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A peer-reviewed article of this preprint also exists.
supplementary.zip (30.07KB )
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Submitted:
28 November 2023
Posted:
30 November 2023
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Section | Question | Formulation |
---|---|---|
A: Are the results of the trial valid? | 1 | Did the study address a clearly focused issue? |
2 | Did the authors use an appropriate method to answer their question? | |
3a | Were the cases recruited in an acceptable way? | |
3b | Was there a sufficient number of cases selected? | |
4 | Were the control groups selected in an acceptable way? | |
5 | Was the exposure clearly defined and accurately measured? | |
6 | Have the authors taken account of the potential confounding factors in the design and/or in their analysis? | |
B: What are the results? | 7 | Was the group effect large? |
8 | Was the estimate of the group effect precise? | |
9 | Do you believe the results? | |
C: Would the results help locally? | 10 | Can the results be applied to the local population? |
11 | Do the results of this study fit with other available evidence? |
Methodological Quality | Presentation of Results | External Validity | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 2 | 3a | 3b | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | |||
Adi-Japha et al., 2007 | Y | Y | Y | Y | Y | Y | Y | C | N | Y | C | Y | ||
Åsberg Johnels et al., 2014 | Y | Y | Y | Y | Y | Y | Y | C | N | Y | Y | Y | ||
Borella et al., 2011 | Y | Y | C | Y | Y | Y | Y | C | C | Y | Y | Y | ||
Capodieci et al., 2018 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | ||
Capodieci et al., 2019 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | ||
Dirlikov et al., 2017 | Y | Y | Y | Y | Y | Y | Y | C | N | Y | Y | Y | ||
Farhangnia et al., 2020 | Y | Y | C | Y | Y | Y | N | C | N | C | C | Y | ||
Flapper et al., 2006 | Y | Y | Y | N | Y | Y | Y | C | N | C | Y | Y | ||
Frings et al., 2010 | Y | Y | C | N | Y | Y | N | C | N | C | C | Y | ||
Hung & Chang, 2022 | Y | Y | C | Y | Y | Y | C | Y | Y | Y | Y | Y | ||
Johnson et al., 2013 | Y | Y | Y | N | Y | Y | Y | C | N | Y | Y | Y | ||
Langmaid et al., 2014 | Y | Y | Y | N | Y | Y | Y | N | Y | Y | Y | Y | ||
Langmaid et al., 2016 | Y | Y | Y | N | Y | Y | Y | Y | Y | Y | Y | Y | ||
Laniel et al., 2020 | Y | Y | N | N | Y | Y | N | Y | Y | C | C | Y | ||
Lofty et al., 2011 | Y | Y | C | Y | C | Y | C | C | N | Y | C | Y | ||
Okuda et al., 2011 | Y | Y | Y | N | Y | Y | C | C | N | C | C | Y | ||
Rosenblum et al., 2008 | Y | Y | Y | N | Y | Y | C | C | N | C | C | Y | ||
Shen et al., 2012 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | ||
Tucha & Lange, 2001 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | ||
Tucha & Lange, 2004 | Y | Y | Y | N | Y | Y | Y | C | N | Y | C | Y | ||
Yoshimasu et al., 2011 | Y | Y | Y | Y | Y | Y | N | C | N | Y | C | Y |
Study | Participants (ADHD and Controls) | Experimental Group | Mean Age (SD) | Gender (Male, Female) | Control Group | Mean Age (SD) | Gender | Inclusion and Exclusion Criteria for ADHD | ADHD Presentation | Medication (Psychostimulant) | Handwriting Measures |
---|---|---|---|---|---|---|---|---|---|---|---|
Adi-Japha et al., 2007 | 40 | 20 | 12.2 (5.7) | 20 M | 20 | 12.8 (3.6) | 20 M | Inclusion criteria: formal diagnosis of ADHD, IQ score > 85, performance within 1.6 SD on a reading test; Exclusion criteria: reading problems | ADHD/C | Off-state for at least a week before the experiment | Graphic production on a digitizing tablet; Letters production |
Åsberg Johnels et al., 2014 | 55 | 20 | 10 to 16 | 20 F | 35 | 10 to 16 | 35 F | Inclusion criteria: formal diagnosis of ADHD, IQ score > 69; Exclusion criteria: ASD, neuropsychiatric and neurodevelopmental disorders, learning disabilities | n.s | No medication | FTF; Parental ratings |
Borella et al., 2011 | 30 | 15 | 9.3 (1.4) | 12 M; 4 F | 15 | 9.4 (1.4) | 12 M; 3 F | Inclusion criteria: formal diagnosis of ADHD; Exclusion criteria: IQ score < 85, MPH medication, learning disability, mathematical or reading disorders, neurological, sensory, motor, psychiatric or mood disorders | 5 ADHD/I; 10 ADHD/C | No medication | Batteria per la valutazione delle competenze ortografiche nella scuola dell’obbligo; Continuous letters production |
Capodieci et al., 2018 | 32 | 16 | 10.5 (6.9) | 12 M; 4 F | 16 | 10.1 (6.4) | 12 M; 4 F | Inclusion criteria: formal diagnosis of ADHD for only one child, all others on the basis of ad-hoc questionnaire; Exclusion criteria: neurological, psychiatric or serious psychological problems; No child had a learning disability | n.s | No medication | BVSCO-2; Words production |
Capodieci et al., 2019 | 52 | 26 | 9.6 (1.2) | 22 M; 4 F | 26 | 9.3 (1.1) | n.s | Inclusion criteria: formal diagnosis of ADHD for all but 3 children; Exclusion criteria: neurological or psychological problems, learning disorders | 10 ADHD/I; 10 ADHD/C; 6 ADHD/HI | No medication | BVSCO-2; Dictation tasks; Sentences and words production; Handwriting Legibility Scale |
Dirlokov et al., 2017 | 167 | 45 | 9.9 (1.2) | 39 M; 6 F | 65 | 9.9 (1.1) | 56 M; 9 F | Inclusion criteria: formal diagnosis of ADHD; Exclusion criteria: intellectual disability, seizure, neurological, chronic medical, genetic, psychiatric (except ODD), speech-related, autistic and psychotic disorders | 7 ADHD/I; 38 ADHD/C | Off-state for at least 24 hrs before the experiment | MHA; Copy task |
Farhangnia et al., 2020 | 48 | 24 | 8.0 (0.7) | 17 M; 7 F | 24 | 8.1 (0.6) | 17 M; 7 F | n.s | n.s | n.s | PHAT; Copy task and dictation task |
Flapper et al., 2006 | 24 | 12 | 9.8 (1.7) | 11 M; 1 F | 12 | 9.7 (1.2) | 11 M; 1 F | Inclusion criteria: formal diagnosis of ADHD+DCD; Exclusion criteria: learning, neurological or psychiatric disorders, IQ score < 70 | 6 ADHD/I; 4 ADHD/C; 2 ADHD/HI | Off-state for the first assessment; On-state for 4 to 5 weeks for the second assessment | BHK; Copy task |
Frings et al., 2010 | 21 | 10 | 12.3 (1.3) | 10 M | 11 | 12.1 (1.8) | 9 M; 2 F | Inclusion criteria: formal diagnosis of ADHD | 10 ADHD/C | On-state | Copy task |
Hung & Chang, 2022 | 60 | 30 | 7.1 (0.5) | 16 M; 14 F | 30 | 7.2 (0.5) | 16 M; 14 F | Inclusion criteria: formal diagnosis of ADHD; Exclusion criteria: ASD, seizure disorder, IQ < 80, mental retardation, mood disorders, anxiety or psychotic disorders | 9 ADHD/I; 18 ADHD/C; 3 ADHD/HI | n.s | BCBL; Copy task and dictation task |
Johnson et al., 2013 | 35 | 14 | 11.0 (1.95) | 14 M | 21 | 11.0 (2.1) | 21 M | Inclusion criteria: formal diagnosis of ADHD; Exclusion criteria: medical, sensory, genetic or neurodevelopmental disorders, intellectual disability | 14 ADHD/C | Off-state at least 24 to 72 hrs before the experiment | HPT; Copy task |
Langmaid et al., 2014 | 28 | 14 | 10.9 (2.0) | 14 M | 14 | 10.6 (2.3) | 14 M | Inclusion criteria: formal diagnosis of ADHD; Exclusion criteria: medical, sensory, genetic or neurodevelopmental disorders, intellectual disability | 14 ADHD/C | Off-state at least 24 to 72 hrs before the experiment | Cursive letters production on a digitizing tablet |
Langmaid et al., 2016 | 28 | 14 | 10.8 (2.0) | 14 M | 14 | 10.5 (2.2) | 14 M | Inclusion criteria: formal diagnosis of ADHD; Exclusion criteria: medical, sensory, genetic, neurodevelopmental disorders, intellectual disability | 14 ADHD/C | Off-state at least 24 to 72 hrs before the experiment | Cursive letters production at 10 mm and 40 mm on a digitizing tablet |
Laniel et al., 2020 | 25 | 12 | 9.5 (1.1) | 8 M; 4 F | 12 | 9.9 (1.3) | 6 M; 6 F | Inclusion criteria: formal diagnosis of ADHD; Exclusion criteria: intellectual disability; One child had ODD and anxiety disorder, another had dyspraxia | n.s | On-state | BHK; Copy task; Pen-stroke test on a digitizing tablet |
Lofty et al., 2011 | 40 | 20 | 7.8 (1.2) | n.s | 20 | 7.8 (1.2) | 20 M | Inclusion criteria: formal diagnosis of ADHD; Exclusion criteria: sensory or psychiatric disorders; 60 % of included children met criteria for dyslexia | n.s | n.s | DDS; Copy task |
Okuda et al., 2011 | 22 | 11 | 8.6 to 11.6 | 11 M | 11 | n.s | n.s | Inclusion criteria: formal diagnosis of ADHD; Exclusion criteria: sensory or psychiatric disorders | n.s | On-state | Scale of Dysgraphia |
Rosenblum et al., 2008 | 24 | 12 | 8 to 10 | 10 M; 2 F | 12 | 8 to 10 | 10 M; 2 F | Inclusion criteria: formal diagnosis of ADHD; Exclusion criteria: other medical diagnosis | n.s | On-state | HHE on a digitizing tablet; Copy task |
Shen et al., 2012 | 42 | 21 | 8.5 (1.2) | 17 M; 4 F | 21 | 8.5 (1.0) | 17 M; 4 F | Inclusion criteria: formal diagnosis of ADHD, with possible ODD and CD in the ADHD group; Exclusion criteria: epilepsy, severe anxiety, psychotic disorder, DCD (score < 15th centile on M-ABC 2) | 6 ADHD/I; 10 ADHD/C; 5 ADHD/HI | Off-state at least 24 hrs before the experiment | THPS; BRWT; Copy task and dictation task on a digitizing tablet |
Tucha & Lange, 2001 | 42 | 21 | 10.7 (0.4) | 21 M | 21 | 10.5 (0.4) | 21 M | Inclusion criteria: formal diagnosis of ADHD, with medication; Exclusion criteria: concurrent psychotropic medications, ADHD/I and ADHD/HI, reading disability or spelling disorder; Four children had mathematics disability | 21 ADHD/C | Off-state at least 10 hrs before experiment and on-state 1 hr after the administration | Copy task and dictation task on a digitizing tablet |
Tucha & Lange, 2004 | 20 | 10 | 9.9 (n.s) | 5 M; 5 F | 10 | 9.9 (n.s) | 5 M; 5 F | Inclusion criteria: formal diagnosis of ADHD, with possible ODD and CD in the ADHD group; Exclusion criteria: neurological and psychiatric disorders | n.s | On-state | Sentences production on a digitizing tablet |
Yoshimasu et al., 2011 | 5699 | 379 | 10.4 (4.6) | 284 M; 95 F | 5320 | n.s | 2666 M; 2654 F | Inclusion criteria: retrospective cohort-based study which has sought formal diagnosis of ADHD (based on DSM criteria); Exclusion criteria: IQ score < 50, written language disorder with or without reading disability | n.s | Possible medication | Information retrieved from individualized education program goals for written language and/or specific writing subtest scores ≤ 90; Legibility and/or writing subtest scores |
Study | Main Results |
---|---|
Adi-Japha et al., 2007 | ADHD children made more errors regarding letter insertions, substitutions, transpositions and omissions, produced confused shaped letters and replaced end-of-word letter with its simpler and more common middle-of-the-word version; Speed of handwriting did not differ between groups; No difference considering spatial features; ADHD children displayed poor time utilization, produced inconsistent and disproportionate writing accompanied by high levels of pressure and multiple corrections; Handwriting problems were associated with attentional problems and reflected an impairment in the graphemic buffer and in kinematic motor production |
Åsberg Johnels et al., 2014 | ADHD children obtained lower scores on parental ratings of handwriting |
Borella et al., 2011 | ADHD children produced fewer writing sequences than control groups; ADHD children showed greater IIV than control groups |
Capodieci et al., 2018 | No difference between groups considering handwriting speed; In condition without WM interference, ADHD children produced about 10 % fewer graphemes than control groups; In spatial condition, difference between groups was slightly greater (- 20 %), though not statistically significant; In verbal condition, ADHD children wrote significantly more slowly (- 38 %) than control groups; Handwriting of ADHD children was generally less legible than control groups, especially in verbal and spatial condition; ADHD group had a higher IIV in verbal condition than control groups; High IIV influenced the reduced speed in the case of the verbal condition for both groups |
Capodieci et al., 2019 | ADHD children made more spelling mistakes than control groups in all conditions; ADHD children who better coped with a concurrent verbal WM load had better spelling performance; ADHD children obtained lower scores for handwriting quality than control groups; No difference between groups in terms of writing speed |
Dirlokov et al., 2017 | ADHD children showed worse letter-form scores compared to control groups across conditions (copy, trace, fast trace); No difference in letter-spacing errors between groups; ADHD children made fewer speed inflections across conditions compared to control groups; Both groups showed a significant correlation between letter form and WM performance in the copy condition only |
Farhangnia et al., 2020 | In the copy task, ADHD children had lower global legibility scores compared to control groups; No significant difference between the two groups for space, alignment, size of letters and slant components of writing as well as for speed of writing; In the dictation task, ADHD children had lower legibility score compared to control groups while there was no difference between the groups in terms of space, alignment and slant components and size of letters |
Flapper et al., 2006 | ADHD+DCD children showed lower scores on quality of handwriting but there was no difference in speed of handwriting between groups; When on-state, of the 11 children with ADHD+DCD who could be assessed a second time, 6 improved their handwriting quality on the BHK, 4 did not improve and one child deteriorated; When assessed off-state, ADHD+DCD children did not improve their handwriting speed |
Frings et al., 2010 | Mean letter height did not differ between groups; Letter height increased during repeated writing of the same sentence in the ADHD group only |
Hung & Chang, 2022 | ADHD children had poorer writing performance than the control groups in both character dictation and character copying; ADHD children wrote less fluently and correctly compared to the control groups; Inattention was the stronger predictor of character dictation in ADHD children; Manual dexterity was significantly correlated with character copying in the ADHD group |
Johnson et al., 2013 | ADHD children made more total handwriting errors than control groups (i.e. correction and formation errors); No difference between groups in average height or width; No difference in the coefficient of variability of phrase height and width; No difference in average word spacing; ADHD children included additional strokes more often than control groups; There was a trend towards significant difference between the groups in terms of speed of handwriting, yet not significant; In the ADHD group, more corrections were associated with slower handwriting speed and maturational processes contributed to handwriting performance |
Langmaid et al., 2014 | ADHD children were more variable in terms of stroke length and showed inconsistent stroke height when compared to the control groups; No difference in the other kinematic variables; Symptom severity scores were correlated to variability of stroke height (vertical size); Higher scores on the inattentive and total ADHD subtests were significantly correlated with more variable writing size; Stroke duration was significantly related to hyperactive behavior such that a more hyperactive child had strokes of shorter duration (faster writing); Ballisticity was significantly associated with hyperactive behavior (more ballistic movement when symptoms of hyperactivity increased) |
Langmaid et al., 2016 | Despite both groups being significantly more inaccurate on the 40 mm task compared to 10 mm, ADHD children were unable to maintain the size of their cursive letter at the 40 mm size contrary to control groups; Groups were comparable on the 10 mm task; ADHD children had more ballistic movements on both tasks; Only pen pressure was positively correlated with inattention scores during the 10 mm task |
Laniel et al., 2020 | ADHD children showed poorer performance on quality scores (BHK), lower writing speed and higher writing size than control groups; On the Pen-stroke test, ADHD children displayed poorer motor planning and execution and greater variability in motor control than the control groups; In the ADHD group only, motor planning on the handwriting task correlated with speed of handwriting on BHK (the faster a child wrote, the shorter the motor production delay); ADHD children showed greater amplitude of movement on the Pen-stroke test which was associated with faster motor speed; No relationship between inattention and hyperactivity symptoms with motor control skills was measured on the Pen-stroke test |
Lofty et al., 2011 | 10 % of ADHD children had normal handwriting with no disability, 40% had excellent handwriting with a minimum of disability and 50% of ADHD children showed mild to moderate handwriting disability; ADHD children had poorer performance in respecting lines, spacing between words, letter direction, spelling a sentence and punctuation (item of the DDS); No difference between males and females in the ADHD group only on DDS scores; No correlation between DDS scores and age in the ADHD group only |
Okuda et al., 2011 | ADHD children manifested poorer performance regarding flowing lines, descending lines, retouched letters, curvatures and angles of "m", "n" and "u" letters; They produced more collisions and adherences, sudden movements, irregular size and incorrect form of letters |
Rosenblum et al., 2008 | Poorer performance of ADHD children when off-state versus on-state on most handwriting process and product measures; When off-medication, ADHD children showed more total time and more in-air time than when on-medication and compared to control groups; No difference in handwriting speed when compared on-state and off-state while on-state and off-state ADHD children wrote faster than control groups; No difference in product handwriting between on-state and off-state but ADHD children regardless of on or off-state differed in comparison to control groups |
Shen et al., 2012 | ADHD children scored lower on THSPC and on BSRWT; Despite speed of writing per se being no different between the two groups, ADHD children spent more on-paper time on the copy task and hence needed more time to end a copy task |
Tucha & Lange, 2001 | When off-state, the quality of handwriting specimens of hyperactive boys was poorer than on-state but more fluent; When off-state, ADHD children did not differ from control groups in handwriting movements; Hyperactive behavior improvement through MPH was associated with increased legibility and greater accuracy of handwriting |
Tucha & Lange, 2004 | When on-state, ADHD children displayed significantly more inversions in the direction of their velocity profiles than control groups; When off-state, there was no difference between the groups; The medication resulted in increased dysfluency during handwriting |
Yoshimasu et al., 2011 | ADHD girls tended to have a single specific writing difficulty whereas ADHD boys were more likely to have multiple writing difficulties (e.g. legibility + poor paragraph organization) |
Recommendations | Level |
---|---|
Eligible Population | |
Ensure a reasonable sample size necessary to conduct the study | high |
Verify the diagnosis of ADHD by formal diagnosis following DSM-5 indications and use of gold standard tools | high |
Verify the diagnosis of HD by standardized, valid and reliable tools | high |
Harmonize the comparator group(s) with previous studies to facilitate comparison | |
ADHD only | high |
HD only | high |
Typical | high |
Harmonize the reference group with previous studies to facilitate comparison | |
ADHD+HD | high |
Ensure children acceptability (motivation to study participation) | low |
Subgroup Analysis | |
Consider demographic characteristics | |
age | high |
gender | high |
handless | low |
IQ | high |
socioeconomic factor | low |
ethnicity | low |
cultural background | low |
Including documentation of ADHD subtypes | high |
Screen for comorbid emotional or behavioral conditions (eg, anxiety depression, sleep disturbance) | high |
Screen for comorbid neurodevelopmental conditions (eg, learning and language disorders, autism spectrum disorders) | high |
Screen for comorbid physical conditions (eg, tics). | low |
Treatment and Care | |
Considered ADHD specific treatment | |
methylphenidate | high |
other medication | low |
behavioral interventions as treatment of ADHD or comorbidities | high |
motor behavioral interventions (psychomotricity) | high |
Expert Panel | |
Harmonize measurement of key handwriting elements to facilitate pooling and comparison between study findings | high |
Use common outcome measures to facilitate pooling and comparison between study findings | high |
Supervise the experimental handwriting testing without knowing the child group (blind test) | low |
Assess the handwriting performance without knowing the child group (blind evaluation) | high |
Assess the handwriting performance by an expert panel of experiment judges (two or more) | high |
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