Existing interventions for the management of different types of dysgraphia or specific learning disorder in written expression: a scoping review

Abstract

Background

Dysgraphia is a specific learning disorder characterised by difficulties in written expression. Identifying and finding remedies for children with this disorder is challenging due to the diverse interventions used in different contexts. Different interventions are used to rehabilitate children with this disorder.

Objective

This scoping review aims to map the existing interventions for dysgraphia across different contexts, that is, schools, rehabilitation centres, home-based services and clinics.

Design

Scoping review.

Eligibility criteria

This review included studies that used educational, therapeutic, technological or behavioural interventions for children and adolescents with dysgraphia or difficulties in written expression. Quantitative, qualitative and mixed-methods studies conducted in school, clinic, home or rehabilitation centre settings were included. Studies focusing on unrelated disabilities, diagnostic studies and theoretical papers without an intervention focus were excluded.

Data sources

PubMed, Europe PubMed Central, Cochrane Library, ScienceDirect, EBSCO, Directory of Open Access Journals and Google Scholar were searched for evidence-based articles.

Charting methods

Two independent reviewers screened titles and abstracts using the Rayyan web application (Cambridge, MA, USA). Discrepancies were resolved by consensus with a third reviewer, and the full texts were retrieved. Two independent reviewers screened the full-text articles. Disagreements were resolved through consultation with a third reviewer. Data were charted using a standardised form. The extraction process was independently conducted by two reviewers to ensure reliability, with discrepancies resolved by discussion with a third reviewer. Findings were synthesised descriptively, and a thematic analysis of reported outcomes was conducted following the six-phase framework of Braun and Clarke.

Results

Forty-seven articles were included in the review, targeting educational, therapeutic, multisensory, computer-based and combined interventions to address dysgraphia. Studies were distributed across six intervention categories: computer-based/technological (n=15), educational (n=13), therapeutic (n=7), combined/multimodal (n=6), psychological (n=4) and multisensory (n=2); most studies were conducted in Asian countries (n=24), followed by the USA (n=10), Europe (n=8), Africa (n=4) and the Arab region (n=1). Four themes were identified: (a) improvements in foundational writing mechanics; (b) advancements in composition and higher-order writing; (c) broader academic and cognitive benefits; and (d) positive affective and behavioural outcomes. Each theme, with its subtheme, is linked to the targeted interventions addressed in the studies.

Conclusion

This review revealed that computer-based and educational interventions were used in most studies, and that foundational writing mechanics were widely addressed as outcomes. There is a lack of studies addressing different types of dysgraphia. A holistic approach through a large-scale study is recommended to address multiple underlying writing mechanics and psychological concerns. The findings have implications for clinical and educational practice, supporting the use of integrated handwriting, composition and assistive-technology approaches, and for policy, highlighting the need for targeted funding of large-scale, multimodal intervention trials in low-income and middle-income countries.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist to ensure transparent and structured reporting.

• Title, abstract and full-text screening were conducted independently by two reviewers using the Rayyan web application (Cambridge, MA, USA), with a third reviewer resolving disagreements.

• Data were extracted using a standardised charting form, applied independently by two reviewers to ensure reliability.

• Only a few databases were accessed due to limited institutional access, and the review was restricted to articles published in English.

Studies on writing difficulties due to acquired neurological conditions and other comorbidities were excluded, which may limit the generalisability of findings.

Introduction

Dysgraphia is a neurodevelopmental condition that is classified as a specific learning disorder (SLD) and manifests through persistent and severe difficulties in written expression skills.¹ It is not classified as a distinct disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, but rather as specific learning disorder (SLD) with impairment in written expression.¹ Dysgraphia is evident through handwriting fluency, automatic letter formation, orthographic accuracy, fine-motor coordination, writing speed and compositional aspects of the written text.^{2 3} With an estimated prevalence of 7%–15% among the school-aged population, dysgraphia poses a significant challenge in both the clinical and educational settings.^{4 5} It has traditionally been conceptualised by Deuel’s (1995)⁶ taxonomy, which proposes three major subtypes: dyslexic dysgraphia (combined with deficits in linguistic processing), spatial dysgraphia (combined with visual-spatial integration impairments) and motor dysgraphia (combined with fine-motor and kinesthetic impairments).⁷ This classification continues to inform contemporary research and diagnostic practices. Another distinction between the types of dysgraphia is that acquired dysgraphia occurs after a neurological event, such as traumatic brain injury or neurodegenerative disease, whereas developmental dysgraphia occurs in early childhood during the early stages of writing acquisition, even in individuals with normal intellectual function and adequate learning opportunities.^{2 4}

The consequences of dysgraphia extend beyond just handwriting challenges. Handwriting is one of the foundational academic skills by which students can display their knowledge, complete their assignments and engage in self-expression throughout their school life.³ Consequently, the condition directly disrupts academic achievement across virtually all subject areas, creating a debilitating gap between a student’s cognitive capabilities and their written performance.⁴ The psychosocial effects are also equally serious and, in some cases, devastating. A meta-analysis by Kavale and Forness found that about 75% of students with SLDs (such as dysgraphia) have significant deficiencies in social skills compared with their peers.⁸ Children with dysgraphia often perceive their poor academic performance as lower, experience increased anxiety levels when engaged in writing activities and report poor self-esteem.⁹ Such a negative self-perception creates a vicious cycle, which makes them less willing to practise writing. If not diagnosed and treated during the early stages, dysgraphia may negatively impact children’s ability to learn academic skills, their emotional well-being and vocational prospects later in life.¹⁰ This calls for early diagnosis and the implementation of evidence-based rehabilitation strategies.

The landscape of interventions for dysgraphia has evolved dynamically over the last 20 years, shifting towards a more balanced, innovative, technologically advanced and comprehensive approach. Han and Wang reported that technology-assisted interventions, such as specialised software, online handwriting applications and real-time biofeedback systems, are the leading interventions, offering benefits in user engagement and measurable skill improvement.⁴ One of the most prominent frameworks of conceptualising support in school settings divides the interventions into three levels: (1) accommodation, where the student receives the mainstream curricula with the help of supportive aids (eg, speech-to-text software, graphics organisers), without modifying the instructional content; (2) modification, where the institution changes the learning goals and objectives of the student; and (3) remediation, where interventions are aimed at directly alleviating the underlying deficiencies of the disability.²

This global landscape is marked by high heterogeneity in dysgraphia interventions largely driven by variability in economic resources and healthcare infrastructure. Research in high-income countries often examines specialised, resource-intensive interventions. For example, psychomotor therapy (PMT) is a popular treatment in Switzerland. Although empirical data show a statistically significant effect of PMT on children’s fine motor proficiency over a 5-month period, the treatment does not have similar effects on handwriting consistency and fluency.¹¹ Similarly, a study from France suggests a trans-disciplinary paradigm, demonstrating that children with dysgraphia have a heterogeneous spectrum of comorbid functional impairment, including oculomotor and neuropsychomotor impairments.⁵

In contrast, interventions in low-income and middle-income countries (LMICs) identify significant systemic failures. For instance, Maulik and Darmstadt¹² emphasise that research on childhood disability in LMICs is woefully inadequate, especially research investigating specific interventions and service use.¹² This research gap highlights that research on childhood disability has often prioritised overcoming challenges in identification and resource allocation. The urgency is further supported by a systematic review that assessed interventions to improve educational outcomes for individuals with disabilities in LMICs. The review found that the available evidence base consists mostly of interventions aimed at improving a child’s functioning, skills and competencies; research on systemic or school-based interventions is lacking.¹³ Furthermore, the review found that most studies on this subject have a low level of confidence due to methodological limitations, in which specific disabilities such as dysgraphia are included in broader categories rather than being considered individually.

The evidence suggests that dysgraphia is prevalent in LMICs, with notable variation in both prevalence estimates and intervention practices. For instance, a survey of schoolchildren conducted in Lahore, Pakistan, revealed high rates of SLD, especially among individuals with writing difficulties, but the authors noted that prevalence estimates are inconsistent across settings.¹⁴ Similarly, an experimental study was conducted in Khyber Pakhtunkhwa, Pakistan, to explore the effectiveness of fine-motor skills interventions in improving handwriting performance among both low and high achievers, and it demonstrated the effectiveness of group-based motor training in classroom settings.¹⁵ This variation in interventions across economic settings creates a notable disparity in the equitable development, dissemination and appraisal of evidence-based interventions for dysgraphia globally.

Rationale

The existing body of literature suggests that interventions for dysgraphia have been addressed in an unstructured manner, leaving a clear gap in mapping specific interventions. For example, an earlier scoping review by Kalenjuk et al explored the perspectives of children, parents and teachers on dysgraphia but did not synthesise evidence on intervention types.¹⁶ Likewise, Bonneton-Botté et al and Blanchet et al provided insights into general handwriting therapy and motor deficits in people with SLD,^{17 18} but lacked an explicit focus on dysgraphia, thereby limiting the generalisation of their findings. Recently, Fajariani et al examined moderating factors and contextual influences on handwriting improvement, but did not categorise intervention strategies.¹⁹ The literature on dysgraphia interventions, therefore, exhibits substantial heterogeneity in methodologies, participant groups, intervention types and reported outcomes, making it challenging to conduct a systematic review and/or meta-analysis to assess the effectiveness of these interventions. For this reason, a scoping review is the most suitable methodological option, as it allows the mapping and categorisation of interventions across a wide and multifaceted body of literature.

This scoping review will be the first to provide a comprehensive synthesis of interventions reported in studies published between 2000 and 2025, drawing on evidence from diverse geographical settings (both low-income and high-income countries), heterogeneous participant groups and varied modes of delivery.

Objectives

The review aims to contribute to the existing evidence base and to identify critical gaps, such as the limited focus on affective outcomes and long-term transfer effects. Specifically, this review seeks to answer the following research question: what interventions have been used to address dysgraphia and written expression difficulties in children and adolescents across different contexts and geographical settings, and what outcomes have been reported in the literature? The findings will provide practical recommendations for future research and for clinical and educational practice.

Methods

Protocol and registration

The review was conducted using a scoping methodology, which is most suitable for mapping the wide range of interventions applied to dysgraphia and written expression difficulties. The framework of Arksey and O’Malley provided the foundation, while the refinements proposed by the Joanna Briggs Institute (JBI, 2020) were followed to ensure a systematic and transparent process.^{20 21} The JBI approach emphasised structured data charting and allowed interventions to be grouped by theoretical orientation (eg, motor-based, linguistic or technological). Reporting adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).²² A detailed protocol was developed before initiating the search and registered on the Open Science Framework (OSF). The protocol was made publicly available and revised prior to data charting on the OSF.²³

Operational definitions

The following definitions were used for the screening and data extraction for this review:

• Dysgraphia: this was operationally defined as a SLD that involves persistent significant difficulties in one or more of the following areas: accuracy of letter formation and legibility of writing, spelling accuracy, grammatical and punctuation accuracy, writing fluency (speed and automaticity), clarity and organisation of written expression.²⁴ These difficulties should not be attributable to intellectual disability, a neurological disorder or insufficient teaching, nor should they be better explained by a lack of cognitive, or sensory impairment.

• Written expression difficulties: these were defined more broadly, following the model of Berninger et al to encompass, without distinction, problems with transcription (handwriting and spelling) and with text generation (vocabulary, syntax and discourse) that persist beyond the point of independent mastery and that interfere with, or are likely to interfere with, a student’s academic functioning, including when a formal diagnostic label had been determined.²⁵

• Intervention categories: interventions were identified as any structured, purposeful strategy, programme or activity (whether implemented by an educator, clinician, researcher or technology) that aims to enhance handwriting and/or written expression or the underlying cognitive, motor or linguistic skills related to the performance of handwriting and/or written expression. For the purpose of synthesis, interventions were broken down into the following six categories:

In line with Chung et al (2020), the definition was broadened to include problems with fine-motor coordination, letter spacing and compositional quality, which are perceived differently by individuals with dysgraphia.²

• Written expression difficulties: these were defined more broadly, following the model of Berninger et al to encompass, without distinction, problems with transcription (handwriting and spelling) and with text generation (vocabulary, syntax and discourse) that persist beyond the point of independent mastery and that interfere with, or are likely to interfere with, a student’s academic functioning, including when a formal diagnostic label had been determined.²⁵

• Intervention categories: interventions were identified as any structured, purposeful strategy, programme or activity (whether implemented by an educator, clinician, researcher or technology) that aims to enhance handwriting and/or written expression or the underlying cognitive, motor or linguistic skills related to the performance of handwriting and/or written expression. For the purpose of synthesis, interventions were broken down into the following six categories:

1. Educational interventions: instructional methods that occur in the classroom or school setting and are primarily the responsibility of teachers or education professionals. These include explicit handwriting instruction, guided writing programmes and strategy-based writing instruction, such as the Self-Regulated Strategy Development (SRSD) model.²⁶ The key is a pedagogical aspect in an academic setting.

2. Therapeutic interventions: clinician-directed interventions focusing on sensorimotor, perceptual-motor and neurodevelopmental aspects of writing. This involves occupational therapy fine-motor training, perceptual-motor programmes, sensory integration approach and handwriting interventions provided by clinicians.²⁷ They differ from educational interventions both in delivery context (clinical) and in rehabilitative/remedial focus.

3. Structured/multisensory interventions: systematic, repeatable and structured programmes that use a range of sensory modalities (visual, auditory, kinaesthetic and tactile) to help teach writing-related skills. The Orton–Gillingham approach is the archetypal one.²⁸ These programmes are sequential, involve explicit multisensory elements and are suitable for use in educational and clinical settings.

4. Use of computers and technological interventions: interventions provided via or with the use of information/communication technology. This encompasses word-processing software, speech-to-text and text-to-speech software, tablet-based handwriting software and other assistive and/or instructional technology that supports written expression.²⁹ The key is that technology is used as the first line of intervention, rather than merely as an administrative control device.

5. Combination/multimodal interventions: intervention programmes that are explicitly and intentionally designed to incorporate two (or more) of the above categories in a single, coherent protocol, for example, technology-assisted tools with therapeutic or instructional components.³⁰ Only a combination that is planned and systematic was classified here.

6. Psychological interventions: modifications of the cognitive, motivational, emotional and/or self-regulatory processes that underlie writing. These include cognitive-motor exercises, crossword puzzle games and social-cognitive model-based programmes to target cognitive and perceptual functions and to promote engagement, motivation and self-efficacy in children with dysgraphia.^{31 32}

Any studies that could not be readily grouped into one of these categories were discussed by the review team, and each study was usually categorised in the most similar category by consensus.

Eligibility criteria

Studies were considered suitable for inclusion if they examined children or adolescents who were identified as having dysgraphia or related written expression difficulties, and if they described an intervention designed to address these challenges. Both educational and therapeutic approaches were accepted, along with technology-assisted and behavioural programmes. Empirical evidence in multiple formats, quantitative, qualitative and mixed-methods, was included, provided it contained clear descriptions of intervention procedures and outcomes. Publications were restricted to English-language studies from January 2000 to June 2025. Studies conducted in schools, clinical services, rehabilitation centres or home settings were all eligible.

Exclusion criteria

Studies with the following features were excluded:

• Focused only on other conditions (eg, dyslexia without a dysgraphia component, attention deficit hyperactivity disorder, autism spectrum disorders and motor-coordination disorder).

• Reported diagnostic approaches or theoretical discussions without testing interventions.

• Consisted of commentaries, editorials or opinion-based pieces.

• Addressed workplace interventions unrelated to learning disabilities.

• Published before the year 2000.

• Written in languages other than English where no reliable translation was available.

Information sources

The evidence base was drawn from several bibliographic databases to capture a wide range of perspectives. Searches were performed in PubMed, Europe PubMed Central (Euro PMC), Directory of Open Access Journals (DOAJ), ScienceDirect, EBSCO, Cochrane and Google Scholar. The decision to use these databases was guided by their coverage of both health sciences and education research, which are central to interventions for learning disorders. The search covered the period from January 2000 to June 2025. This time frame was selected because the early 21st century marks the period of widespread adoption of computers and digital technologies in education and rehabilitation, which substantially shaped both the nature and the delivery of interventions for dysgraphia. Restricting the search to this period, therefore, ensured that the included studies reflected contemporary educational practices, technology-assisted approaches and current intervention models relevant to children with dysgraphia and written expression difficulties. To supplement electronic searches, the reference lists of relevant articles and reports were also screened for additional studies. The most recent search was executed on 30 June 2025.

Search

A comprehensive search was carried out in PubMed, Europe PMC, ScienceDirect, DOAJ, Google Scholar and the Cochrane Library for studies published between 1 January 2000 and 30 June 2025. Search strategies combined controlled vocabulary (eg, Medical Subject Headings) and free-text terms relating to dysgraphia, interventions and child/adolescent populations. Filters were applied for English-language articles, participants aged ≤18 years and study types (eg, clinical trials and randomised controlled trials where available). Database-specific strategies were developed and adapted to indexing terms and functionalities. The full search strings for each database are provided in table 1.

Table 1. Search strategy.

Database	Filters applied	Example search string
PubMed	Date: 2000–2025; English; age ≤18 years; abstract available; clinical trials and RCTs	(‘Dysgraphia’(MeSH)) OR ‘Specific Learning Disorder’(MeSH)) OR ‘learning disabilities’(MeSH)) OR dysgraphia(tiab)) OR ‘written expression disorder’(tiab)) OR ‘writing difficulties’(tiab)) AND (‘Intervention’(tiab)) OR ‘therapy’(MeSH)) OR ‘treatment’(tiab)) OR ‘remediation’(tiab)) OR ‘educational therapy’(tiab)) OR ‘occupational therapy’(tiab)) AND (‘Children’(MeSH)) OR ‘Adolescents’(MeSH)) OR ‘Students’(tiab)) OR ‘Education’(MeSH))
Europe PMC	Full text; research articles; date: 2000–2025; sorted by date	(Dysgraphia OR ‘Specific Learning Disorder in Written Expression’ OR ‘Writing Difficulties’ OR ‘Written Expression Disorder’ OR ‘Learning Disabilities in Writing’) AND (Intervention OR Therapy OR Treatment OR Remediation OR ‘Educational Therapy’ OR ‘Occupational Therapy’ OR ‘Assistive Technology’ OR ‘Cognitive Therapy’) AND (Children OR Adolescents OR Students OR ‘School-Based’ OR Education)
ScienceDirect	Date: 2000–2025	Dysgraphia OR ‘Specific Learning Disorder in Written Expression’ AND (Intervention OR Treatment OR Therapy OR ‘Educational strategies’) AND (Children OR Students OR Learners)
DOAJ	Articles; abstract field; subject: education, social sciences	Dysgraphia AND Intervention
Google Scholar	No date filters beyond 2000–2025; searched titles and full text	(intitle:‘Dysgraphia’ OR intitle:‘Specific Learning Disorder in Written Expression’ OR intitle:‘Writing Disorder’) AND (intext:‘Intervention’ OR intext:‘Treatment’ OR intext:‘Therapy’ OR intext:‘Remediation’ OR intext:‘Cognitive Therapy’ OR intext:‘Occupational Therapy’ OR intext:‘Educational Therapy’ OR intext:‘Assistive Technology’) AND (intext:‘Children’ OR intext:‘Adolescents’ OR intext:‘Students’ OR intext:‘School-age’)
Cochrane Library	Date: 2000–2025; trials only	(dysgraphia OR ‘specific learning disorder in written expression’ OR ‘written expression disorder’ OR (learning disabilit* AND written expression) OR ‘written communication’) AND (intervention* OR therap* OR treatment* OR manag* OR strateg* OR approach* OR rehabilitation)

DOAJ, Directory of Open Access Journals; Euro PMC, Europe PubMed Central; RCTs, randomised controlled trials.

Selection of sources of evidence

All search results were imported into the Rayyan web application (Cambridge, MA, USA),³³ which facilitated screening, blinding between reviewers and resolution of conflicts. Duplicate studies were removed before screening. In the first stage, titles and abstracts were screened against the inclusion and exclusion criteria by MA and an independent second reviewer (MAP, US, SA or SAJ). Each record was marked as include, exclude or maybe, with reasons for exclusion recorded. Discrepancies were first discussed between the two reviewers and where consensus could not be reached, a third reviewer was consulted to make the final decision. Full texts of potentially eligible articles were retrieved and imported back into Rayyan,³³ where MA and the same independent reviewer (MAP, US, SA or SAJ) assessed them against the full eligibility criteria. Reasons for exclusion at the full-text stage were documented for the PRISMA-ScR flow diagram. When discrepancies occurred, they were first discussed between the two reviewers, and if consensus was not reached, a third reviewer was consulted.

The full process of identification, screening and final selection was documented and summarised in the PRISMA-ScR flow diagram (figure 1).

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. DOAJ, Directory of Open Access Journals; EuroPMC, Europe PubMed Central.

Data charting process

To capture essential study information consistently, a data charting form was developed in MS Excel. Before its use, the form was piloted on three studies completed independently by two reviewers to minimise inconsistencies between reviewers. This pilot tested clarity and the consistency of interpretation across reviewers and refined categories where ambiguity emerged. Minor revisions to category wording were made after this pilot. The form was then completed independently by two reviewers for all included studies. The extracted information included bibliographic details, study design, participant characteristics, intervention type and theoretical basis, frequency and duration, outcomes and contextual information such as whether the programme was delivered at school, clinic, home or rehabilitation centre, which gave insight into acceptability and feasibility. Once both the reviewers completed the extraction independently, their entries were compared on a study-by-study basis. Discrepancies in extracted data were resolved through discussion between the two reviewers, and where consensus could not be reached, a third reviewer was consulted. The final, agreed dataset was used for the synthesis and has been made publicly available.³⁴

Each study was then assigned to one of the five intervention categories defined a priori in the Operational definitions subsection (educational, therapeutic, multisensory, computer-based/technological or combined/multimodal). Categorisation was carried out independently by the two reviewers, with disagreements resolved through discussion and a third reviewer was consulted where consensus could not be reached.

Data items

The charting process focused on a core set of items:

• Study characteristics: author, publication year and country.

• Design: quantitative, qualitative or mixed-methods.

• Population: age group, diagnostic confirmation of dysgraphia or related written expression disorder.

• Interventions: type, theoretical basis, duration and delivery format.

• Outcomes: measures of writing fluency, legibility, motor coordination or participant experiences.

• Context: setting of the intervention (school, clinic, rehabilitation centre and home).

Critical appraisal

Consistent with JBI’s methodological guidance for scoping reviews, no formal critical appraisal of included studies was conducted. As the objective was to map available interventions rather than evaluate effectiveness or risk of bias, quality assessment was deemed inappropriate.

Synthesis of results

MA and MAP reviewed all the charted data from all studies included; the data were subjected to two independent data reviews (MA and MAP), and the information extracted from the studies was synthesised descriptively. The studies were first classified by intervention type (educational, therapeutic, multisensory, computer-based/technological or combined/multimodal, as described in the subsection on Operational definitions) and by the outcomes reported (eg, handwriting legibility and higher-order cognitive functions).

Thematic analysis of the reported results of the included articles was performed, following the six phases of qualitative approach outlined by Braun and Clarke.³⁵ The analysis was conducted at a semantic level using an inductive approach, in which codes and themes were identified from the outcomes of the studies reviewed and included in the analysis, rather than from a prior framework.

Phase I: obtaining the data

Both reviewers (MA and MAP) carefully read and re-read the highest number of outcomes reported for each study included in the data charting form to familiarise themselves with the scope and content of those outcomes. Analytical notes were recorded for each study to record initial impressions of repeats.

Phase II: creating the starting codes

The initial codes were entered into an Excel sheet based on the retrieved outcome data using different colour codes. A short descriptive code, using the author’s own terms and similar to the wording used in the study, was assigned to each meaningful unit (a phrase or sentence describing a reported outcome). The coding process was conducted independently by the two reviewers, and errors were assessed and resolved through discussion to reach agreement; coding discrepancies were addressed until consensus was reached. The codes obtained from the outcomes of two exemplary studies are presented in figure 2.

Figure 2. Codes of extracted data from outcomes of two studies.

Phase III: looking for themes

All codes were collated together and conceptually similar codes were merged into candidate sub-themes. These sub-themes were then grouped into larger candidate themes, which reflected patterns in the outcomes reported across the included studies. At this point, a preliminary thematic map of the possible themes and sub-themes was created (figure 3).

Figure 3. Initial thematic map.

Phase IV: discussing the themes

Internal coherence was assessed using the coded versions of the themes relevant to the stories and all extracted themes, codes and/or outcomes to test whether the themes were coherent with respect to the codes included within them. External coherence was evaluated with the coded versions of the themes against all the extracted themes, codes and/or outcomes to determine whether the themes were connected to one another through the stories within each theme or were distinctly different. Overlapping themes were grouped, and themes with limited supporting data were either made more general or removed.

Phase V: themes identified and named

The reviewers (MA and US) were responsible for defining each theme and sub-theme with respect to their scope and essence. Two other reviewers (SP and MAP) also reviewed the candidate themes and subthemes; the final themes and subthemes were agreed on by consensus of the review team. Figure 4 shows the end product thematic map.

Figure 4. Final thematic map.

Phase VI: producing the report

Themes and sub-themes were finalised, then recoded into the intervention categories derived from the data charting stage, enabling each theme to be linked to the intervention categories that contributed to it. This enabled the synthesis to not only highlight which outcomes had been reported in the included studies but also identify the most frequently reported intervention type for each thematic outcome. The outcomes of this synthesis are shown in the Results section.

Patient and public involvement

Patients and the public were not involved in the design, conduct, reporting or dissemination plans of this scoping review.

Results

Selection of sources of evidence

The database search yielded 6115 citations; after removing 628 duplicates, 5487 records were screened by title and abstract. Of these, 5279 were excluded for reasons including irrelevant populations, incorrect study design (eg, correlational studies), incorrect publication type (eg, editorials), incorrect outcomes, non-English language or irrelevant content. The remaining 208 records were retrieved for full-text review. Following full-text screening, 163 articles were excluded for the following reasons: not open access, incorrect study design, non-English language, incorrect population, incorrect publication type, duplicate studies and incorrect outcomes. This yielded 45 included studies. An additional 2 studies were identified through backward reference list searching, resulting in a final total of 47 studies included in this scoping review (online supplemental appendix 1).

Characteristics of the included studies

A total of 47 articles met the inclusion criteria (January 2000–June 2025). Relevant studies were identified beginning in 2008, with the highest number published in 2024 (n=10). Five studies were published in 2014 and 2022; four in 2019; three in 2015, 2017 and 2018; and one or two in other years; no studies were published in 2012.

Geographically, 24 studies were conducted in Asian countries (primarily Iran and India), 10 in the USA, 8 in European countries, 4 in African countries and 1 in an Arab country. Sample sizes ranged from a single case to 154 participants; 26 studies included ≤30 participants, while 21 involved >30 participants. The age of participants ranged between 5 and 19 years.

Most studies used experimental (n=41) or quasi-experimental (n=6) designs. Forty-two were quantitative, four used mixed methods and one was observational. Fourteen studies focused specifically on dyslexic dysgraphia, nine on motor dysgraphia, three on dysgraphia with dyscalculia and one on spatial dysgraphia; the remaining 20 studies did not specify the type of dysgraphia.

The mode of delivery was predominantly face-to-face (n=38). Three studies used hybrid approaches; one was fully online and five did not report. Interventions were delivered mainly in schools (n=27), followed by learning disability centres (n=11), university research centres (n=2) and homes (n=3); four studies did not specify the setting. Online supplemental appendix 1 presents outcomes of the studies with relevant citations together with the corresponding themes, sub-themes, contributing studies, and types of interventions used.

Critical appraisal with sources of evidence

As noted in the Methods section, no quality appraisal was undertaken in line with JBI scoping review guidance.

Results of individual sources of evidence

Interventions map

Across 47 studies, six categories of interventions were identified to address dysgraphia and written expression difficulties: educational, psychological, therapeutic, computer-based/technological, multisensory and combined/multimodal approaches. These categories correspond to those defined a priori in the Operational definitions subsection of the Methods section.

Educational interventions (n=13) primarily focused on structured writing instruction, sentence combining interventions, rote learning practice, ART (Ask, Reflect, Text) strategy, task-oriented teaching and SRSD to improve writing accuracy and fluency. Computer-based/technological programmes were the most frequently reported (n=15), using computerised reading/writing and translation strategies, computerised visual perception training, software and assistive technologies designed to enhance handwriting performance, provide feedback or support practice through interactive learning tools. Psychological interventions (n=4) used cognitive-motor exercises, crossword puzzle games and the social cognitive model to address cognitive and perceptual functions in children with dysgraphia, as well as engagement, motivation and self-efficacy.

Therapeutic interventions (n=7) concentrated on fine and gross motor exercises, visual-motor integration and proprioception exercises to strengthen the physical components of handwriting. Multisensory approaches (n=2) engaged multiple sensory components, visual, auditory, tactile and kinesthetic to reinforce letter formation and fine-motor and perceptual-motor skills through experiential learning activities. Combined or multimodal interventions (n=6) integrated features from two or more categories, such as pairing educational and therapeutic interventions or combining multisensory and educational elements.

Figure 5 illustrates the range of interventions identified in the scoping review.

Figure 5. Types and subtypes of interventions identified for dysgraphia.

Synthesis of results

Thematic findings

A thematic analysis was conducted to examine the outcomes of different interventions for dysgraphia. Four themes were identified (eg, improvements in foundational writing mechanics, advancements in composition and higher-order writing, broader academic and cognitive benefits, and positive affective and behavioural outcomes). All themes, sub-themes, their contributing studies, intervention types used and related outcomes are presented in online supplemental appendix 1. Each of these themes, with respective subthemes, is linked with types of interventions and is discussed below:

Improvements in foundational writing mechanics

This theme reflects interventions targeting the sensorimotor and transcription foundations of handwriting, including legibility, fluency and spelling accuracy. Three subthemes were identified:

Enhanced legibility and letter formation

Multisensory, educational, therapeutic and computer-based/technological interventions consistently improved handwriting clarity, including letter size, spacing and alignment. For instance, assistive technology applications improved global legibility scores in small samples,³⁶ while large-scale therapeutic and educational programmes led to improvements in both handwriting and academic performance.³⁷

Increased writing speed and fluency

Real-time auditory feedback (sonification)³⁸ and computerised instruction³⁹ enhanced writing fluency and reduced pauses without compromising legibility. Educational approaches also improved sentence construction and speed, though effects varied across participants.

Reduced spelling and transcription errors

Multisensory and play-based approaches reduced spelling mistakes, visual memory errors and dictation problems, while also lowering anxiety and improving self-confidence.^{40 41}

Advancements in composition and higher-order writing

This theme highlights interventions that enhanced text quality, productivity and strategic writing skills. Three subthemes were as follows:

Improved composition quality and structure

Strategy-focused interventions such as SRSD and sentence-combining programmes improved organisation, coherence and writing quality among children with dysgraphia.^{42 43}

Gains in productivity and ideation

Assistive technologies like speech-to-text support students in producing longer, more meaningful texts with improved accuracy.⁴⁴ Direct instruction methods also improved fluency and comprehension.⁴⁵

Development of writing strategies and processes

Computerised translation and planning strategies helped students strengthen narrative and summary writing, especially when paired with scaffolding across tasks.^{46 47}

Broader academic and cognitive benefits

This theme captures evidence of cross-domain improvements beyond writing. The following two subthemes were identified.

Cross-domain academic transfer

Educational and hybrid interventions improved mathematics, reading fluency and dictation accuracy. For example, peer tutoring enhanced maths skills among students with dysgraphia,⁴⁸ while tele-rehabilitation programmes improved both reading and executive functions.⁴⁹

Enhanced underlying cognitive and perceptual functions

Gamified and cognitive-motor interventions improved visual perception, attention and motor skills, enabling participants to recognise symbols and improve handwriting accuracy.^{50 51}

Positive affective and behavioural outcomes

This theme highlights interventions that supported motivation, engagement and self-efficacy. The subthemes identified were:

Increased engagement, motivation and self-efficacy

Therapeutic programmes improved fine-motor stamina and reduced the severity of dysgraphia.⁵² Strategy-based approaches enhanced self-efficacy and writing confidence, particularly among girls.⁵⁰ Creative and blended learning activities also fostered greater student engagement and enjoyment.^{53 54}

The bubble matrix (figure 6) highlights the uneven distribution of evidence across intervention–outcome domains. It displays the relationship between intervention types (x-axis) and outcome measured (y-axis). The figure demonstrates that most interventions target foundational writing mechanics, while few address psychological outcomes or broader academic transfer.

Figure 6. Mapping of dysgraphia interventions against reported outcomes.

Discussion

This review aimed to map existing interventions for different types of dysgraphia and writing disorders. Forty-seven studies met the inclusion criteria, reflecting a diverse range of approaches, including educational, therapeutic, multisensory, computer-based, psychological and combined interventions. Overall, the distribution of intervention types indicates a predominant reliance on educational and technology-based methods, with increasing attention to integrative and therapeutic models that address the multifaceted nature of dysgraphia. Most interventions targeted foundational handwriting mechanics, with fewer addressing higher-order composition and academic outcomes and even fewer addressing affective and behavioural factors. It highlights the breadth of intervention strategies currently described in the literature. Below, we synthesise these findings by major themes and subthemes.

Improvements in foundational writing mechanics

Children with dysgraphia frequently struggle with legibility, letter formation and transcription accuracy, which compromise both the readability and efficiency of their writing.

The majority of studies emphasised legibility as a primary outcome, addressing important characteristics of dysgraphia—letter reversals (eg, confusing b with d, c with e, etc).⁵⁵ Overall, multisensory and technology-assisted interventions consistently enhanced legibility and letter formation, though gains were often limited by small sample sizes. For instance, app-based tools (eg, Write-Rite⁵⁶) improved alignment, spacing and proportion,³⁶ while occupational therapy kits that integrate fine motor training with handwriting curricula, such as Handwriting Without Tears, demonstrated improvements in spacing and spelling.⁵⁷ These findings from the included studies align with the broader occupational therapy literature, which shows that multisensory handwriting programmes produce significant improvements in legibility and fluency compared with traditional drill approaches.⁵⁸ Larger-scale studies, such as the study by Indira and Vijayan,³⁷ revealed that improvements in legibility were accompanied by increased academic confidence,^{27 37} which is consistent with the meta-analysis by Graham et al, which linked handwriting instruction to gains in both writing performance and motivation.⁵⁹

Evidence on writing speed and fluency varied across technology-based supports, including real-time auditory feedback³⁸ and visual-motor training,⁶⁰ which produced short-term fluency gains, but sustainability beyond controlled sessions was rarely tested. Spelling and transcription accuracy received less attention in the reviewed articles, with only isolated findings from computerised writing instruction.³⁹ While such programmes improved composing fluency, spelling accuracy remained a persistent challenge, which is consistent with research indicating that orthographic encoding difficulties in dysgraphia are more resistant to remediation than motor-based impairments.^{61 62} This highlights the need for integrative approaches that combine handwriting fluency training with explicit spelling and orthographic instruction.

Taken together, evidence suggests that multisensory and technology-supported approaches are effective in enhancing legibility and speed in the short term, but the field still lacks large-scale, longitudinal and cross-linguistic trials to determine generalisability. While these interventions strengthened handwriting mechanics, they provided limited insights into higher-order composition and idea generation. The next theme addresses these broader writing skills. Furthermore, while mechanical improvements are necessary, they may not be sufficient without concurrent support for spelling and higher-order writing.⁶³

Advancements in composition and higher-order writing

Beyond mechanical handwriting skills, 11 studies in this review focused on composition and higher-order writing processes. These interventions emphasised idea generation, organisation and strategy use, which are often compromised in children with dysgraphia due to the cognitive load imposed by transcription difficulties. This aligns with the model of writing, which conceptualises writing as an interplay of planning, translating and reviewing processes.⁶⁴

Across studies, strategy-based educational interventions consistently improved the quality and structure of composition. Programmes such as Plan It, Write It,⁶⁵ sentence-combining tasks⁴³ and SRSD⁴² enhanced organisation, idea expansion and structural coherence. These findings from the included studies resonate with the meta-analysis of Graham and Perin, which identified strategy instruction as one of the most effective approaches for struggling writers.⁶⁶

Interventions aimed at productivity and ideation, such as speech-to-text and text-to-speech, demonstrated increased text length, maintained accuracy and greater use of punctuation.⁴³ However, these studies were limited by very small samples and short intervention periods, consistent with broader concerns in the external literature that assistive technology such as word prediction and speech recognition can be beneficial for some students but require careful matching to individual needs. This highlights a need for case studies using tools that fit children’s skills and address their challenges.⁶⁷ Similarly, direct instruction techniques⁴⁵ improved reading and comprehension skills, reinforcing evidence that targeted writing instruction supports broader gains in writing.⁶⁸

Finally, evidence on the development of writing strategies and processes showed that computer-based translation training⁴⁶ enabled students to use more effective planning and revision strategies. These findings are consistent with those of Berninger et al, who argued that combining handwriting and spelling instruction with composing practice best predicts long-term writing outcomes.⁴⁷

Collectively, the evidence suggests that strategy instruction and assistive technologies are effective in improving higher-order writing outcomes for students with dysgraphia. Although these studies reported improvement in composition skills, they rarely examined whether these gains transferred to other academic or cognitive domains. The next theme focuses on such broader benefits. Future research should investigate how strategy-based interventions and technology supports can be sustained and generalised to authentic classroom writing tasks, while also testing integration of handwriting fluency and composition instruction in a single framework.

Broader academic and cognitive benefits

A smaller but notable subset of studies addressed whether interventions for dysgraphia can transfer beyond writing to benefit other academic domains and underlying cognitive functions. This aligns with the notion of cross-domain academic transfer where improvements in one domain (eg, handwriting fluency) free up cognitive resources for others such as reading and mathematics.⁶⁹

Several studies in this review reported cross-domain academic improvements. For example, Rote Practice Technique improved mathematical performance among learners with dysgraphia,⁴⁸ while tele-rehabilitation, a hybrid approach using flash cards and dictation interventions, enhanced reading fluency and executive functions.⁴⁹ These findings are consistent with previous research showing that targeted handwriting instruction can indirectly improve reading fluency and spelling in children with learning disorders.⁶² Similarly, multimodal, multisensory interventions demonstrated broad benefits in both reading and writing.⁷⁰

Evidence for enhanced cognitive and perceptual functions was more limited. A previous study suggests that gamified learning interventions improved visual-perceptual skills and symbol recognition in Persian-speaking students.⁷¹ Such findings are consistent with neurocognitive research indicating that visual-motor integration and working memory are strong predictors of writing performance.^{72 73} However, the extremely small sample sizes (eg, three participants) limit generalisability.

Overall, this body of evidence suggests that dysgraphia interventions can yield secondary gains in reading, mathematics and cognitive-perceptual domains, but research remains fragmented and preliminary. Despite these broader academic and cognitive benefits, relatively few studies explored emotional, motivational or behavioural outcomes. These dimensions are covered in the final theme. More rigorous longitudinal designs are required to clarify whether these benefits reflect genuine transfer effects or are limited to overlapping skill domains (eg, phonological processing supporting both spelling and reading).

Positive affective and behavioural outcomes

A final theme emerging from the review was the psychological and behavioural impact of interventions, particularly regarding motivation, engagement and self-efficacy.

Findings from the included studies suggested that increased engagement and self-confidence often accompanied handwriting and strategy instruction. For instance, Balint reported that children receiving individualised physical therapy showed improved stamina and motor skills, as well as a greater willingness to participate in learning activities.⁵² Similarly, Garcia and Fidalgo found that SRSD and social cognitive models enhanced self-efficacy and engagement, particularly among girls.⁵⁰ These results are consistent with the broader literature, where SRSD has been shown to improve not only writing outcomes but also motivation and self-regulation.⁷⁴

However, evidence in this area remains limited and uneven. Most interventions were small-scale and did not systematically measure psychological outcomes as primary endpoints. This mirrors a broader gap in dysgraphia research, where affective variables such as writing anxiety, self-efficacy and motivation are often neglected despite their strong influence on academic persistence ³¹.

These findings emphasise that targeting affective and behavioural aspects is essential to sustaining mechanical, compositional and academic improvements. In summary, while preliminary evidence indicates that dysgraphia interventions may foster positive emotional and behavioural outcomes, this remains an underexplored area. Future work should integrate standardised measures of engagement and self-efficacy into intervention studies, ensuring that affective outcomes are given equal weight alongside mechanical and cognitive measures of writing.

Implications for practice

The findings of this review have direct implications for clinicians and educators working with children with dysgraphia. First, occupational therapists and educators should pair handwriting fluency training with explicit spelling and orthographic instruction within the same intervention, rather than addressing transcription and composition in isolation. Second, classroom teachers can integrate strategy-based instruction, such as SRSD and sentence-combining, into routine writing lessons for students with written expression difficulties, as these approaches have consistently shown benefits across the included studies. Third, where access to digital tools is available, assistive technologies such as speech-to-text, text-to-speech and tablet-based handwriting applications can serve as scaffolds for productivity and ideation, particularly for students whose transcription difficulties limit their ability to demonstrate cognitive abilities through writing. Fourth, practitioners should explicitly address affective dimensions, including writing anxiety, self-efficacy and motivation, alongside mechanical outcomes, since these factors mediate persistence and long-term progress.

Implications for policy

There are three policy implications in the wake of this review. First, the large number of small-scale studies and the relative lack of intervention research in LMICs suggest a pressing need for dedicated funding for large-scale intervention trials in under-represented contexts. Second, a few studies in this review report on various subtypes of dysgraphia, making it difficult to assess consistency in their reporting. This instability in reporting dysgraphia subtypes across the included studies suggests that ministries of education and professional bodies should support consistent reporting to ensure interventions are matched to the specific type of dysgraphia. Third, since the majority of interventions in this review were carried out in classrooms, education systems should focus on improving teacher training programmes, classroom resources and accommodation policies to facilitate the consistent identification and support of children with dysgraphia in resource-poor settings.

Implications for research

Moving beyond individual short-lived, single-site studies and using multi-site and culturally diverse (longitudinal) studies are recommended for future research regarding dysgraphia interventions. Priorities are: (1) trials which explicitly compare interventions between the sub-categories of dysgraphia (dyslexic, motor, spatial and dysgraphia with co-occurring conditions); (2) studies where there is a combination of transcription, composition and affective elements within a single multimodal intervention framework; (3) studies from LMICs, given the geographical imbalance of evidence; and (4) studies that systematically include affective and behavioural outcomes as primary endpoints rather than incidental findings.

Limitations and future recommendations

This scoping review identified existing interventions for dysgraphia and synthesised their outcomes, but some limitations remain. These are all outlined and future recommendations are developed for each. Restrictions on institutional access limited access to article retrieval. In the health and education sciences, two databases commonly used for scoping and systematic reviews (MEDLINE and Scopus) could not be accessed, partly because some pertinent studies were missed and only their indexes were available. This limitation could have resulted in database-coverage bias and a lack of range in the data collected, including specific research published in journals that, although included in MEDLINE or Scopus, were not included in the database searched. In the future, other databases (MEDLINE, Scopus etc) can be used to include additional studies in the literature. Future reviews may also consider forming a multi-institution or multi-country review team to aggregate complementary database access across institutions, providing more comprehensive coverage when access to specific databases is restricted to a single institution. This review aimed to include articles that discussed interventions to address dysgraphia; however, non-dysgraphia-related writing problems associated with acquired neurological conditions were excluded. Future research projects may be planned with developmental and acquired dysgraphia in mind, focusing on cross-comparison. Follow-up reviews (scoping and/or systematic) may be conducted to examine the facilitators and barriers that practitioners may face while working with children with dysgraphia. Only articles in the English language were included in this review; articles in other languages were excluded. Future studies should be conducted with a clear goal in mind: using a translation strategy to present articles in other languages.

Conclusion

This scoping review identified available evidence on interventions for children and adolescents with written expression difficulties and dysgraphia, drawing on 47 studies published from January 2000 to June 2025. The review revealed six types of intervention (educational, computer-based/technological, therapeutic, psychological, multisensory and combined/multimodal). It summarised findings based on four intervention categories (mechanical aspects of writing, aspects of writing composition, other academic and cognitive processes, and affective/behavioural aspects). Most importantly, the review uncovered new, articulated categories of intervention types and outcomes first established across a broad range of the literature, and comparatively under-addressed areas of evidence such as writing domain (composition), transfer across domains and affective outcomes, while also documenting the obvious geographical imbalance in the evidence, with limited representation of LMIC countries.

This review revealed that research on large-scale studies of interventions for dysgraphia is limited. There is a dire need to design large-scale multimodal interventions across settings to generalise the study findings by addressing different types of dysgraphia, thereby addressing a core issue and resolving overall writing difficulties.

Future research should, in particular:

• Plan and conduct multi-centre, long-term studies (at least 6–12 months duration) to measure short-and sustained outcomes (maintenance and transfer) from the intervention stage, including sub-group analysis by specific type of dysgraphia (dyslexic, motor, spatial and dysgraphia with co-occurring conditions).

• Create and test jointly planned multimodal intervention packages for training handwriting fluency, explicit spelling and orthographic instruction, strategy-based composition instruction (eg, SRSD) and assistive-technology supports in a single programme, instead of separately testing each component.

• Incorporate consistently psychosocial and affective outcomes as primary outcomes in intervention studies and also measure these outcomes with the same standardised instrument for anxiety in writing, self-efficacy, motivation and engagement in writing, and give equal weighting to other mechanical and academic outcomes.

• Encourage research focusing on LMICs, particularly research testing the feasibility, acceptability and cost-effectiveness of school-delivered interventions in resource-constrained environments and exploring generalisation across languages and away from an English-language-only setting.

• Future intervention studies on dysgraphia should set an agreed-on reporting standard for dysgraphia subtypes based on uniform diagnostic criteria in order to match interventions with the type of dysgraphia and to be able to compare future evidence syntheses directly.

These recommendations would address the methodological and contextual gaps identified in this review and move the field from a fragmented body of small-scale studies towards a more coherent and clinically useful evidence base to support children with dysgraphia and written expression difficulties.

Data availability statement

Data are available in a public, open access repository.