children

Review
Tools and Methods for Diagnosing Developmental Dysgraphia
in the Digital Age: A State of the Art
Jérémy Danna 1 , Frédéric Puyjarinet 2 and Caroline Jolly 3, *

1 University of Toulouse, Centre National de la Recherche Scientifique (CNRS), Laboratoire Cognition, Langues,
Langages, Ergonomie (CLLE), 31058 Toulouse, cedex 9, France; [email protected]
2 UFR de Médecine de Montpellier-Nîmes, Institut de Formation en Psychomotricité de Montpellier, 2 rue Ecole
de Médecine, CS 59001, 34060 Montpellier, cedex 2, France; [email protected]
3 University Grenoble Alpes, University Savoie Mont-Blanc, Centre National de la Recherche
Scientifique (CNRS), Laboratoire de Psychologie et NeuroCognition (LPNC), 38000 Grenoble, France
* Correspondence: [email protected]

Abstract: Handwriting is a complex perceptual motor task that requires years of training and
practice before complete mastery. Its acquisition is crucial, since handwriting is the basis, together
with reading, of the acquisition of higher-level skills such as spelling, grammar, syntax, and text
composition. Despite the correct learning and practice of handwriting, some children never master
this skill to a sufficient level. These handwriting deficits, referred to as developmental dysgraphia,
can seriously impact the acquisition of other skills and thus the academic success of the child if
they are not diagnosed and handled early. In this review, we present a non-exhaustive listing of the
tools that are the most reported in the literature for the analysis of handwriting and the diagnosis of
dysgraphia. A variety of tools focusing on either the final handwriting product or the handwriting
process are described here. On one hand, paper-and-pen tools are widely used throughout the world
to assess handwriting quality and/or speed, but no universal gold-standard diagnostic test exists.
On the other hand, several very promising computerized tools for the diagnosis of dysgraphia have
been developed in the last decade, but some improvements are required before they can be available
to clinicians. Based on these observations, we will discuss the pros and cons of the existing tools
and the perspectives related to the development of a universal, standardized test of dysgraphia
Citation: Danna, J.; Puyjarinet, F.;
combining both paper-and-pen and computerized approaches and including different graphomotor
Jolly, C. Tools and Methods for
and writing tasks.
Diagnosing Developmental
Dysgraphia in the Digital Age: A
State of the Art. Children 2023, 10,
Keywords: handwriting; developmental dysgraphia; product; process; diagnosis
1925. https://doi.org/10.3390/
children10121925

Academic Editor: Matteo

1. Handwriting: Acquisition and Role
Alessio Chiappedi
Handwriting, considered language by hand, is a complex perceptual motor task
Received: 15 November 2023 involving attentional, perceptual, linguistic, and fine motor skills. It occupies a large
Revised: 7 December 2023 proportion of children’s daily activities at school [1,2] and is the basis, together with
Accepted: 11 December 2023 reading, of the acquisition of higher-level skills such as spelling, grammar, syntax, and text
Published: 14 December 2023
composition. A relationship between the mastery of handwriting movement and the quality
of writing content has been established both at the semantic level in text production [3]
and at the orthographic level in word formation [4]. If children pay too much attention to
Copyright: © 2023 by the authors.
handwriting movements, they may have difficulties in the allocation of cognitive resources
Licensee MDPI, Basel, Switzerland. to higher-level processes.
This article is an open access article From a developmental perspective, handwriting originates from drawing, from which
distributed under the terms and it slowly differentiates as the child grows. In younger children, the quality of drawings is
conditions of the Creative Commons correlated to the quality of handwriting [5]. Then, with the acquisition of handwriting, this
Attribution (CC BY) license (https:// relationship between drawing quality and writing quality remains correlated but attenuates,
creativecommons.org/licenses/by/ with more discrepancies [6]. The formal acquisition of handwriting begins around the
4.0/). age of 5 at preschool, and its mastering requires about 10 years of practice and training.

Children 2023, 10, 1925. https://doi.org/10.3390/children10121925 https://www.mdpi.com/journal/children

Children 2023, 10, 1925 2 of 16

The automation of handwriting is partial at the age of 10 (5th grade) and is considered
almost complete around the age of 14 (9th grade) (for a review, see [7]). During acquisition,
handwriting evolves first in terms of quality (primarily between 1st and 5th grade), then in
terms of speed (from 4th grade onward, essentially). Efficient, fully automated handwriting
relies on a balance of speed and quality; it should be fast enough to allow the retranscription
of a course or the transcription of ideas and of sufficient quality to be readable by the writer
and by others.

2. Handwriting Deficits
Despite the correct learning and practice of handwriting, some children never mas-
ter this skill to a sufficient level of automation (reviewed in [8–10]). These handwriting
deficits, referred to as developmental dysgraphia in children, have been defined as a
written-language disorder that concerns mechanical writing skills in children of average
intelligence and with no distinct neurological or perceptual motor deficits [11]. Currently,
dysgraphia is not recognized as a disorder per se in the Diagnostic and Statistical Man-
ual of Mental Disorders, fifth edition (DSM-5) [12], or the International Classification of
Diseases, 11th edition (ICD-11). The DSM-5 only mentions “deficits in the fine motricity
required for handwriting” in the chapter dedicated to the development and evolution of
learning disorders. Due to the diversity of methodological approaches and the absence
of a consensual definition, the exact prevalence of dysgraphia is not known and probably
differs between countries and writing systems.
Dysgraphia is generally found in association with neurodevelopmental disorders,
namely dyslexia (DL), Developmental Coordination Disorder (DCD) and Attention Deficit
Disorder/Hyperactivity Disorder (ADHD) [13–18]. Dysgraphia preferentially affects boys
(3:1 ratio), most likely because of the prevalence of the associated disorders in boys [8,19].
Many studies have shown differences in handwriting deficits depending on the associated
disorder [20–26]. DCD primarily affects handwriting quality [22,27,28] while DL affects
both speed and, to a lesser extent, handwriting quality [26,29]. Children with comorbid
DL and DCD present nearly the same profile of difficulties as children with DL, although
with a much higher within-group variability. Comorbidity seems to lead to the addition of
DCD and DL writing difficulties but without aggravation of the deficits in each of the two
dimensions [24].
Dysgraphia can vary according to graphic and linguistic systems. Firstly, the per-
ceptual and motor complexities of different graphic systems vary widely. Some graphic
systems require many hours of practice to reach a comparable level of automation, while
others are much easier to learn. For example, the Kanji system, which requires a minimum
knowledge of 2136 essential kanji (jōyō kanji), according to the Japanese Ministry of Educa-
tion, even though they are made up of a large number of strokes (up to 23 strokes for the
most complex kanji), is much more complex than the Latin alphabet, which is based on
26 letters only. As a result, the risk of difficulty is much greater in the former than in the
latter. Secondly, within the same graphic system, some linguistic systems are also more
complex than others: in the grapheme–phoneme relationship, for example. Italian and
English are examples of transparent and non-transparent languages, respectively, for which
the amount of reading and writing practice can vary to reach the same level of expertise.
Knowing the interaction between orthographic and graphomotor constraints [4], one may
assume that the risk factor for developing dysgraphia is higher in the case of English than
in the case of Italian, especially when dysgraphia is subsequent to dyslexia [30].
Given the central role of handwriting in the acquisition of other skills, these deficits
can seriously hamper the acquisition of other skills [31–33]. It has been shown that, given
equal content, the worst quotes are attributed to less legible school works [34], resulting in
a decrease in the child’s self-esteem. Dysgraphia may thus impact the academic success
of a child if it is not diagnosed and handled early [35,36]. To this end, different tools are
available to allow researchers and clinicians to analyze the two dimensions of handwriting:
the final product and the dynamic process that generates the trace [37,38].
Children 2023, 10, 1925 3 of 16

Evaluation of the handwriting product refers to the static, spatial features of the written
trace. This kind of analysis is performed afterward. This is the principle of many tests used
in different countries (for a review, see [8]). The quality of the trace is evaluated based on
different features such as letter size and form, the spatial organization of handwriting on
the paper sheet, margins, etc.
Evaluating the handwriting process refers to the analysis of the dynamic, kinematic,
and temporal features of handwriting. Several types of variables can be analyzed, depend-
ing on the tools used for the evaluation: posture, finger and arm movements, pen grip and
finger pressure on the pen, in-air and on-paper durations, pen velocity, pen pressure, etc.
The increasing number of publications on the analysis of the handwriting process over the
past years attests to the growing interest of researchers in this field (e.g., [39–43]).
The objective of this review is to make a concise listing of the tools and methods that
are the most reported in the literature for the analysis of handwriting and the diagnosis
of dysgraphia. Tools focusing on both the final handwriting product and the handwriting
process will be considered. We will then discuss the pros and cons of the existing tools and
the perspectives for the development of future tools.

3. Handwriting Tools Based on the Product

In order to list the diagnosis tools based on the analysis of the handwriting product,
we searched two scientific browsers, PubMed and Google Scholar, using the following
keywords: Handwriting, Assessment, Test, Tool, Quality, Evaluation, Battery, Children,
Students, and Questionnaire.
The tools meeting our search criteria are listed in Table 1. We included only tools
for which the following data were available: norms or age class, type of task, subdomain
analyzed, and criteria evaluated.

Table 1. List of the most commonly used tools for the diagnosis of dysgraphia in children based on
the analysis of the handwriting product (presented in alphabetical order). N.A.: not available.

Duration
Tool Name Reference Age/Class Language Task(s) Subdomains
of Test
BHK: Brave Quality
[44] 1st to 5th grade 5 mn Multi-language Copy
Handwriting Kinder Speed
BHK Ado: Rapid Writing
Evaluation Scale for
Adolescents (Echelle Quality
[45] 6th to 9th grade 5 mn French Copy
d’Evaluation Rapide de Speed
l’Ecriture Chez
l’Adolescent)
BVSCO-3: Test for the Copy
Evaluation of Writing Dictation Speed
[46] 6–14 y Variable Multi-language
and Orthographic Spontaneous % of errors
Ability, 3rd ed. production
CHES: Children’s
Quality
Handwriting Evaluation [47] 3rd to 8th grade 2 mn English Copy
Fluency
Scale
CHES-M: Children’s
Handwriting Evaluation Quality
[48] 1st to 2nd grade 2 mn English Copy
Scale—Manuscript Fluency
Writing
Alphabet copy
DASH: Detailed at normal and
Assessment of Speed of [49] 9–16 y 14 mn English high speed Speed
Handwriting Spontaneous
production
Children 2023, 10, 1925 4 of 16

Table 1. Cont.

Duration
Tool Name Reference Age/Class Language Task(s) Subdomains
of Test
Spontaneous
DRHP: Diagnosis and
production
Remediation of [50] From 3rd grade Variable English Quality
from images
Handwriting Problems
observation
Copy
ETCH-M: Evaluation Dictation
Tool of Children’s Spontaneous Quality
[51] 1st to 2nd grade 15–20 mn English
Handwriting— production Speed
Manuscript Handwriting
from memory
EVEDP: Evaluation de la
Vitesse 2nd to 5th
[52] Variable French Dictation Speed
d’Ecriture—Dictée grade
Progressive
Alphabet
Copy
HHE: Hebrew Quality
[53] 6–18 y 5 min Hebrew Dictation
Handwriting Evaluation Speed
Spontaneous
production
HLS: Handwriting Spontaneous
[54] 9–14 y 10 mn English Quality
Legibility Scale production
Copy
Dictation
MMHAP: Mac Master
Preschool to 6th Spontaneous Quality
Handwriting [55] Variable English
grade production Speed
Assessment Protocol
Handwriting
from memory
MHA: Minnesota
Alphabet Quality
Handwriting [56,57] 1st to 2nd grade 2.5 mn English
Copy Speed
Assessment
QNST-3 Revised: Quick
Neurological Screening [58] 5–80 y 30 mn English Copy Quality
Test, 3rd ed. Revised
SCRIPT: Scale of
Children’s Readiness in [59] N.A. 3–8 mn English Copy Quality
Printing
Spontaneous
production
TOLH: Test of Legible 2nd to 12th
[60] Variable English Text Quality
Handwriting grade
composition at
school
Alphabet
THS-R [61] 6–18 y N.A. English Quality
Copy

Although mainly designed for a developmental population (from the age of 5 onward),
some diagnosis tools can also be used on adults up to the age of 80 (QNST-3; [58]). The
test duration is variable, from a few minutes to up to 30 min. This parameter is interesting
because deficits may not be visible during the first few minutes of handwriting but may
appear during a continuous handwriting task, as is the case in the classroom. The tasks used
in the tests are of three main types: copying a text or a sentence, writing under dictation
(letters, digits, words, or text), and spontaneous writing. These complementary tasks
explore different aspects of handwriting. The copy task is the easiest and can be used with
Children 2023, 10, 1925 5 of 16

beginner writers. Moreover, it resembles the condition of the classroom, where children are
often asked to copy texts. However, the reading component can pose problems for children
with dyslexia, introducing a possible bias in the interpretation of the test results. The
dictation task is ecological too, without the reading component, but the spelling processes
and the orthographic components may again pose problems for children with dyslexia.
Finally, the spontaneous writing task is likely to be the most relevant. The difficulty here is
the establishment of norms, since the texts produced are all unique. The general criteria
of legibility and quality are thus used in this case, which may provide a less fine-grained
analysis of handwriting.
It should be noted that one test includes an analysis of texts produced at school: the
TOLH (Test of Legible Handwriting [60]). Two others include writing from memory: the
ETCH-M (Evaluation Tool of Children’s Handwriting—Manuscript [51]) and the MMHAP
(Mac Master Handwriting Assessment Protocol [55]). Two tests also add another level of
analysis thanks to two conditions in the copy task: normal speed and maximum speed (the
DASH [49]). This approach is particularly interesting, since it mimics certain classroom
conditions, and it is well-known that adding constraints (temporal or spatial) during
handwriting helps reveal handwriting deficits [62,63]. Combining different tasks and/or
conditions can provide a fine and detailed analysis of handwriting. It is worth noting
that although these tasks are complementary, only three tests involve all three types: the
BVSCO-3 [46], the ETCH-M [51], and the MMHAP [55].
The majority of the tests listed in Table 1 analyze handwriting quality using different
criteria such as legibility, letter form, the spatial organization of letters or words, alignment,
etc. Some tests also measure handwriting speed by evaluating the number of characters
or letters (BHK [44]; French adaptation [64]; BHK-ado [45]; BVSCO-3 [46]; CHES-M [48];
ETCH-M [51]; EVEDP [52]; MMHAP [55]; MHA [56,57]) or the number of words produced
in a fixed period of time (DASH [49]; EVEDP [52]). Since a universal, gold-standard test
for the diagnosis of dysgraphia is not available, it is sometimes necessary to combine
several tests to perform an optimal clinical assessment. The DASH test appears to be the
most complete one, since it includes various types of tasks and different constraints of
writing and it requires about 15 min of writing. Its weakness is that it only evaluates
handwriting speed.
Finally, we should also mention the existence of questionnaires, which can be interest-
ing to use to complement the other tests. Indeed, these questionnaires provide subjective
information about the evaluation of handwriting quality by the teacher or the child, which
can be useful in the perspective of a rehabilitation program. In addition, these question-
naires could also be used for the screening of children with handwriting difficulties on a
larger scale. The Handwriting Proficiency Questionnaire (HPSQ [65]) has been developed
in different languages for children from 7 to 14 years old. It has to be completed by adults
(teachers or clinicians). An adaptation of this questionnaire, the HPSQ-C, was developed
later to inform about a child’s perception of his/her handwriting quality. This autoques-
tionnaire has been shown to be suitable for the identification of handwriting deficiency
among school-aged children and to be appropriated for clinical use [66]. Likewise, the
“questionnaire for children” [67] is an autoquestionnaire in which children self-report their
handwriting quality and difficulties. It targets children from 1st to 5th grade, but only a
French version is available.
Another important point to consider when choosing which test to use is the existence
of standards. Table 2 presents the psychometric properties of the main tests used both
in research and in clinical practice. A number of tests have relatively good inter-rater
and test–retest reliabilities (the French adaptation of the BHK, for example [64]), while
others have reached high validity-related standards (the MHA [56] and the TOLH [60],
for example).
Children 2023, 10, 1925 6 of 16

Table 2. Psychometric properties of the main diagnosis tools for handwriting assessment. BHK:
Brave Handwriting Kinder; CHES-M: Children’s Handwriting Evaluation Scale for Manuscript
writing; DASH: Detailed Assessment of Speed of Handwriting; DRHP: Diagnosis and Remediation
of Handwriting Problems; ETCH-M: Evaluation Tool for Children’s Handwriting—Manuscript; HHE:
Hebrew Handwriting Evaluation; HPSQ: Handwriting Proficiency Screening Questionnaire; THS-R:
Test of Handwriting; TOLH: Test of Legible Handwriting; N.A.: not available.

Test Name Number of Country of Inter-Rater Test–Retest Internal

Validity
[Ref] Participants Validation Reliability Reliability Consistency
Content and
BHK [11,44] 121 Netherlands .71 to .89 .74 to .86 N.A.
construct
BHK—French Content and
837 France .68 to .90 .80 to .92 N.A.
Adaptation [64] construct
BHK Ado [45] 471 France Construct .24 to .66 N.A. N.A.
.82 to .93 for
BHK—Italian
Content and speed
adaptation 562 Italy N.A. N.A.
construct .42 to .63 for
[68,69]
quality
CHES-M [48] 643 USA N.A. .85 to .93 N.A. N.A.
Content and
DASH [49] 1163 Netherlands .85 to .99 .50 to .92 .81 .88 to .94
construct
DRHP [50] 300 UK Construct .61 to .65 N.A. N.A.
ETCH-M [51] N.A. N.A. N.A. .75 to .92 .63 to .77 N.A.
Content and
HHE [53] N.A. Israël .75 to .79 N.A. N.A.
construct
Content and
HPSQ [65] 230 Israël .92 .84 .90
construct
Content and
MHA [56,57] N.A. USA .87 to .98 .58 to .94 N.A.
construct
THS-R [61] N.A. USA Construct N.A. .82 N.A.
Content and
TOLH [60] 1723 USA .95 .90 .86
construct

More recently, a few computerized diagnostic tools based on the analysis of the final
products of handwriting have also been developed. They are listed in Table 3.

Table 3. List of the computerized diagnosis tools in children based on the analysis of the handwriting
product. CNN: Convolutional Neural Network; RF: Random Forest; SVM: Support Vector Machine;
ANN: Artificial Neural Network.

Characteristics
Ref Age/Class Task(s) Language Approach Performances
of Participants
Sensitivity: 83%
Algorithms for
[70] 7–10 y Dysgraphic BHK (5 lines) Italian Specificity: 98%
document analysis
Precision: 96%
Letter and digit Machine learning
[71] 7–12 y Dyslexic Malaysian Sensitivity: 73%
writing (ANN)
Typically Letters, syllables, Machine learning
Precision:
[72] 8–15 y developing and words, pseudowords, Slovak (CNN, RF, SVM,
79.7%
dysgraphic and sentences AdaBoost)
Children 2023, 10, 1925 7 of 16

These algorithms are all based on pattern recognition methods using images of letters,
digits, words, or sentences. They use a large database of images from which the char-
acteristic features of “poor writing” are extracted and analyzed using machine learning
approaches. The performances of computer tools are evaluated using a series of criteria.
Precision, also called the positive predictive value, is defined as the number of correct
classifications of dysgraphic children divided by the total number of classifications. Sensi-
tivity represents the true-positive detection rate (the correct classification of children with
dysgraphia). Specificity represents the true-negative detection rate (the correct classification
of typically developing children).
As shown in Table 3, the performance of these classification tools is below that of
the paper-and-pen tools listed above (73% for [71]; 79.7% for [72]). The only exception
is TestGraphia, the algorithm developed by Dimauro et al. [70], with good performances
very close to that of the original BHK test. It analyzes the same criteria as the original
BHK test [68] but using scanned images of the BHK texts. The sensitivity of TestGraphia is
83%, and its specificity is 98%. This algorithm thus seems very promising for the future
development of computerized diagnostic tools.

4. Handwriting Tools Based on the Process

Collecting the spatio–temporal characteristics of a written trace has become possible
thanks to the development of digital tablets. The principle is simple: the tablet records the
x, y, and sometimes z (up to 2 cm) positions of the pen with a high frequency (every 5 or
10 milliseconds), as well as the time, the pen pressure, and the angle of the pen to the tablet.
From these data, a large variety of static (size, alignment. . .), kinematic (speed, acceleration,
jerk. . .), and dynamic (pen pressure, pen tilt. . .) features can be calculated. To avoid the
undesirable effects of loss of surface roughness (e.g., [1]), a sheet of paper must be attached
to the digital tablet and an ink pen compatible with the tablet must be used.
Over the last decades, a growing number of studies have focused on the development
of tools for the diagnosis of dysgraphia using digital tablets. In this review, we present a
non-exhaustive overview of these tools, which are not yet available to clinicians (Table 4).

Table 4. List of the algorithms and computer tools for the diagnosis of handwriting deficits. In
blue: tools based on statistical approaches; in black: tools based on machine learning approaches.
ADHD: Attention Deficit/Hyperactivity Disorder; BEM: Beta-Elliptic Model; BVSCO-2—Test for
the Evaluation of Writing and Orthographic Ability, 2nd ed.; CNN: Convolutional Neural Network;
DG: dysgraphic children; FDM: Fourier Descriptor Model; FOD: Fractional Order Derivative; KNN:
K-nearest Neighbors; MHA: Minnesota Handwriting Assessment; MLP: Mumti Layers Perceptron; P:
precision; RBF: Radial Basis Function; RF: Random Forest; SE: sensitivity; SP: specificity; TD: typically
developing children.

Language/ Criteria
Reference Age/Class n Tasks Approach Performances
Alphabet Analyzed
Static
SE: 96.6%
242 TD Copy of a text Kinematic
[73] 6–10 y French RF SP: 99.2%
56 DG (BHK) Pressure
P: 97.98%
Pen tilt
390 TD Letters, words, PCA + K-means Static SE: 91%
[39] 5–12 y French
58 DG sentences clustering Kinematic SP: 90%
39 TD Letters, words,
[74] 10–13 y Slovak SVM Kinematic SE: 75.5%
39 DG sentences
Children 2023, 10, 1925 8 of 16

Table 4. Cont.

Language/ Criteria
Reference Age/Class n Tasks Approach Performances
Alphabet Analyzed
SE: 75.1%
(RF)
SVM, RF, MLP, extra
SP: 72.1%
262 TD Copy of graphic trees, AdaBoost,
[75] 7–11 y N.A. Kinematic (MLP)
63 DG shapes Gaussian Naive
P: 73%
Bayes
(extra trees),
73.4% (RF)
SE: 91%
458 TD Copy of a text Kinematic
[76] 7–11 y French SVM SP: 81%
122 DG (BHK) Spatial
P: 86%
Letters, syllables,
words, SE: 79.7%
63 TD
[40] 8–15 y pseudowords, Slovak AdaBoost, RF, SVM Kinematic SP: 76.7%
57 DG
sentences with P: 80%
speed constraints
Copy of words Statistical
76 TD Kinematic
[77] 5–8 y (8y), graphic Italian comparisons between N.A.
28 DG Pressure
shapes (5 and 8 y) groups
Subtest of the
BVSCO-2 (digits,
Statistical
[78] 7–8 y 52 TD sequences of Italian Kinematic N.A.
comparisons
small and large
loops, words)
241 SE: 75%
Copy of graphic One-dimensional
[79] 5y “at-risk of N.A. Kinematic SP: 77%
shapes CNN
DG” P: 76%
26 TD Statistical Static
[80] 6–7 y MHA English N.A.
9 DG comparisons Kinematic
26 TD Q factor wavelet
Copy of graphic Static
[81] 8–12 y Czech transform + statistical P: 84%
27 DG shapes Kinematic
comparisons
Statistical Static
218 TD Copy of a text comparisons between Kinematic
[82] 7–10 y French N.A.
62 DG (BHK) groups (linear Pressure
regression), clustering Pen tilt
Dictation of Statistical correlations
5 TD Static
[83] 6–11 y letters and digits English between manual and N.A.
9 ADHD Kinematic
MHA digital data
Copy of words,
RF, decision tree, SE: 92.8%
[84] 7–12 y 60 sentences, and Latin Kinematic
SVM P: 92.6%
graphic shapes
Kinematic
63 TD Letters, words, KNN, SVM, RF, SE: 78.5%
[85] 8–15 y Slovak (on-surface
57 DG sentences AdaBoost P: 80.8%
and in-air)
27 TD RF, linear
[86] 8y Letters Hebrew Kinematic SE: 96%
27 DG discriminant analysis
61 TD Copy of patterns
[87] 8–9 y Czech XG-Boost Kinematic SE: 90%
15 DG and figures
Statistical
14 TD Static
[88] 8–9 y Copy of a text Hebrew comparisons between N.A.
14 DG Kinematic
groups
Children 2023, 10, 1925 9 of 16

Table 4. Cont.

Language/ Criteria
Reference Age/Class n Tasks Approach Performances
Alphabet Analyzed
SE: 90%
50 TD Copy of letters Static
[42] 8–9 y Hebrew SVM SP: 90%
49 DG and sentences Kinematic
P : 89.9%
Spontaneous
writing
[89] 8–11 y 32 TD Indonesian SVM and RBF Kernel Kinematic P: 82.5%
(sentences),
drawings
Tunable Q-factor SE: 88.7%
33 TD
[90] 8–9 y Copy of a text Czech wavelet transform, RF Kinematic SP: 83%
32 DG
and SVM classifiers P: 84.7%
Correlation between
30 TD Spontaneous
[91] 8–9 y Czech the kinematic features Kinematic N.A.
25 DG writing of letters
and the HPSQ-C

The different digital tools for the diagnosis of dysgraphia, presented in Table 4, com-
bine dynamic, kinematic, and static features extracted from handwritten tracks. These
features are then analyzed using mainly machine learning approaches to classify the data
(i.e., classifiers). These tools differ by the natures of the tasks analyzed (handwriting or
graphomotor tasks), the sizes of the datasets, and the computational approaches used to
analyze the data.
Of the 22 studies reported here, four used graphomotor tasks; the others used hand-
writing alone or a combination of handwriting and drawings. It is interesting to mention
that several studies have used tasks that have been validated in clinical practice, such
as the BHK [39,73,76,82], the BVSCO2 [78], or the Minnesota Handwriting Assessment
(MHA [80]).
The size of the dataset used varied between 35 and 580 participants, and the children
included in the different studies were between 5 and 15 years of age.
Nine studies used classical statistical comparisons to identify discriminative features
between groups (in blue in Table 4; [39,77,78,80–83,87,91]). The others (in black in Table 4)
used different algorithms of machine learning (Random Forest, Support Vector Machine,
Convolutional Neuron Network, etc.) to classify children into different groups. These
methods are called “supervised learning approaches”, since the algorithm was trained to
identify groups that were previously labeled. Most of the studies reported here present a
simplistic classification of children in two groups: with or without dysgraphia. Only one
study classified the children into four groups: typically developing, with mild dysgraphia,
with mean dysgraphia, and with severe dysgraphia [89]. This approach is interesting, since
it considers dysgraphia as a continuum of severity. This is probably closer to reality than a
dichotomic classification, as has been recently suggested by Lopez and Vaivre-Douret [92],
who have described three levels of handwriting disorders in children from 1st to 5th grade:
mild disorder, moderate disorder, and dysgraphia.
The tools based on the analysis of handwriting samples obtained the best classification
performance. For example, Asselborn et al. [73] reached a sensitivity of 96.6% and a
specificity of 99%, and Mekyska et al. [86] reached a sensitivity of 96%. It is worth noting,
however, that the excellent performances obtained in [73] must be considered with caution,
since they may be biased by the fact that the authors only included participants with severe
dysgraphia [93]. The most discriminative features between children with and without
dysgraphia varied among the studies but generally included a larger size in dysgraphic
handwriting, numerous velocity variations, a lower mean speed, increased lift and stop
duration, and variations in the pen angle to the tablet.
Children 2023, 10, 1925 10 of 16

The tools based on the analysis of drawing samples appeared promising too, although
their performances were slightly lower than of those based on handwriting. For instance,
the algorithm developed by Mekyska et al. [87] obtained a sensitivity of 90%. The idea
that dysgraphia can be identified based on graphomotor tasks suggests that it can be
independent from higher-order processes, namely linguistic ones. Developing diagnostic
tools based on drawings is interesting for two reasons: these tools would be more universal,
since they are independent of the language and the alphabet, and they can be used with
younger children to identify “at-risk” children, which could be handled earlier.
Developing a computer tool for the diagnosis of dysgraphia is not trivial, as attested to
by the variability in the performances of the tools presented in Table 4. Several reasons can
explain these differences. First, the variety of the tasks used and the number of participants
led to large differences in the sizes of the databases, which was a critical determinant
in a classifier’s performances. Second, a large panel of machine learning approaches
was used, with different numbers of features analyzed among studies. Although certain
classification methods appeared better than others (Random Forest, for example), none
have currently reached excellent performances. Since the interest of researchers in these
tools is growing, it seems obvious that their efficiency will rapidly be improved. To do so,
however, a number of key elements will be important to consider. First, it will require the
constitution of large databases of handwriting and drawing samples from children that are
perfectly characterized from a clinical point of view. It will also be necessary to estimate the
severity of dysgraphia and not only provide a dichotomic classification of children with or
without dysgraphia, as proposed by Sihwi et al. [89]. Moreover, other processes involved
in handwriting, such as visuomotor aspects, which are currently being investigated [94],
would be interesting to include in future diagnostic tools. Finally, it is also worth noting
that diagnostic tools fully integrated into the pen and using machine learning approaches
are also under investigation [95–97].

5. Perspectives: Toward a Universal Standardized Test of Dysgraphia?

Since dysgraphia is a very heterogenous disorder encompassing a large variety of
difficulties, it would be interesting to think about developing a reliable, comprehensive, and
universal diagnostic tool for dysgraphia, combining computer and paper-and-pen tools.
The main diagnostic features assessed with the paper-and-pen tools can be complemented
with the computerized tools, which would provide precise information about the specific
handwriting difficulties of each child (for a review, see [43]).
Several important points need to be considered for the development of such an
instrument. First, an “ideal” diagnostic tool would probably combine computer and paper-
and-pen approaches, since they are complementary and provide distinct information on
the writing process and product, respectively. A fully computerized tool could also be
envisaged, provided that it is complemented by the assessment of a clinician, who must
remain the reference assessor. Indeed, the spread of tablets and the rapidity of computerized
analyses could allow the collection of written samples in school or at children’s houses;
they could then be sent to a clinician. Standard pen-and-paper tools could subsequently
be used in case the computer tools detect a risk of dysgraphia in the child’s handwritten
productions in order to firmly confirm the diagnosis. From this perspective, the goal of the
computer tools is thus not to replace the clinician or the existing, validated tests but to help
in screening larger populations of children and in facilitating clinician diagnosis (Figure 1).
In addition, these tools could provide valuable information on the process of handwriting
itself by identifying dynamic or kinematic features that may be altered in each particular
child. This information would be very relevant to clinicians, since it would offer cues for
an individualized rehabilitation of handwriting.
Children 2023, 10, x FOR PEER REVIEW 11 of 16
Children 2023, 10, 1925 11 of 16

Figure
Figure1.1.Examples
Examplesofofthethecomplementary
complementary use of of paper-and-pen
paper-and-penteststestsand
andcomputerized
computerized tools
tools forfor
thethe
diagnosis
diagnosisand
andrehabilitation
rehabilitationof
of handwriting deficits.In
handwriting deficits. Inaddition
additiontotohandwriting
handwriting traces
traces collected
collected
bybyclinicians using
clinicians standard
using standardpaper-and-pen
paper-and-pentools,
tools,written
writtensamples
samples could
could also bebe
also collected
collectedusing
usingtab-
lets and/or smart pens, both by clinicians (top panel) and by teachers in their classrooms
tablets and/or smart pens, both by clinicians (top panel) and by teachers in their classrooms (bottom (bottom
panel).
panel).Kinematic
Kinematicfeatures
featuresreflecting
reflecting the
the handwriting processcould
handwriting process couldthen
thenbebeextracted
extracted from
from these
these
computerized traces and transmitted by the teachers to the clinicians. The practitioner
computerized traces and transmitted by the teachers to the clinicians. The practitioner could combine could com-
bine all these static, dynamic, and kinematic parameters with the evaluation of other skills to even-
all these static, dynamic, and kinematic parameters with the evaluation of other skills to eventually
tually propose a complete diagnosis and an adapted rehabilitation program for the children.
propose a complete diagnosis and an adapted rehabilitation program for the children.

Second,
Second,using
using aa combination
combinationofoftasks tasks targeting
targeting different
different skillsskills
seemsseems
crucialcrucial
to pro-to
providing
viding moremoreinformation
information about
about handwriting
handwriting difficulties.
difficulties. Indeed,
Indeed, some
some children
children with
with
dysgraphia
dysgraphiamay maysucceed
succeedat atcertain
certain tasks
tasks and thusthus bebeundiagnosed
undiagnosedififonly onlya asingle
single one
one is is
used.
used.Combining
Combiningdifferent
different tasks
tasks in inaaunique
uniquetest testwould
would thusthus greatly
greatly increase
increase its efficacy,
its efficacy, as
ashas
hasbeen
beenpreviously
previously suggested
suggested by Safarova
by Safarovaet al.et
[98].
al. Namely, the testthe
[98]. Namely, should include include
test should spon-
taneous handwriting,
spontaneous handwriting, the copying
the copying of words and/or
of words sentences,
and/or writingwriting
sentences, to dictation, digit
to dictation,
writing, writing under speed and accuracy constraints, and drawing
digit writing, writing under speed and accuracy constraints, and drawing and/or graph- and/or graphomotor
tasks. tasks.
omotor Temporal (i.e., speed)
Temporal and spatial
(i.e., speed) (i.e., size)
and spatial (i.e.,constraints add a cognitive
size) constraints load and
add a cognitive load
are known to increase handwriting difficulties [16,61,62]. With regard to the spontaneous
and are known to increase handwriting difficulties [16,61,62]. With regard to the sponta-
production task, we could, for example, ask the participant to write a seven-sentence text
neous production task, we could, for example, ask the participant to write a seven-sen-
corresponding to the writer’s ideal weekly schedule. This would enable a specific analysis
tence text corresponding to the writer’s ideal weekly schedule. This would enable a spe-
of the days of the week to be made, which would be common to all texts produced. As
cific analysisabove,
mentioned of thethedays of theofweek
addition to be made,
graphomotor and/or which would
drawing bewhich
tasks, common to all texts
are language-
produced. As mentioned
independent, would enable above,the the addition
targeting of graphomotor
of younger and/or
children more drawing
than tasks,tests
the existing which
are
and thus the earlier detection and handling of children “at-risk” of dysgraphia. In addition,the
language-independent, would enable the targeting of younger children more than
existing
it wouldtests andathus
provide the earlier
universal detection
test, allowing and handling
comparisons between of countries
childrenand “at-risk” of dys-
alphabetical
graphia.
systems.InInaddition,
addition, it thewould provide
test needs to lasta at
universal
least 20 min test,inallowing comparisons
order to enhance between
the difficulty
countries and
of the task andalphabetical
induce fatigue. systems.
Finally,Incompleting
addition, the the test
testwith
needs to last at least 20would
a self-questionnaire min in
enable the clinician to better characterize the difficulties experienced
order to enhance the difficulty of the task and induce fatigue. Finally, completing the test by the writer.
with a self-questionnaire would enable the clinician to better characterize the difficulties
experienced by the writer.
Thirdly, the choice of the cohort of participants would be crucial. A large develop-
mental window ranging from 5 to at least 15 years old should be included, and the content
Children 2023, 10, 1925 12 of 16

Thirdly, the choice of the cohort of participants would be crucial. A large developmen-
tal window ranging from 5 to at least 15 years old should be included, and the content
of the test should be adapted depending on the age and/or class of the child and the
level of handwriting automation. The number of participants should be important enough
to allow machine learning approaches. It would also be important to include children
presenting dysgraphia in various clinical contexts and precisely characterized from a clin-
ical perspective. This would enable the evaluation of the severity of dysgraphia, which
could eventually be an additional evaluation criterion provided by the diagnostic tool.
Finally, participants should be recruited in multiple sites that are representative of different
socio-economic and educational statuses.
Developing such a complete diagnostic tool implies the collection of large databases
of handwriting and drawing samples in different places around the world. This would
be possible with the implication of a consortium of laboratories and clinicians. Besides
the diagnostic tool itself, the benefits of these developments would be twofold: (i) from
a clinical perspective, it would allow the estimation of the prevalence of dysgraphia in
different countries, and it would further tailor rehabilitation programs to the characteristics
of handwriting difficulties; and (ii) from a research perspective, it would provide large,
annotated databases that could be freely available to researchers working in the fields of
graphonomics, whether in educational, clinical, or human movement sciences.

Author Contributions: Writing—original draft preparation, C.J.; writing—review and editing, C.J.,
F.P. and J.D. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Data sharing not applicable.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design
of this study; in the collection, analysis, or interpretation of the data; in the writing of the manuscript;
or in the decision to publish the results.

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