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2008 23: 399J Child NeurolMarie Brossard Racine, Annette Majnemer, Michael Shevell and Laurie Snider

Handwriting Performance in Children With Attention Deficit Hyperactivity Disorder (ADHD)  

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399

The etiology of ADHD is still unclear, but it is pre-sumed to be multifactorial with genetic and neurologicalfactors playing a substantial role in the occurrence of thecondition.5 Although extrinsic factors, such as environ-mental context, cannot cause ADHD in isolation, theycan exacerbate the symptoms and contribute to the pres-ence of other associated deficits.4

Treatment of ADHD commonly includes the use of phar-macological agents. The most prescribed class of medicationsused for treatment is stimulants such as methylphenidate.There are many prospective studies showing the effectivenessof medication in the diminution of disruptive behaviors andin the improvement of the overall child performance in a vari-ety of domains.4 Other nonpharmacological efforts, such asbehavioral, cognitive, and educational techniques, to improveself-regulation, diminish the disruptive behaviours, andimprove school performance are also used either in isolationor in conjunction with medication.

In addition to the disruptive behaviors commonly asso-ciated with ADHD, learning disability, delay in speechdevelopment, low mastery motivation, sleep disturbances,and problems with arousal have also been documented. Avariety of activity limitations in daily-living skills and dimin-ished socialization skills have been reported for thesechildren.4 It is increasingly appreciated that leisure andrecreational activities, academic productivity, and social-emotional well-being are negatively impacted by this con-dition. Motor difficulties have also been reported. Harvey

Attention deficit hyperactivity disorder (ADHD) is acomplex health condition that is characterized by theinability to marshal and sustain attention, modulate

activity level, and moderate impulsive actions.1 Symptomsreported are numerous and may have heterogeneous pat-terns. According to the Diagnostic and Statistical Manual ofMental Disorders (4th ed), 3 different broad subtypes ofADHD are recognized: inattentive, hyperactive, or com-bined. Typical features can vary and often include poororganization skills, difficulty in sustaining attention, motoroveractivity, and impulsivity. Comorbidities are common andinclude anxiety disorders, conduct disorders, affectivedisorders, learning disabilities, and tics.2 As the most com-mon pediatric neurobehavioral syndrome, the prevalence ofADHD has been estimated to be between 1% and 5% of theschool-age population in North America,3-5 affecting males 6times more often than females.6

Original Article

Handwriting Performance in Children With Attention Deficit Hyperactivity Disorder (ADHD)Marie Brossard Racine, BSc, OT, Annette Majnemer, PhD, OT, Michael Shevell, MD, CM, and Laurie Snider, PhD, OT

Attention deficit hyperactivity disorder (ADHD) is the most com-mon neurobehavioral condition of childhood. Consequences aremultifaceted and include activity limitations in daily-living skills,academic challenges, diminished socialization skills, and motordifficulties. Poor handwriting performance is an example of anaffected life skill that has been anecdotally observed by educatorsand clinicians for this population and can negatively impact aca-demic performance and self-esteem. To guide health and educa-tional service delivery needs, the authors reviewed the evidencein the literature on handwriting difficulties in children withADHD. Existing evidence would suggest that children with

ADHD have impaired handwriting performance, characterizedby illegible written material and/or inappropriate speed of execu-tion compared to children without ADHD. Studies with largersample sizes using standardized measures of handwriting per-formance are needed to evaluate the prevalence of the problemand to better understand the nature of handwriting difficultiesand their impact in this population.

Keywords: attention deficit hyperactivity disorder; hand-writing; motor performance

From the Departments of Neurology and Neurosurgery and Pediatrics(AM), School of Physical and Occupational Therapy (AM, LS, MBR),McGill University, and Departments of Neurology and Neurosurgeryand Pediatrics, Montreal Children’s Hospital, McGill University HealthCentre (MS), Montreal, Quebec, Canada.

Address correspondence to: Annette Majnemer, PhD, OT, Lab: MontrealChildren’s Hospital, Division of Neurology, Room A-509, 2300 Tupper Street,Montreal, Quebec, H3H 1P3 Canada; e-mail: annette.majnemer@mcgill.ca.

Brossard Racine M, Majnemer A, Shevell M, Snider L. Handwritingperformance in children with attention deficit hyperactivity disorder(ADHD). J Child Neurol. 2008;23:399-406.

Journal of Child NeurologyVolume 23 Number 4April 2008 399-406

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and Reid7 concluded, after reviewing 49 studies publishedbetween 1949 and 2002, that children with ADHD aremore likely to exhibit impaired movement skills comparedwith nonaffected peers. The prevalence of motor impair-ment in the ADHD population has been estimated to beapproximately 50%.4,8,9 It appears that there may be an exist-ing comorbidity between ADHD and developmental coordi-nation disorder (DCD).8,10

Poor handwriting performance is an example of anaffected life skill that has been anecdotally observed by edu-cators and clinicians for this population.4 Children with poorhandwriting produce illegible material (Figures 1 and 2) thatis often graded as unsatisfactory by the teacher,11 leading tomuch frustration on the part of the child, parents, andteacher. Handwriting performance difficulties are associatedwith lower academic achievement and with poorer self-esteem.12 In comparison with peers, the decreased fluency ofhandwriting may result in increased time needed for writingtasks such as homework and assignments. Students some-times cannot read their own messy handwriting, leading toinefficient note-taking, errors in homework organization, andrejection by peers for the team work (ie, cooperative work),which is an increasingly common feature in classroom edu-cation. In class, the child’s need to increase the concentra-tion and effort when writing may result in decreasedattention paid to spelling, grammar, and lesson content, fur-ther jeopardizing overall academic success.13 Finally, childrenstruggling with handwriting will avoid writing-related tasks,which may be interpreted by parents and teachers as opposi-tional behaviors leading to conflict at home and at school.

Handwriting difficulties are not specific to children withADHD but may be documented in children with a variety ofdevelopmental disabilities. There has been a recent interestin handwriting performance among different diagnostic

groups in pediatric and adult neurology. For example,handwriting has been used as a marker of neurologicaldeficits among individuals with basal ganglia disease.14

Abnormal patterns of handwriting have been documentedin a variety of psychiatric and neurological disorders, suchas depression,15 obsessive-compulsive disorder,16

Parkinson’s disease,17 schizophrenia,18 and also DCD.19

Although there is an increasing appreciation that theneurological disorders across the life span can affecthandwriting performance, there is a paucity of evidenceregarding intrinsic or extrinsic factors that are associatedwith decreased handwriting performance among thesevarious diagnostic groups. In one study, Feder et al20

found that handwriting legibility at early school age inpreterm survivors was associated with poor visual percep-tual abilities and eye-hand coordination, gender and behav-ioral difficulties, whereas in-hand manipulation skills andfinger identification (ie, sensory awareness) were posi-tively associated with the speed of handwriting in thispopulation. Knowledge of factors associated with poorhandwriting performance is helpful in guiding strategiesfor remediation. Although the presence of handwritingdifficulties has been reported in different studies amongchildren with ADHD, the factors predicting these task-specific impairments remain to be determined.

To guide future research studies, interventions, and serv-ices, we have conducted a comprehensive review of existingevidence on handwriting difficulties in children with ADHD.

Search Strategy

The following electronic databases were searched: CINAHL(1982 to August week 1, 2006), MEDLINE (1966 to

400 Journal of Child Neurology / Vol. 23, No. 4, April 2008

Figure 1. This sample of part of the alphabet was scored using the legibility criteria on the Evaluation Tool for Children’s Handwriting. The cir-cled letters were scored as illegible for the following reasons: letters q, r, and s can be confused for another letter or numeral; letters u and w are noteasily recognized out of context and at first glance; the letter z is reversed.

Figure 2. This is a sample of numbers that were scored using the Evaluation Tool for Children’s Handwriting. Numbers 10 and 15 are two exam-ples of number reversal that are considered illegible.

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August week 1, 2006), EMBASE (1980 to August week 2,2006), and PsycInfo (1967 to August week 2, 2006). Thesearch was limited to articles that contained the followingkeywords; handwriting or writing and then ADHD and werepublished in the English language. Qualitative and quanti-tative research studies whose primary purpose was todescribe handwriting performance in individuals withADHD were included in the review. There were few pub-lished studies found documenting the nature of handwrit-ing disorders for the population of interest. There weremore studies relating to the effect of medication onhandwriting performance in children with ADHD. In total,there were 12 articles published between 1966 and 2006 onthe topic.21-32 A summary of these studies is provided inTable 1.

Handwriting Performance in Children With ADHD

The presence of handwriting difficulties among childrenwith ADHD was reported in several studies. However,none of these studies compared the prevalence of thisproblem to a control group or to normative data. Doyle et al21 concluded that 58% of a sample of 38 children withADHD had poorer handwriting than the typically devel-oped peers according to the parent’s subjective percep-tion. Subjects included a sample of outpatients from theattention deficit disorder clinic of a hospital in Australia.Because the children referred to this specialized clinicmay have had more severe ADHD, this sample may not berepresentative of the ADHD population at large. Anotherlimitation was that the prevalence of handwriting diffi-culties was estimated by parental perception alone.

Handwriting performance in this population is often ofpoor quality. Whalen et al32 reported on teachers’ reportsthat handwriting in children with ADHD was immature,messy, and illegible and that they associated poor handwrit-ing with low motivation or negativism. More specifically,Lerer et al23,24 reported on a constellation of handwritingproblems: poor organization of written material within thespace available, poor spacing within and between words,poor overall legibility, inconsistent letter size and shape,poor alignment, frequent erasures, frequent omissions ofletters or words, and letter inversions. Although less fre-quent than a decreased quality of written output, poorrhythm and flow of writing, and a diminished speed werealso documented in this study. However, because one of thestudy’s inclusion criteria for the study sample was that chil-dren had moderate to severe handwriting difficulties asidentified by their teachers, information on ADHD childrenwith mild handwriting difficulties is lacking. Further,these subjects were not compared to peers without ADHD.Other studies have reported limitations in written expres-sion (ie, writing, copying, and composition),27 suggestingthat the handwriting difficulties may not be limited to just 1

dimension of this life skill and may impact multiple aca-demic tasks that involve writing at school.

Handwriting performance has been characterized by dif-ferent kinematic measures.13,33 Schoemaker et al28 studiedmotor planning and parameter setting in a graphic task inchildren with ADHD compared to children without ADHDor motor impairment. They found that the motor planning(ie, the sequence of abstract spatiotemporal trajectoriesoccurring before and throughout the execution of the task)of children with ADHD was not different from that of thecontrol group; however, parameter setting (ie, force, timingof agonist and antagonist muscles, and pen pressure)appeared to be weaker for the ADHD group. Specifically,even in a simple graphic task, children with ADHD were notable to adapt their approach to execution of the task whenmore accuracy was required and had poorer fine motorskills than the control population.

Tucha and Lange29-31 studied the effects of methyl-phenidate on quality and fluency of handwriting amongchildren and adults with ADHD. The conclusions werethat once withdrawn from the medication, children withADHD had poorer handwriting legibility and accuracy incomparison with the control group of children withoutany neurological or psychiatric disease and matched forage, grade, and handedness to the ADHD children.Although the nature of the handwriting difficulties werenot documented, the researchers highlighted improve-ment in form, alignment, spacing, legibility, and unifor-mity of handwriting with medication use, suggesting (butnot confirming) that these aspects might have been dimin-ished before medication. Legibility was measured by 4 inde-pendent examiners who were asked to rate the form,alignment, spacing, legibility, and uniformity of handwrit-ing, using a 5-point Likert-type scale, ranging from excellentto poor. Handwriting movement was also registered using adigitizing tablet with a specific pen. Decreased fluency(more inversions in the direction of velocity and accel-eration profiles) was identified during treatment withmethylphenidate.29-31

Similar results were reported by Flapper et al22 whoexamined the effects of methylphenidate on motor skills andhandwriting in children with both ADHD and DCD. Theyconcluded that for this specific subgroup of ADHD childrenwith motor impairment, fine motor skills and handwritinglegibility improved with pharmacologic intervention but stillremained lower than a matched control group of childrenwithout neurological, motor, or behavioral problems. No dif-ference was found in the speed of handwriting between theADHD-DCD group and the control group.

Predictors of Handwriting Performance

Functional handwriting is comprised of legible letter forma-tion and a reasonable speed of execution.11 Handwriting is acomplex task that, to be performed successfully, requires the

Handwriting Performance in Children With ADHD / Racine et al 401

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402 Journal of Child Neurology / Vol. 23, No. 4, April 2008

Table 1. Summary of Studies on Children With ADHD That Includes Evaluation of Paper Pencil Tasks Such as Handwriting

Authors (y) Subject (n), Control (n) Main Conclusions Handwriting Measures Other Measures

Doyle et al21 (1995) ADHD (38) Better gross motor than fine Parent’s subjective Conners (T/P);CBC motor skills, and poor rating of Child Behavior; handwriting skills; parent’s handwriting Checklist (T/P); report showed significant QNST; WISC-III; association with ADHD Standford-Binet; BOTMP; severity and handwriting parent’s subjective

(motor skills)Flapper et al22 ADHD + DCD ADHD + DCD who had ↓ FMS: MABC (fine motor MABC (total);

(2006) (12), control (12) ↓ handwriting quality; no subtest); concise DSM-IV checklistdifference was found on assessment method speed; ADHD + DCD with for children’s medication: FMS and handwritinghandwriting improved but still remained ↓ than the control group

Lerer et al24 (1977) MBD + handwriting With medication 52% Visual-Motor-Gestalt Conners (T); Wide Range disorder (50) had their handwriting ↑; Test; qualitative Achievement Test

↓ handwriting when observation of medication was handwritingdiscontinued; ↑ behavior with medication

Lerer et al.23 (1979) hyperactive + learning ↑ handwriting on medication; Visual-Motor-Gestalt Conners (T); Wide Range difficulty + ↑ visuomotor skills on Test; qualitative Achievement Testhandwriting medication observation of disorder (50) handwriting

Peeples et al25 ADHD (1) Legibility was poor even Digitizing tablets(1995) on medication but

improved with ageRaggio26 (1999) ADHD combined ↓ visuomotor perception Bender-Gestalt test Conners (P); Raggio

type (26) and ↓ written (visuomotor Evaluation of Attention expression perception) Deficit Disorder

Continuous Performance Test; Wide Range Achievement Test

Resta and Eliot27 ADHD with ADHD groups: Bender visual motor CBC; child attention (1994) hyperactivity similarly ↓ perceptual Gestalt test; written profile; parent’s

(10), ADHD motor skills compared language assessment checklist; teacher’s without to control; copying report formhyperactivity (11), (constructional control (11) dyspraxia) may be an area

of weakness for ADHD with hyperactivity

Schoemaker et al28 ADHD (16), ADHD: ↓ speed, Handwriting WISC-III; MABC; computer (2005) control (16) ↓ time pausing, observational program OASIS

↑ fluency, ↑ axial scalepressure, ↑ under/over shoots, ↑ errors; ADHD: ↓ FMS; No difference between groups for motorplanning; ADHD: ↓ parameter setting and produced ↓ accurate strokes

(continued)

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integrity of different components. Kinaesthesia,13,33 motorplanning,34 in-hand manipulation,35 visual-motor skills,34-36

and sustained attention11 have been identified as precursorsof good handwriting legibility in typically developing chil-dren. Thus, the origin of diminished handwriting perform-ance is likely multifactorial. A few studies that examinedthese variables among children with ADHD as possibledeterminants of poor performance are highlighted below.

Demographic Characteristics

In typically developed children, demographic variables donot seem to be important predictors of handwriting. Indeed,it appears that only sex is a significant predictor of handwrit-ing legibility.37 In the study of handwriting performance oftypically developing children in grade 1 by Feder et al, boysshowed significantly lower legibility scores compared with

Handwriting Performance in Children With ADHD / Racine et al 403

Table 1. (continued)

Authors (y) Subject (n), Control (n) Main Conclusions Handwriting Measures Other Measures

Tucha and Lange29 ADHD combined No difference between Digitizing tablet to Conners (P/T)(2001) type (21), groups on medication register handwriting

control (21) for quality of spacing, movement; qualitativeform, alignment, assessment (form, uniformity, and alignment, spacing,legibility; ADHD, off legibility, and medication: ↓ handwriting uniformity)quality; no difference between groups off medication in the kinematic analysis of the movements; ADHD: ↑ inversions of velocity and acceleration when on medication

Tucha and Lange30 Experiment 1: Experiment 1: ADHD Digitizing tablet to (2004) ADHD (8) on medication: ↑ inversion register handwriting

and ↓ fluency of the movementhandwriting

Experiment 2: Experiment 2: no differenceADHD/combined in the handwriting type children between groups following (10), control withdrawal of medication; children (10), ADHD children onADHD adults (10), medication: ↓ fluency control adults (10) of handwriting (↑ number

of inversions of velocity), ↑ accuracy and ↑ legibility; No statistical differences for adults

Tucha and Lange31 Study 1: healthy Study 1: attention given to Digitizing tablet Study 2, Conners (P/T)(2005) adults (26) accuracy of handwriting, (WACOM IV)

visual feedback, and mental control of graphomotor output results in less fluent handwriting

Study 2: ADHD/ Study 2: ADHD combined children:↓ fluencychildren (12) of handwriting on

medicationWhalen et al32 Hyperactive boys For hyperactive boys: Qualitative

(1981) (22), control ↑ handwriting when observation ofboys (39) on medication, and handwriting

↓ handwriting when off medication

NOTE: ADHD = attention deficit hyperactivity disorder; BOTMP = Bruininks-Oseretsky Test of Motor Proficiency; CBC = child behavior checklist; Conners = ConnersRating Scale; DCD = developmental coordination disorder; FMS = fine motor skills; MBD = minimal brain damage; P = parent’s version; QNST = Quick NeurologicalScreening Test; T = teacher’s version; MABC = movement assessment battery for children; ↓ = less/worse/decreased; ↑ = more/better/increased.

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girls on a standardized assessment of handwriting. Handed-ness has not been identified as a predictor of handwritingquality.38 In studies on children with ADHD, demographiccharacteristics, such as sex, handedness, socioeconomic sta-tus, parental education, and parental handwriting ability,have not been studied as possible predictors of handwritingquality. However, several studies controlled for the possibleeffects of this demographic variable. For example, sex wascontrolled for by either exclusively testing male subjects27,29,32

or by using a sex-matched control group.22,28,30,31 Withrespect to handedness, Tucha’s group used either a matchedcontrol group or only right-handed subjects.29-31. The Lerer et al23,24 studies noted that all subjects were from a middle-class environment and were all Caucasians. However, only 2studies controlled for age. Schoemaker et al28 and Tucha andLange29 used an age-matched control group in their method-ology. Future studies are needed to determine if sociodemo-graphic variables have a modifying effect on the quality ofhandwriting for children with ADHD.

Behavior

Tucha and Lange29-31 suggested that children with ADHDare able to write legible answers when increasing their con-sciousness of the task but that hyperconsciousness dimin-ishes handwriting fluency and automatism. This suggeststhat the handwriting difficulties of ADHD children can-not be explained simply by diminished attention alone.Nevertheless, attention appears to be an important modify-ing factor. Flapper et al22 reported that when behavioralproblems (ie, inattention and hyperactivity) were moderatedwith a pharmacological agent, the fine motor skills of chil-dren with both ADHD and DCD improved, as did theirhandwriting. Perhaps, with the comorbidity of DCD, theeffect size of attention is greater than among ADHD chil-dren without DCD; therefore, these findings may not begeneralizable to children with ADHD alone.

Subtyping of ADHD has been explored as a potentialexplanatory variable for the differences noted in hand-writing performance. Doyle et al21 suggested that thehandwriting performance was associated with the severityand subtype of the ADHD disorder, indicating poorerhandwriting was evident when more ADHD symptoma-tology was reported on the behavioral assessments.However, a parent’s judgment of the quality of the hand-writing was the only measure of the handwriting per-formance construct and may not have been reliableenough to ascertain this relationship. Resta and Eliot27

compared ADHD children with and without hyperactivebehavior. Those with hyperactive behavior had objectivelypoorer visual-motor skills, but no difference was foundbetween their written abilities, as measured by the par-ent’s subjective rating of their own child’s handwriting.

Finally, in a single case study, Peeples et al25 reportedthat the subject’s quality of handwriting increased more

with age and academic-level status than when medicationwas taken at an early age.

Motor Performance

Lerer et al23,24 reported that once taking methylphenidate,children with ADHD and handwriting difficulties appearedto require less effort to write and used a diminished pres-sure on the pencil. Children also had better coordinationand smoother hand movements, suggesting that improve-ment in fine motor skills occurred concurrently with betterhandwriting skills. However, these reports relied on subjec-tive observations by the evaluator of the fine motor skillsand handwriting performance. Very recently, Flapper et al22

found that children with ADHD and DCD who showedpoor fine motor skills on a screening tool for motor impair-ment (Movement Assessment Battery for Children) hadpoor handwriting, the latter measured by subjective rating.Preliminary evidence, therefore, indicates that in childrenwith coexisting ADHD and DCD, fine motor deficits predicthandwriting difficulties. Flapper et al22 also reported thatchildren with ADHD and DCD had poorer handwritingquality and drew more rapidly and more fluently (but withless accuracy) in a graphomotor task than the control group.However, only a between-groups comparison was con-ducted, and the extent to which kinematic variables can pre-dict handwriting performance was not specifically evaluated.

Visual-Motor Perception

It is known that visual-motor integration is an importantpredictor of handwriting legibility involving copying let-ters.39 Resta and Eliot27 reported difficulties in copyingskills (constructional dyspraxia) for both the hyperactiveand inattentive ADHD groups compared with the typi-cally developing peers. Raggio26 further noted that thevisual-motor perception skills were diminished amongchildren with the ADHD combined type compared withnorms. Difficulties in visual-motor and perceptual-motorskills may have an impact on handwriting; however, thisrelationship has not been extensively studied empiricallyin children with ADHD.

Conclusion

There are few published studies on handwriting perform-ance in children with ADHD; therefore, further studies areneeded to more accurately define the prevalence, the nature,and the origin of the problem. Preliminary evidence wouldsuggest that the handwriting performance in this populationis often impaired compared with children without ADHD.Nevertheless, the extent of the problem is still unknown, andstudies with larger sample sizes and control groups areneeded to evaluate the prevalence of the problem, usingstandardized measures of handwriting performance.

404 Journal of Child Neurology / Vol. 23, No. 4, April 2008

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Handwriting performance can be documented using for-mal (ie, standardized tests) or informal (ie, teacher con-sultation, comparison with peers, qualitative observation)methods. A standardized, valid, and reliable instrument pro-vides a quantitative score, which enables the evaluator tomeasure the individual’s progression following an interven-tion.40 There are a variety of objective measures of children’shandwriting performance for different age groups, with dif-ferent advantages and limitations.41 Many of these toolsmeasure the legibility and the speed of handwriting withacceptable reliability.41 The principal difference betweenthese tools lies in the selection of the administered tasks.Some tests only use a near-point copying task, whereas oth-ers incorporate composition, dictation, and/or far-pointcopying. The instrument selected should use tasks that bestrepresent the child’s experiences and difficulties.11 Thus,future studies on handwriting among children with ADHDshould optimally use standardized instruments that evaluatea variety of tasks to better identify problem areas and todetermine the impact of any intervention.

Furthermore, individual factors associated with hand-writing difficulties need to be identified to develop strategiesfor interventions, particularly when handwriting difficultiespersist following pharmacologic intervention. A recentreview of interventions for handwriting reports that supple-mentary handwriting instructions (ie, additional practiceusing either educational or motor learning models) are effec-tive in the improvement of legibility.42 Therefore, it is imper-ative that elucidation of the nature and persistence ofdifficulties in this important life skill be actively pursued infuture studies, so that we may ultimately enhance academicsuccess and self-competency in children with ADHD.

Implication for Child Neurologists

It has been increasingly apparent over time that ADHDsymptomatology negatively affects many areas of a child’slife. Handwriting is an integral element of academic per-formance and life skills, even in the computer era. Studiesare confirming that handwriting is adversely impacted inchildren with ADHD. More attention needs to be paid bytreating physicians to this life skill when initially assessingand diagnosing a child for possible ADHD. Furthermore,improvement in handwriting may be a marker of success fol-lowing pharmacologic and therapeutic interventions.

Acknowledgment

We acknowledge studentship support from the CanadianOccupational Therapy Foundation, the Children andYouth Home Care Network and SickKids Foundation, andthe Richard and Edith Strauss Foundation provided toMarie Brossard Racine for her doctoral study. Manythanks to Nick Hall for assistance in manuscript prepara-tion. This article was presented at the CRIR-CIRRISColloquium.

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