of the individual handwriting elements, the only significant feature in girls with ADHD was line direction (never horizontal or ascending) (p < 0.05; Fig. 2). Significant features in boys with ADHD were line spacing (abnormal) and writing speed (never slow) (p < 0.05).

Although it is well known that children with ADHD have handwriting difficulties and that their handwriting improves after treatment with methylphenidate [14], this is the first study to our knowledge to use graphology as a tool for evaluating ADHD. In support of our hypothesis, we found that graphology had a sensitivity of 75% and specificity of 76.2% for detecting ADHD.

Handwriting is a complex task requiring the integration of different components, including behavior (inattention, hyperactivity), motor planning, fine motor skills, and visual motor perception [15]. Lerer et al. [16] reported that the specific handwriting problems in children with ADHD were poor organization of written material within the space available, poor spacing within and between words, poor overall legibility, inconsistent letter size and shape, poor alignment, frequent erasures, frequent omissions of letters or words, letter inversions, poor rhythm and flow of writing, and slow speed. In our study, despite the good overall specificity and sensitivity of graphology, further analysis of the individual handwriting features yielded only a limited number of significant differences. Among the boys, writing speed was never slow in the subjects with ADHD compared to the control group who showed more variability. This finding differed from the study of Lerer et al. [15] but was in line with the results of Adi-Japha et al. [17] who reported that the kinematic manifestations of writing deficits in children with ADHD were a fast, inaccurate, and inefficient written product accompanied by high levels of axial pen pressure. The authors putatively explained this finding by the hyperactivity-associated hyperkinetic movements and lack of response inhibition characteristic of ADHD [18], leading the children to complete the task as quickly as possible. It is supported by the present study wherein there was no significant difference between the girls with and without ADHD, as females with ADHD are known to have fewer hyperactive/impulsive symptoms and more inattentive symptoms than males [19]. Other studies suggested that children with ADHD have a less appropriate speed of execution and more motor difficulties than children without ADHD [4, 20], but they did not distinguish the comorbid learning difficulties in ADHD that can cause lower writing speed [21]. Among the females, the handwriting of subjects with ADHD was never ascending compared to variable findings in the control group. Ascending/descending/fluctuating lines have been shown to be the most prevalent (53.6%) indicator of dysgraphia [22].

Thus, our study showed that handwriting evaluation by a graphologist can have incremental validity in terms of diagnostic accuracy in children with ADHD and can contribute to decision-making by the multidisciplinary team, especially in complicated cases Li-Tsang et al. [22] suggested that handwriting assessment can effectively distinguish children with ADHD or ADHD with learning disorders (ADHD-LD) from control subjects by the degree of variation in speed of writing or pen pressure.. Others have analyzed handwriting patterns in children with ADHD using computerized software [23]. The results showed that the ADHD group had poorer motor planning and execution skills and greater variability in motor control than the control subjects.

The handwriting of children with ADHD has specific characteristics. The use of graphology for the diagnosis of medical disorders is a highly disputed branch of handwriting analysis. It is likely that handwriting problems in ADHD have less to do with the writing itself and more to do with factors related to motor control. Our study suggests that graphology is a promising potential auxiliary tool for use by clinicians in the diagnosis of ADHD.