Speech Therapy 
Disorder of Written Expression
Disorder of Written Expression may be a condition speech language pathologists (SLPs) treat as they continue to expand the scope of clients they treat. This diagnosis refers to a Specific Learning Disorder that includes an impairment in written language.
According to the American Speech-Language-Hearing Association (ASHA), SLPs play a critical role in developing literacy and in the assessment, diagnosis, and treatment of written language disorders. Speech therapy can effectively address an individual’s difficulties with spelling and writing (such as at the word or sentence level).
Let’s explore the role of speech therapy in improving skills within written expression. We’ll dive into ICD-10 coding, assessment, intervention, assistive technology and accommodations, and challenges to consider.
Definition and characteristics of Disorder of Written Expression
Disorder of Written Expression is a term that is used to refer to individuals who demonstrate abilities in writing that are not at the expected level for their cognitive level and age, despite exposure to adequate instruction. This is often used interchangeably with the term Dysgraphia. However, some use the term Dysgraphia to refer specifically to difficulties with handwriting.
Individuals with this disorder may struggle with various aspects of writing. This can include impairments in spelling and in the more conceptual aspects of writing, such organizing thoughts on paper to form a cohesive, organized message.
Spelling is the process of mapping from a phoneme to a grapheme in order to spell a spoken word in written form. This requires the ability to first segment words into phonemes, and then translate these phonemes into graphemes (units of letters) in both the correct order and written form.
Writing includes both the writing process and the written product. The writing process includes the ability for the individual to plan, organize, and edit written text. It also includes the ability to address a specific audience and convey a certain purpose.
The written product has several components, including: morphology, syntax (sentence level; content, complexity, punctuation), text level (coherence and cohesiveness), communicative functions, and organizational structure (including sequential/chronological order).
Speech therapy assessment for the Disorder of Written Expression
A comprehensive assessment is an essential component of successful intervention for clients with a Disorder of Written Expression.
An assessment will likely include:
- Standardized testing. Assessments such as the Oral-Written Language Scale - 2nd Edition (OWLS-II) provide normed measures of written language. Spoken language assessments and speech sound assessments may also be completed.
- Case History. The SLP should interview parents/caregivers and other professionals working with the child to obtain information about the child’s medical history, developmental milestones, and specific areas of concern.
- Phonological Processing Assessment. Assessment of the client’s phonological awareness, retrieval, memory, and production.
- Analysis of a writing sample. Clinicians can specifically analyze areas such as spelling, printing all letters of the alphabet, printing first and last name, and showing communicative intent in writing.
Other areas may also be included in the assessment, depending on the specific areas of concern for the client.
ICD-10 coding for the Disorder of Written Expression
F81.81 is the ICD-10 code for Disorder of Written Expression. This is a medical classification listed by the World Health Organization (WHO) under the range of Mental, Behavioral and Neurodevelopmental Disorders.
The official descriptor of F81.81 is: Specific Learning Disorder, with impairment in written expression. Attaching the accurate ICD-10 code to therapy notes and billing documentation can ensure compliance with HIPAA regulations and reimbursement from payers.
Speech therapy interventions for Disorder of Written Expression
Speech therapy intervention for Disorder of Written Expression focuses on improving the client’s written language skills by building on the reciprocal relationships between spoken and written language.
A process-oriented approach to writing focuses on the process involved, such as organizing and editing. A product-oriented approach focuses on the written form. This includes areas such as vocabulary, letter formation, spelling, and syntax.
It’s important to keep in mind that there are certain foundational language knowledge areas that support spelling, including:
- Phonological awareness
- Orthographic knowledge (the ability to understand how oral language is represented in writing)
- Semantic knowledge (how meaning affects spelling, as in using the correct form of “their” versus “there”)
- Morphological knowledge (the structure of words)
SLPs can incorporate evidence-based programs to improve a client’s spelling, such as the Barton Reading and Spelling System, which is a multisensory, Orton-Gillingham approach.
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Progress monitoring and documentation
Tracking a client’s progress is critical for assessing the effectiveness of speech therapy intervention and adjusting strategies as indicated.
Speech therapists can monitor a client’s progress by comparing scores on periodic re-administrations of standardized assessments of writing and spelling. This provides an objective measurement of changes in a client’s skills, which the SLP can document in a re-evaluation.
The SLP can also collaborate with parents and other professionals working with the child (such as teachers, tutors, and occupational therapists) to discuss and assess a client’s progress in regards to their written expression skills. Comparing and analyzing writing samples at regular intervals can also be helpful in monitoring a client’s progress.
Assistive technology and accommodations
Assistive technology and accommodations can support individuals with Disorders of Written Expression in order to bridge the gap between challenges in writing and their academic goals.
Speech-to-text software, word prediction tools, and interactive literacy apps can empower children to overcome writing and spelling difficulties.
Accommodations such as allowing the use of a computer or assistive device, and utilizing alternative methods of assessment other than through written expression, can be used to modify the child’s learning environment so that it better fits their needs.
Challenges in treating the Disorder of Written Expression
When treating Disorders of Written Expression, SLPs should be aware of some potential challenges.
First, it can be challenging to motivate individuals with this diagnosis to engage in writing activities. Therapists can tailor writing activities to match the client’s specific interests, and incorporate digital tools such as gamified exercises, to encourage individuals to engage in therapeutic tasks.
Frustration and low self-esteem are potential barriers to progress in therapy. According to research, children with Dysgraphia frequently experience higher levels of anxiety and daily stress, particularly when asked to complete academic tasks.
Therapists can foster a positive, supportive environment and build a strong rapport with the client to allow him or her to feel empowered to persist despite the challenges they face.
Speech therapists play a critical role in improving the spelling and writing abilities of clients with a Disorder of Written Expression. Using the appropriate ICD-10 code in documentation, completing a thorough assessment, and using evidence based therapy techniques, can improve the effectiveness of speech therapy.
A collaborative approach that includes ongoing communication with caregivers and other professionals working with the client can also enhance a treatment plan.
Resources
Speech therapists working with clients who have a Disorder of Written Expression can utilize TheraPlatform, an all-in-one EHR, practice management and teletherapy solution for helpful resources. Consider starting with a 30-day, free trial of TheraPlatform today. No credit card required. Cancel anytime.
References
Chung, P. J., Patel, D. R., & Nizami, I. (2020). Disorder of written expression and dysgraphia: definition, diagnosis, and management. Translational pediatrics, 9(Suppl 1), S46–S54. https://doi.org/10.21037/tp.2019.11.01
Elvira Kalenjuk, Stella Laletas, Pearl Subban & Sue Wilson (2022) A scoping review to map research on children with dysgraphia, their carers, and educators, Australian Journal of Learning Difficulties, 27:1, 19-63, DOI: 10.1080/19404158.2021.1999997
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