Handwriting in children with ADHD

Associations of ADHD-Risk and Motor Competence With School Functioning

OBJECTIVES

This study investigated the unique associations of motor competence and ADHD risk status on school functioning. Additionally, this study examined the factor structure of the Bruininks-Oseretsky Test of Motor Proficiency, Short Form (BOT2-SF).

METHODS

Participants included early elementary school children (N = 202, Mage = 6.83, SD = 0.96, Male = 53.5%, ADHD-risk = 46.5%). Child assessments of motor competence and teacher and parent reports of school functioning were used.

RESULTS

A two-factor model of the BOT2-SF with correlated fine and gross motor factors and correlated residuals best fit the data. Fine and gross motor competence were unique positive predictors of academic performance, after accounting for the effects of ADHD-risk on academic performance. ADHD-risk was the only unique predictor of adaptive school behavior.

CONCLUSION

Findings suggest that assessing for ADHD and motor competence in children demonstrating school functioning problems may better allow for targeted intervention in school.

Is There a Deficit in Product and Process of Handwriting in Children with Attention Deficit Hyperactivity Disorder? A Systematic Review and Recommendations for Future Research

Handwriting abnormalities in children with attention deficit hyperactivity disorder (ADHD) have sometimes been reported both (i) at the product level (i.e., quality/legibility of the written trace and speed of writing) and (ii) at the process level (i.e., dynamic and kinematic features, such as on-paper and in-air durations, pen pressure and velocity peaks, etc.). Conversely, other works have failed to reveal any differences between ADHD and typically developing children. The question of the presence and nature of handwriting deficits in ADHD remains open and merits an in-depth examination. The aim of this systematic review was, therefore, to identify studies that have investigated the product and/or process of handwriting in children with ADHD compared to typically developing individuals. This review was conducted and reported in accordance with the PRISMA statement. A literature search was carried out using three electronic databases. The methodological quality of the studies was systematically assessed using the Critical Appraisal Skills Program (CASP) criteria. Twenty-one articles were identified. Of these, 17 described handwriting quality/legibility, 12 focused on speed and 14 analyzed the handwriting process. All the studies (100%) with satisfactory methodology procedures reported an impaired product and process in children with ADHD, while 25% evidenced a difference in the speed of production. Most importantly, the studies differed widely in their methodological approaches. Substantial gaps remain, particularly with regard to ascertaining comorbidities, ADHD subtypes and the medical status of the included children. The lack of overall homogeneity in the samples calls for higher quality studies. We conclude with recommendations for further studies.

Handwriting legibility and fluency and their patterns of concurrent relations with spelling, graphomotor, and selective attention skills

Recent research suggests that handwriting comprises two separate subskills: legibility and fluency. It remains unclear, however, how these subskills differ in their relationship to other abilities associated with handwriting, including spelling, graphomotor, and selective attention skills. In this study, we sought to examine the extent and nature of concurrent relationships that may exist among these skills. Children in Year 3 (n = 293), Year 4 (n = 291), and Year 5 (n = 283) completed a large, group-administered battery to assess each of the above skills. Using multigroup structural equation modeling, we found that spelling, graphomotor, and selective attention skills together explained a moderate amount of variance in handwriting legibility (R2 = .37-.42) and fluency (R2 = .41-.58) and that these subskills differed in their concurrent relations. Graphomotor skills accounted for a relatively greater proportion of variance in legibility than did spelling. Conversely, there were relatively stronger contributions from variations in spelling ability to variations in fluency than from graphomotor skills. Furthermore, selective attention predicted handwriting fluency only, and it partially mediated the influence of graphomotor skills. This study further demonstrates that handwriting legibility and fluency are separable and complex skills, each differentially related to spelling, graphomotor, and attentional abilities even during later primary school years.

Psychomotor intervention to improve handwriting skills in children with ADHD: A single-case experimental design with direct inter-subject and systematic replications

Dysgraphia is highly prevalent in children with attention deficit hyperactivity disorder (ADHD) and adversely affects academic and developmental trajectories. To date, no study has rigorously examined the effects of a training program on handwriting quality in this specific population. Our objective was thus to develop an innovative program - we entitled PRO-PEN - and to evaluate its effects. We planned a multiple-baseline design across participants from grade 3-5, with direct inter-subject and systematic replications. Children of Group 1 (n = 4) were diagnosed with ADHD. Systematic replication was conducted in a second group of participants (Group 2, n = 4) with a diagnosis of developmental coordination disorder in addition to ADHD. The primary assessment focused on quality of handwriting. Generalization measures evaluated diverse neuropsychological and behavioural domains. In Group 1, effect sizes regarding handwriting quality were large (Taus > .60). Improvement was also observed for children of Group 2 (Taus > .50). Importantly, the positive effects persisted three months after the end of the training. Generalization effects extended beyond handwriting sphere. Therefore, PRO-PEN can be considered a promising training program for improving handwriting quality in ADHD, with a possible impact on wide cerebral regulation loops underpinning both handwriting and other neuropsychological and behavioural domains.

Functional Assessment of Handwriting Among Children: A Systematic Review of the Psychometric Properties

IMPORTANCE

Handwriting legibility and speed assessments have a critical role in identifying and evaluating handwriting problems, which are common among children.

OBJECTIVE

The objective was to evaluate the psychometric properties and clinical utility of handwriting assessments for children ages 3 to 16 yr.

DATA SOURCES

A systematic review was conducted in CINAHL, PubMed (MEDLINE), Scopus, and education databases, with no time limits. The search strategy included a combination of the following keywords: handwriting, write, children, assessment, and validity. The exclusion criteria were assessment tools that were electronic, that focused on cognitive components of handwriting, or that only evaluated alphabets other than Latin.

STUDY SELECTION AND DATA COLLECTION

The systematic review was carried out on the basis of the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The protocol was registered in the Prospective Register of Systematic Reviews (PROSPERO).

FINDINGS

The 14 included instruments had a total sample of 4,987 children. Internal consistency ranged from moderate (.73; Writing Readiness Inventory Tool in Context) to high (.98; Letter Writing). The interexaminer reliability values of the 11 direct assessment instruments ranged from .77 (Systematic Screening for Handwriting Difficulties) to 1.00 (Handwriting Speed Test).

CONCLUSIONS AND RELEVANCE

In this systematic review, existing tools were evaluated by clinical utility and the quality of psychometric properties. Direct assessments showed good psychometric properties. Indirect and self-assessment tools demonstrated poor psychometric properties. Further research on screening tools and tools in other languages is needed. What This Article Adds: Specific learning disorders (e.g., dysgraphia) negatively affect academic learning and, when prolonged in time, self-concept. However, handwriting legibility and speed assessments could be used to identify and evaluate these learning disorders if an early referral to occupational therapy is carried out.

Enhancing Executive Functions and Handwriting with a Concentrative Coordination Exercise in Children with ADHD: A Randomized Clinical Trial

Handwriting difficulties are common in children with Attention-Deficit/Hyperactivity Disorder (ADHD), and they have been associated with lower academic achievement and self-esteem. Our aim in this study was to determine if training coordination of the head, eyes, and arm and engaging in the necessary visual concentration associated with table tennis would improve executive functions and school-based handwriting among children with ADHD. We designed a randomized controlled trial to explore the therapeutic efficacy of this table tennis training and recruited 48 children with ADHD that we randomly assigned to one of three equal-sized training groups: (a) actual table tennis, (b) simulated table tennis (exergame), or (c) a control group receiving no additional training. The training intervention lasted 12-weeks in which the two different table tennis trainings (i.e., actual or simulated) were scheduled for three one-hour sessions per week. Outcome measures included a computerized handwriting evaluation, the Stroop test, and the Wisconsin Card Sorting Test (WCST). Participants in each table tennis training group showed significant improvements in handwriting performance, response time, and required time to achieve automation. Both intervention groups also showed significant improvements on the Stroop Color-Word test, but only the actual table tennis training group showed a significant improvement on the WCST. This study provided evidence of at least short-term improvements in executive functions and handwriting problems in children with ADHD through their participation in table tennis motor coordination activities.

A rapid systematic review of attention-deficit/hyperactivity disorder (ADHD) and high order writing: Current findings and implications for intervention

BACKGROUND

Theoretical writing models and empirical studies have suggested a possible strong association between attention-deficit/hyperactivity disorder (ADHD) and high order writing (e.g., planning, text production, and revising).

AIM

A rapid systematic review was conducted to examine this relationship with the aim of informing writing interventions specific to the ADHD population.

METHOD

A systematic search for empirical studies on ADHD and high order writing performance from the last two decades identified 18 eligible studies.

RESULTS

Most studies showed that, compared to their peers, students with ADHD have more significant difficulties in high order writing performance. Writing quality and writing process (e.g., planning and editing) were identified as a challenge for ADHD students and may be more challenging than writing productivity and meta-cognitive knowledge of writing. Individuals' inattention, short-term memory, working memory, executive functions, reading, oral language skills, and externalising behavioural problems were identified as significant predictors of high order writing performance.

CONCLUSIONS AND IMPLICATIONS

The findings support theoretical writing models that propose writing as a complex process influenced by multiple cognitive factors, which are commonly impaired in individuals with ADHD. Interventions specific to the identified problems are discussed.

How effective is fine motor training in children with ADHD? A scoping review

Background

Motor deficiencies are observed in a large number of children with ADHD. Especially fine motor impairments can lead to academic underachievement, low self-esteem and frustration in affected children. Despite these far-reaching consequences, fine motor deficiencies have remained widely undertreated in the ADHD population. The aim of this review was to systematically map the evidence on existing training programs for remediating fine motor impairments in children with ADHD and to assess their effectiveness.

Methods

The scoping review followed the PRISMA-ScR guidelines. In March 2020, PsycINFO, MEDLINE (PubMed), Web of Science, Google Scholar and The Cochrane Database of Systematic Reviews were searched for evidence. The eligibility criteria and the data charting process followed the PICO framework, complemented by study design. The investigated population included children with a formal ADHD diagnosis (either subtype) or elevated ADHD symptoms aged between 4 and 12 years, both on and off medication. All training interventions aiming at improving fine motor skills, having a fine motor component or fine motor improvements as a secondary outcome were assessed for eligibility; no comparators were specified.

Results

Twelve articles were included in the final report, comprising observational and experimental studies as well as a review. Both offline and online or virtual training interventions were reported, often accompanied by physical activity and supplemented by training sessions at home. The training programs varied in length and intensity, but generally comprised several weeks and single or multiple training sessions per week. All interventions including more than one session were effective in the treatment of fine motor deficiencies in children with ADHD and had a wide range of additional positive outcomes. The effects could be maintained at follow-up.

Conclusions

Fine motor training in children with ADHD can be very effective and multiple approaches including specific fine motor and cognitive training components, some kind of physical activity, feedback mechanisms, or multimodal treatments can be successful. Training programs need to be tailored to the specific characteristics of the ADHD population. A mHealth approach using serious games could be promising in this context due to its strong motivational components.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02916-5.

Oculomotor deficits in attention deficit hyperactivity disorder (ADHD): A systematic review and comprehensive meta-analysis

Atypical motor coordination and cognitive processes, such as response inhibition and working memory, have been extensively researched in individuals with attention deficit hyperactivity disorder (ADHD). Oculomotor neural circuits overlap extensively with regions involved in motor planning and cognition, therefore studies of oculomotor function may offer unique insights into motor and cognitive control in ADHD. We performed a series of pairwise meta-analyses based on data from 26 oculomotor studies in ADHD to examine whether there were differences in performance on visually-guided saccade, gap, antisaccade, memory-guided, pursuit eye movements and fixation tasks. These analyses revealed oculomotor disturbances in ADHD, particularly for difficulties relating to saccade inhibition, memorizing visual target locations and initiating antisaccades. There was no evidence for pursuit eye movement disturbances or saccade dysmetria. Investigating oculomotor abnormalities in ADHD may provide insight into top-down cognitive control processes and motor control, and may serve as a promising biomarker in ADHD research and clinical practice.

Phenotyping features in the genesis of pre-scriptural gestures in children to assess handwriting developmental levels

Acquiring writing skills is a long developmental process that is conditioned by both the mastery of the gesture and the spatio-temporal arrangement of characters across the page. While the researches in the literature mainly focused on spatio-temporal and kinematics parameters of tracing letters or words using digitizing tablets, no recent research has previously studied the developmental prerequisites of the organization of handwriting useful for clinical assessment and remediation. Aims of the present study was to investigate and validate the phenotyping of the developmental genesis of pre-scriptural graphomotor gestures among school-aged children in achieving correct handwriting. The subject was examined in depth in an ecological setting similar to school, with the objective of assessing handwriting developmental levels. The pre-scriptural graphomotor task studied was to copy a line of cycloid loops on a paper sheet put on the table. This task was chosen because it reflects the execution of the hand movements from one end of the line to the other and in an anti-clockwise direction, as in handwriting. A new methodological approach was applied incorporating both the maturative evolution of postural-gestural features (video-recorded for analysis in 2D reconstruction) and spatio-temporal/kinematic measures collected with a digital pen connected to an analysis software tool to assess the developmental level and provide an understanding of the phenotypical features of the graphomotor gesture. And we also evidence the concurrent validity of the data in displacements, and the better are the spatio-temporal and kinematic measures. Consequently there are phenotypical features, both postural-gestural and spatio-temporal/kinematic in the developmental genesis of the graphomotor gesture with an easy pre-scriptural task. Typically developing school children from 1st to 5th grade, was collected from elementary schools. Five main patterns of displacement gestures were found for the production of the line of loops with a significant developmental progress from 1st to 5th grade. In addition, significant results in comparisons with spatio-temporal and kinematic age-related normative data were highlighted, associated with the quality of the coordination gesture. Lastly external validity in relation to normative values with the standardized handwriting scale BHK (French adaptation of the Concise Evaluation Scale for Children’s handwriting) showed certain significant correlations with spatio-temporal and kinematic measures and the evolution of the displacement gestures (five patterns) used to draw the loops. The better the motor control of the handwriting gesture, the less variety there is in inter-segmental and joint-scriptural task, enabling handwriting developmental levels to be assessed in screening for handwriting disorders, possibly co-occurring with other learning disabilities, and also useful in clinical decision-making processes for handwriting remediation, or simply to assist handwriting gesture acquisition in elementary school.

Effects of ADHD on Writing Composition Product and Process in School-Age Students

Objective: This study examined the relationship between ADHD and writing performance. Method: Students in Grades 3 to 7, 84 with ADHD and 135 age- and gender-matched controls completed a writing task (including process logs), and measures of working memory and attention. Results: Students with ADHD wrote texts of similar length but with poorer structure, coherence, and ideation. In all, 6.7% of the variance in writing quality was explained by whether or not the student had an ADHD diagnosis, after control for IQ and age-within-year, with ADHD students producing text that was less coherent, well structured, and ideationally rich, and spending less time thinking about and reviewing their text. Half of the effect on text quality could be attributed to working memory and sustained attention effects. Conclusion: ADHD has some effect on writing performance, which can, in part, be explained by working memory and attentional deficits.

Literacy and Numeracy Underachievement in Boys and Girls With ADHD

Objective: To determine literacy and numeracy outcomes, among children with and without ADHD by gestational age and gender. Method: De-identified linked population data from the Western Australian Monitoring of Drug Dependence Systems, Western Australian Literacy and Numeracy Assessment database, and the Midwives Notification System used information on 6,819 children with ADHD compared with 14,451 non-ADHD children. Results: Twenty-three percent of boys and 28% of girls with ADHD had numeracy scores below the benchmark in School Year 3, compared with 11% of children without ADHD. These differences were also evident in reading, writing, and spelling through primary school. Children with ADHD and reduced gestational age were at a greater risk of not meeting numeracy and reading benchmarks, compared with children born at term. Conclusion: Children with ADHD are disadvantaged from an early age in key areas of learning, and this risk increased with reduction in gestational age at birth.

Literacy and Numeracy Underachievement in Boys and Girls With ADHD

Objective: The aim was to determine literacy and numeracy outcomes, among children with and without ADHD by gestational age and gender. Method: De-identified linked population data from the Western Australian Monitoring of Drugs of Dependence System and Western Australian Literacy and Numeracy Assessment databases, and the Midwives Notification System used information on 6,819 children with ADHD compared with 14,451 non-ADHD children. Results: A total of 23% of boys and 28% of girls with ADHD had numeracy scores below the benchmark in School Year 3, compared with 11% of children without ADHD. These differences were also evident for reading, writing, and spelling through primary school. Children with ADHD and reduced gestational age were at a greater risk of not meeting numeracy and reading benchmarks, compared with children born at term. Conclusion: Children with ADHD are disadvantaged from an early age in key areas of learning, and this risk increased with reduction in gestational age at birth.

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

Background

Handwriting difficulties are common in children with attention deficient hyperactive disorder (ADHD). The aim of our study was to find distinctive characteristics of handwriting in children with ADHD by using graphology to analyze physical characteristics and patterns, and to evaluate whether graphological analysis is an effective ADHD diagnostic tool for clinicians.

Method

The cohort included 49 children aged 13–18 years attending a tertiary neurology and epilepsy center in 2016–2017; 22 had a previous DSM-IV/V diagnosis of ADHD. The children were asked to write a 10–12-line story in Hebrew on a blank sheet of paper with a blue pen over a 20-min period. The samples were analyzed by a licensed graphologist blinded to the clinical details of the children against a predetermined handwriting profile of individuals with ADHD. Each ADHD characteristic identified in each sample was accorded 1 point, up to a total of 15 points. Patients with a graphology score of 9–15 were considered to have ADHD.

Results

There were 21 boys (43%) and 28 girls (57%) in the cohort; 15 boys (71.4%) and 7 girls (25%) had a DSM-IV/V diagnosis of ADHD. The mean graphology score was significantly higher in the children who had a DSM-IV/V diagnosis of ADHD than in the children who did not (9.61 + 3.49 vs. 5.79 + 4.01, p = 0.002, respectfully). Using a score of 9 as the cutoff, in the girls, graphology had a specificity of 80% (95% CI 59.2–92.8) and a of sensitivity 71.4% for predicting ADHD. Corresponding values in the boys were 75.0 and 76.2%.

Conclusion

The handwriting of children with ADHD has specific characteristics. Graphology may serve as a clinically useful tool in the diagnosis of ADHD.

Reduced graphomotor procedural learning in children and adolescents with ADHD

PURPOSE

The present study sought to determine if children and adolescents with ADHD demonstrate reduced procedural learning of a graphomotor program.

METHOD

Thirty-two children and adolescents between age 9 and 15 with (n = 16) and without ADHD (n = 16) participated in the study. Each group of participants practiced a novel grapheme on a digitizing tablet 30 times. Participants with ADHD were off stimulant medication or were medication naïve.

RESULTS

Control participants demonstrated significant improvement in graphomotor fluency from the beginning to the end of practice, T = 2, z = -2.534, p = .009, whereas participants with ADHD did not, T = 4, z = -1.810, p = .074.

CONCLUSIONS

Consistent with findings in adults with ADHD, results indicate that graphomotor procedural learning in children and adolescents with ADHD is attenuated. Findings have implications for future research that may inform remediation of handwriting difficulties, academic accommodations, and using digitizing technology for neuropsychological assessment.

Kinematic analysis of fast pen strokes in children with ADHD

In this study, we aimed to determine whether a new measure of fine motor skills, the Pen Stroke Test (PST), can discriminate between children with and without attention-deficit/hyperactivity disorder (ADHD). Twelve children with ADHD and 12 controls age 8-11 were asked to produce handwriting strokes on a digitizer. The sigma-lognormal model derived from the Kinematic Theory of rapid human movements was used to analyze the strokes. Standard measurements of fine motor skills and handwriting were also obtained. Children with ADHD demonstrated poorer motor planning (t₀, D) and execution (nbLog) and greater variability in motor control (SNR/nbLog) than did controls. Parameters extracted from the PST were significantly correlated with performance on other motor and handwriting measures. This study provides preliminary evidence that the PST may be useful as a tool for rapidly detecting motor skill problems in the context of ADHD.

Handwriting assessment to distinguish comorbid learning difficulties from attention deficit hyperactivity disorder in Chinese adolescents: A case-control study

OBJECTIVES

Attention deficit hyperactivity disorder (ADHD) and learning difficulties (LDs) are proposed as 2 overlapping disorders. The objective of this study was to investigate the handwriting performance in ADHD and comorbid ADHD-LD adolescents.

METHODS

The study examined the Chinese and English handwriting performance and sensorimotor skills of 32 ADHD, 12 ADHD-LD, and their matched controls.

RESULTS

Participants with ADHD had comparable writing time and speed, but the readability was lower than their controls. Participants with ADHD-LD had lower writing speeds in both Chinese and English handwriting than their controls. The ADHD and ADHD-LD groups also showed larger variations in either speed or pen pressure than their controls. Chinese handwriting assessment effectively classified ADHD and ADHD-LD with good sensitivity and positive predictive value.

CONCLUSIONS

Clinicians should be aware of the fundamental difference between the 2 disorders and make good use of handwriting assessment as a reference to deliver effective therapies and trainings.

Handwriting difficulties in children with attention deficit hyperactivity disorder (ADHD)

Handwriting is fundamental in school and everyday life situations. Legibility guarantees that writing productions communicate information, and speed is often crucial, especially in children with attention deficit and hyperactivity disorder (ADHD), in order to increase the likelihood of their being able to work efficiently and stay on-task during school activities. Preliminary reports have shown an impairment in handwriting of children with ADHD, but evidence is still unclear, especially in the case of speed where research has offered contradictory results. Children's performance, furthermore, has yet to be investigated under the cognitive loading conditions typical of academic tasks in classroom. To shed light on this matter, we examined the handwriting performance in a simple condition but also under (verbal or spatial) working memory (WM) load in 16 fourth- and fifth-grade children with symptoms of ADHD and 16 matched control children. Our results showed that the groups speed differed significantly only in the verbal WM loading condition, where children with symptoms of ADHD wrote more slowly and showed a greater intra-individual variability than controls. Handwriting legibility was affected by verbal WM loading too. These findings are discussed in relation to their educational and clinical implications.

Associations between motor proficiency in children with history of maltreatment and living in social economically vulnerability

Maltreatment and living in poor socioeconomic conditions during childhood may implicate in deficits on motor proficiency, nevertheless, the literature on this issue is still scarce. The goal of the study was to investigate the possible associations among manual dexterity, aiming and catching tasks, and balance tasks for children who suffers maltreatment and lived in social vulnerability. Eighty-two (82) children (08-09 years old) participated in the study. Forty-one (41) belong to the (SEV-M Group) children living in social economic vulnerability and were previously maltreated (lived in foster homes as results of parental neglect and domestic violence), and 41 belong to the (SEV Group) children living in social economical vulnerability with no history of childhood maltreatment. Children were assessed using the Movement Assessment Battery for Children -2nd Edition. Structural Equation Modeling was used to analyze the data. The results suggest the existence of a variety of motor difficulties in the group of children who suffered from neglect and domestic violence. The statistics model showed a negative effect for children in at-risk environments (regression coefficient=-0.30) and only showed a significant effect (p=0.04) for balance abilities. Traumatic experiences may have a negative effect on children' balance proficiency.

Movement Scaling in Children With ADHD-Combined Type

OBJECTIVE

The aim of the study was to investigate motor performance in children with ADHD using a size-scaling handwriting task.

METHOD

In all, 14 male children with ADHD and 14 typically developing (TD) children (age 7-15) wrote 10-mm and 40-mm cursive letter "l."

RESULTS

Children with ADHD were unable to maintain their writing accurately at 40 mm, falling short by several millimeters; this was not evident in the TD children. Children with ADHD also had slightly faster and more fluent writing than TD children.

CONCLUSION

It was concluded that children with ADHD have difficulties scaling handwriting movement in the larger 40-mm condition that may reflect poor planning and modulation of movement, despite having faster and more fluent movements.

Narrative writing competence and internal state terms of young adults clinically diagnosed with childhood attention deficit hyperactivity disorder

OBJECTIVE

The first objective of this study was to compare the written expression competence of young adults with attention deficit hyperactivity disorder (ADHD) with that of young adults without ADHD on three types of measures: indicators of the story's microstructure with regard to productivity and morphosyntax; indicators of the macrostructure (story grammar); and expressions of the mental states of the story's characters (internal state language). The second objective consisted of determining the relationships among the different narrative writing measures and the ADHD behavior ratings of inattention and hyperactivity obtained using the family observer report.

METHOD

The sample was composed of 54 participants, aged from 18 to 24, divided equally into a group with a childhood clinical diagnosis of combined subtype ADHD and a control group without ADHD. Written composition was assessed using a narrative task based on a sequence of images.

RESULTS

As expected, the young adults with ADHD obtained significantly worse results than the control group on the majority of the parameters of the story's microstructure and macrostructure. Likewise, they included a significantly lower number of terms about the characters' mental states. A correlation was also observed between measures of narrative competence and core symptoms of ADHD, as well as between the use of words with an emotional content and estimations related to core symptoms of ADHD.

CONCLUSION

The findings of this study point out that expressive writing should be assessed in individuals with ADHD as part of screening and comprehensive evaluation. More research is needed to design and implement effective interventions in this area.