(People with ADHD & Bipolar Disorder are more likely to have this.)

---------------------------------------------------------------------------------------------------------------------------------

Think of when you jot down a list to take with you the supermarket? You scan the house and pull from memory different food items or supplies that you need: refrigerator (need milk, butter, juice); cabinets (we're out of sandwich bags and sponges); canisters (need coffee and tea); laundry room (need detergent and bleach); dinner (mmm... good question). All this information requires a steady, even flow of memory, organization, and planning. Next we put that list on paper. As automatic as it seems, writing simple words like "coffee," "sandwich," and "juice," requires us to recall a sequence of letters and shapes for each word (called spelling) and an ability to maneuver the pen or pencil in order to encode the letters. During the act of writing that list, you control several muscle groups to keep the pen/pencil flowing in a direction -- moving vertically, horizontally, and in a circular fashion (rotary movement).

Now think of a child who writes letters in a laborious, illegible manner; who has spelling greatly below par; and who has poor moment-to-moment recall so that several items or ingredients are missing. A shopping list becomes a whole new order of task, demanding major effort even at this elementary level.

It is estimated that at least half of children with ADHD and bipolar disorder have disorders of written expression. I believe the number is closer to 60-70%.

The problem for some children is weak skills in identifying language sounds (called phonemic awareness); for others it is a motor processing (or, physical movement) difficulty. And, then, for others the problem is a difficulty in organizing thoughts, letting-go of one set of ideas, shifting to another set and re-organizing them; and, then, gathering the energy and attention to complete the task. Any one of these problems will make writing an overwhelming and frustrating task, one that a child will avoid or actively resist -- strongly, and with increasing irritation and anger.

What Happens to a Child Over the Years?

Writing is actually a very complex task. It requires putting together and coordinating thinking, language, and muscle skills. As noted just above, in the elementary school years, some children have difficulty in producing legible handwriting, some in spelling, while others have difficulty organizing and sequencing their ideas. Also, difficulties in one area can delay skill development in the other areas.

Then, as the student moves on to higher grades, another level of writing skill needs to develop: the abilities to use an expanded vocabulary, to develop knowledge and ideas, and to present both in a logical manner. Here is another turning-point where ADHD and Bipolar kids hit a "wall".

Furthermore, these kids often have difficulties with the "mechanics" of writing (periods, commas, and capitals may be slow to develop), working memory, intention (the "just do it" part), and sustained attention. For Bipolar kids in a hypo-manic state, their thoughts may race and ideas pour out faster than their motor or organizational controls can handle. While in a depressed phase, they may experience a slow-down of thoughts and a lack of ideas.

"But, some of these kids are such good talkers!"

Speaking is a more spontaneous act while writing is a directed task. Verbally, we can voice our thoughts, talk about and around them, go off into different directions, and come back to some point. Writing goes much more slowly and requires more precision. Writing is a task of drafting, elaborating, re-drafting, re-vising, and … eventually polishing. For kids who have low frustration tolerance (that’s most ADHD and Bipolar kids) this is a prescription for failure. No wonder they often have a very negative reaction to the demand that they write.

Other areas of functioning where ADHD and Bipolar kids have trouble are self-monitoring, regulating the flow of ideas and self-pacing. When it comes to writing, again, they are at a disadvantage. Each step of a writing task, as it feels more tedious and time-consuming, they become overwhelmed, and tend to resist more. Uncompleted tasks then become another stress. As the stresses begin to accumulate, the student simply shuts down and refuses to even attempt the task.

Many of these processes that a child uses in writing are in the realm of "executive functions." Research is increasingly showing that a high number of children with ADHD and bipolar disorder have deficits in executive functions.

Executive Function Deficits

"Executive functions" (EF) refers to a group of mental control abilities, such as the ability to plan ahead, choose and implement strategies, and organize one's thinking and behavior. Executive functions also include abilities such as staying aware of what one is doing, staying on task, controlling one's impulses, and monitoring the quality of one's own performance and making adjustments if necessary. Another very important executive function is called Working Memory. This is the ability to hold in memory information you need in order to do something within the next 1-60 seconds.

Executive functions are performed in the brain by the frontal lobes and the pre-frontal cortex (your forehead). Brain scans have shown that the frontal lobes may be divided into seventeen or more sub-regions, each responsible for a different function. So a problem anywhere in this area will impact the way a child approaches and performs any task.

How do the Executive Functions (EF) Affect the Writing Process?

Whenever a human being approaches a problem or a project, they must use the following executive functions:

* Analyze the problem

* Plan and implement strategies

* Anticipate problems

* Organize strategies (break them down into components and assign a time-line for each sub-strategy to be accomplished)

* Monitor the progress and assess whether the plan is working

* Remain flexible and reformulate the plan if the monitoring and assessment process shows it’s not working

* Reassess any new strategy

* Follow the adjusted plan through to the finish

* Monitor one’s need for rest, sleep, and food during the task (ability to continue without these)

* Inhibit any impulses that might throw this process off-track

* Store thoughts and ideas for instant use and re-use during this entire task

ADHD and Bipolar kids encounter difficulties in most of these areas! Just think about your child as you review the above list. You can probably picture their negative reactions at each step, right?

Working Memory

Working memory is the ability to hold information in short-term memory while "working" with it toward solving some problem or putting it in some particular order.

Most ADHD and Bipolar kids have trouble with writing because they are either unable to keep information in working memory, or because they are not able to recall that information from of working memory. These kids tend to forget parts of the writing task while they are writing. While they are trying to decide if they need a comma or a period, they lose track of ideas for the next sentence.

Experts say that writing requires more memory (working, short-term and long-term) than almost anything else a student is asked to do in school. Writing requires the abilities to simultaneously recall and hold in mind things like spelling, punctuation, capitalization, grammar and sentence structure rules, vocabulary, not to mention keeping in mind what it is that you are writing about.

It is virtually impossible to produce legible, sensible writing without a good working memory.

Fine Motor Problems

Have you ever seen a child's handwriting on a piece of paper and see letters awkwardly formed, too little or too much space between letters and words, obviously heavy pressure on many letters, and/or sentences going above the line as well as below? This is the child with a "Fine Motor Coordination Disability" - also known as "Grapho-Motor Dysfunction", and, as "Dysgraphia". In brain function terms, it is a glitch in the connection between the part of the brain that handles motor memory and the part that controls movement of the wrist, hands and fingers.

Taken all together, a combination and sequence of visualizing one’s hand in relation to the paper and pencil, plus tiny, exact muscle movements translate the thought of a word into letters. Meanwhile, working memory, sequencing, organization, impulse control (to keep frustration and the urge to do something else in check!), and sustained attention go into the writing process. Not until later does creativity and mature character development enter the picture. Those elements present even further trouble for the ADHD/Bipolar child.

So, I hope you can now see why these children refuse to write, produce unreadable writing, or end up with very little their paper. Their writings are usually a greatly reduced, brief version of what is expected. As teachers and parents, you find yourselves increasingly anxious, frustrated, and angry as the child resists and puts off written assignments until the last minute. You try to motivate the child with encouragement, promises of rewards, or more. When this doesn't do the trick, negative feelings arise as evenings and weekends go from a series of small hassles to major battles. Everyone becomes exhausted and demoralized.

Writing is a part of every school day, every subject, and most homework assignments. Therefore, it is very important to find out what is impeding the writing process for your child.

Most significant disorders in writing show up by the second or third grade (fine motor difficulties are usually noticed earlier). Since, as I have said, writing problems cause major and wide-ranging academic struggles, it is very important to evaluate and intervene in these early stages. Waiting until later is always more difficult. Also, younger students are usually more receptive to using a "multi-sensory" approach like sculpting letters in the air or using graph paper; sixth graders will sneer and become negative before you can explain the purpose of the exercise.

What Tests Reveal Problems In Writing?

There are many tests that can be used to determine which areas of the writing process are problematic. Each school psychologist or resource specialist typically will use those with which they are most familiar. Here are ones most often used by the public school system:

Woodcock-Johnson Psychoeducational Battery—Revised = for ages three to eighty. It tells at what grade level the child is functioning in Reading, Writing and Math.

Wechsler Individual Achievement Test (WIAT-II) = similar to the one above.

Test of Written Language (TOWL) = specifically looks at writing skills in ages 7 ½ to 17. It measures the abilities to get thoughts onto paper, use of punctuation, capitalization, and spelling, grammar, sentence structure, and the ability to write in a logical, coherent and sequenced manner.

Conner’s Continuous Performance Test, or, the Test of Variables of Attention (the TOVA) = Both examine attention over a long period—14 to 22.5 minutes--and are performed on a computer. They measure several specific aspects of attention.

The WISC-IV = newest version of the well-known intelligence test; has some new parts that focus more specifically on "executive functions".

Although ADHD and Bipolar children are now known to have significant executive functioning difficulties, public schools have not generally caught-on. Thus, they tend not to use any of the following tests that specifically examine EF:

The Wisconsin Card Sort

Tower Of Hanoi

Tower of London

Trails A & B

Stroop Color and Word Test

In most writing, but especially mathematics, many images and ideas must be translated into sequences of motor (physical) actions. Research indicates that this process most likely involves the pre-frontal cortex and the motor cortex--the strip that begins the frontal lobes of the brain (same area where EF’s are handled). Writing is very much a task of motor sequencing. Testing in this area is rarely, if ever, done by public schools. Tests that measure executive motor skills include:

Luria Test of Praxis

Fine Motor Coordination

Purdue Pegboard or the Grooved Pegboard

Hallstead-Reitan Finger Tapping Test

Remediation – The Process of Correcting Learning Problems

Strategies to improve hand-writing, writing fluency (getting it on the paper), and language mechanics (grammar, sentence structure, capitalization, punctuation), should be done at home and at school. Specific strategies to be used should be written into the child’s teaching plan (504 Plan or IEP) at school. In public schools these strategies are called "Accommodations".

1: Hand-Writing Problems (Dysgraphia) – Trouble with the shape of letters (called "encoding") and putting them in order onto paper in a legible fashion.

* Try "air writing", "skin writing", or writing with finger-paints or side-walk chalks.

* Use of different size/shape pencils or "grips".

* Use graph paper, or paper with raised lines, to help the child recognize where to place and how to space letters.

* Slant boards allow the child work at a 20-drgree angle. This helps promote development of proper hand and wrist position. * A slant board plus a foot stool can help the child keep their body more upright and their head from getting too close to the paper.

* A company called Therapro has a Web site that sells slant boards, pencil grips, and products to promote better writing. Web site

* Individual therapy provided by a Pediatric Occupational Therapist can be helpful to this child, as well.

2: Writing Fluency & Language Mechanics Problems -- Student writes in a slow and effortful manner. Writing is short and gives minimal information. Grammar, sentence structure, capitalization, use of punctuation are slow to appear and/or haphazard.

* Teach and encourage the student to use a keyboard/PC and allow use of same for assignments.

* Provide pre-printed assignment descriptions.

* Any information to-be-copied, provide in pre-printed form, or, have another student with

legible handwriting make a carbon copy.

* Allow student to tape record classes.

* Allow use of a peer’s notes (photo copy).

* Provide paper copies of notes to the student.

* Allow extra time for assignments.

* Allow the student to give test answers orally.

* Do not penalize the student for handwriting or spelling errors.

* Provide voice recognition software, such as "Dragon Naturally Speaking ".

* Provide QuickLink Pen. (A hand-held scanner that allows a student to scan relevant sentences or paragraphs from books, newspapers and articles and to transfer the information to a computer where the notes are printed for the student, bypassing laborious note-taking.

Available at


3: Attention Difficulties -- Student has difficulty staying on task and paying attention for any length of time; very fidgety; trouble getting started.

* Seat the student close to the teacher where the teacher can get student's attention.

* Schedule frequent breaks.

* Offer choices, such as going to a study carrel or to a quiet area outside the classroom.

* Assign a study-buddy ("study-partner" for an older student). A well focused, organized student to provide modeling and guidance with homework & organization.

* Develop a private signal to prompt focus.

* Provide sound-dampening headphones for the student who is easily distracted by extraneous noises.

* Provide "Distraction Free Environment" for testing.

* Emphasize "high interest" topics for most/all subjects.

* Use teaching methods that emphasize hand-on, movement, activities, music - "multi-modal" methods.

* Avoid verbal-only teaching.

4: Organization Problems -- Student is disorganized and often misplaces needed books and materials; often forgets to bring home assignments and/or fails to turn in work; work is messy; poor sense of time-passage.

* Use a "travel folder." This is a pocket portfolio that has necessary papers to complete on the left-hand side (mark this "To Do"), and all completed homework is transferred to the right-hand side (mark this "Completed").

* Alternative - get two brightly colored 9x12 or 10x13 envelopes; mark one with a bold-colored marker, "To Do", mark the other, "Finished"; glue one to the inside front cover of the student’s binder, the other to the inside back cover.

* Give the student a planner book and have teacher check that daily assignments are recorded properly.

* Privately brainstorm with the student about techniques that both of you can use to "trigger" them to remember certain things, to start something, or to use the techniques you develop.

* Give student a written daily schedule of subjects, tasks.

* Break assignments down into smaller steps.

* Provide a second set of books (for home & school).

* Avoid using traditional planners or other traditional time-management tools.

* Have teacher or aide give the student a prompt before leaving school:"What do I need to do tonight and what materials do I need?"

Teacher or aide photocopy list of items and have student check items off as they are put in backpack. Student should be taught to pack backpack to return to school the same way.

* Teach student to number assignments in the order in which they should be done before beginning homework.

* Have student start with an assignment that is short and easy (but don’t save the hardest or longest assignment for last).

* Have the student estimate how much time it will take to complete each assignment and measure the estimates against the actual time (these students have difficulty with time

management).

* Have them use a stopwatch to assign chunks of time to each step of a study plan (to help them budget time and move on).

* Teach them skim reading (preview questions at the end of each chapter to focus on important concepts; preview photos, captions, diagrams, headings and italicized sections throughout the chapter).

* Color-code subject folders and notebooks to match textbook covers.

* If the student uses a locker, teach them to place morning text books and materials on top shelf of locker, and afternoon materials on lower or bottom shelf.

* Have the student (with the help of an assistant if necessary) clean out locker at least once a week. Schedule cleanup on Fridays to ensure that P.E. clothes and needed materials arrive home for the weekend.

5: Standardized (yearly) Testing --

These tests of grade-level performance are typically given near the end of each year. Students are generally given a topic or starting sentence and are asked to compose a narrative story that is interesting and rich in detail. This is a major stumbling block for children with disorders of written expression. Although extended time (time-and-a-half or double-time) and/or a "Distraction Free" environment can be requested for students with learning disorders, that may not be enough. A book called "The Most Wonderful Writing Lessons Ever" by Barbara Mariconda gives a step-by-step process and helps children and adults clearly understand how to do good narrative writing. The book can be used with students in almost any grade.

The Bottom Line --

Writing is so heavily involved in every subject in school, it is clear that any child struggling with written expression will find school torturous and humiliating. In the late afternoon and evening (times that are particularly difficult for ADHD and Bipolar kids) the child will feel especially stressed and will react with anger, fatigue, and feelings of failure when confronted with any homework assignments that require writing.