Handwriting in Children with Attention Deficient Hyperactive Disorder: Analyzing by graphology

Objective: 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 study group included 21 (43%) males and 28 (57%) females, with 15 (71.4%) males and 7 (25%) females diagnosed with ADHD. A graphologist analyzed handwriting text from 49 patients, 22/49 previously diagnosed with ADHD, aged 13-18 years, in a randomized, single-blinded study. All study participants wrote a story in Hebrew in 10-12 lines, on a blank paper with a blue pen, during a period of twenty minutes. A licensed graphologist was given the papers, without details, for characterization analysis. The graphologist suggested a profile of a person with ADHD based on graphology theory for ADHD, and gave patients one point for each ADHD handwriting characteristic, up to 15 points. Patients with 9-15 points were considered to have ADHD, based on their graphology evaluation. Results The mean graphology score in the DSM based ADHD group was significantly higher than in the control group (9.61+3.49 vs. 5.79+4.01, p=0.002, respectfully). Using score of 0 as a cutoff point graphology-based ADHD score had an 80% specificity (95% CIs 59.2-92.8), and a sensitivity of 71.4%. Conclusion: Handwriting in ADHD children and adolescence has specific characteristics, thus graphological analysis could be a useful tool to help clinicians in the diagnosis of ADHD.

esteem [1,2,3]. Teachers report that the handwriting of both boys and girls with ADHD is immature, messy, and illegible . These findings may reflect poor motor skills and visualmotor integration, which are directly correlated with low handwriting legibility [2].
Furthermore, studies have shown that force, timing of agonist and antagonist muscles, and pen pressure are all weaker in children with ADHD [2,4].
Motor skill and visual-motor integration were found to correlate positively with legibility; force, timing of agonist and antagonist muscles, and pen pressure were weaker for children with ADHD [2,4]. Tucha and Lange (2004) studied the effect of methylphenidate on quality and fluently of handwriting in children and adults with ADHD, but didn't characterize the handwriting difficulties [5 ].
Graphology is an ancient discipline developed in China for purposes of analyzing the personality and behavior of individuals through the physical characteristics and patterns of their handwriting [6]. Following publication of the systematic theory of handwriting analysis by Ludwig Klages, a nineteenth century German philosopher and psychologist, the use of graphology for various purposes, including psychiatric research and evaluation, spread throughout Europe [7]. In 1942, the graphologist T.S. Lewiston and psychologist J.
Zubin developed L-Z scales to objectively evaluate quantitative and qualitative handwriting elements, using statistical evidence to differentiate between handwriting of abnormal and normal personalities [8]. The scales made it possible for expert graphologists to identify relevant handwriting features in different languages .and determine how they interact. Conclusions regarding either specifics or absolutes could not be reached on the basis of a single feature alone. It was the combination of several different features interacting in various ways that made it possible for clinicians to achieve a full and clear interpretation.
Since the mid-20th century, graphology has been applied in many settings: to find suitable employees, establish the authenticity of a signature or text, and establish the state of the author of a signature or a text, (e.g., drunk or anxious). It has also been used in court and during criminal investigations. Handwriting examinations are recognized clinical tools in psychiatry [7] for the diagnosis of suicide attempts [9] and severe major depressive disorder [10].
We hypothesized that children with ADHD might be distinguished by the types and number of abnormalities found in their handwriting The aim of the present study was to use graphology to analyze the characteristics and patterns of the handwriting of children diagnosed with ADHD compared to children without ADHD and to determine if graphology might serve as an objective auxiliary tool in the diagnosis of ADHD.

Participants
Forty-nine children aged 13 to 18 years were included in the cohort. The study group  [11,12]. The control group included 27 otherwise healthy children without ADHD who presented at the Pediatric Neurology and Epilepsy Center of Schneider Children's Medical Center of Israel, a major tertiary pediatric hospital or at the Meuhedet Health Services (North District, Israel) clinics during the same time period because of a mild/moderate headache or simple viral infection. Inclusion criteria for all study participants were ability to speak and read Hebrew, attendance in a mainstream school, absence of a severe learning disability or a psychiatric comorbidity (such as anxiety disorder, oppositional disorder, depressive disorder) requiring treatment or psychiatric intervention. None of the children had developmental coordination disorder.
One child had Tourette syndrome with variable tics that did not need treatment.
The study was approved by the Ethics Committee of Schneider Children's Medical Center of Israel. The parents or guardians of all children provided written informed consent prior to enrollment in the study.

Procedure
Handwriting samples were collected from all participants. The children were given a blank sheet of paper and a blue pen and asked to write a story in Hebrew of 10-12 lines over a 20-minute period. The papers were collected then submitted for analysis to a licensed forensic graphologist (B.C.-K.) who was blinded to the background and clinical data of the subjects

Graphology analysis
The graphologist established a predefined handwriting profile of individuals with ADHD based on graphology theory that handwriting can determine the type of personality and evaluated each sample accordingly. The profile was composed of 15 characteristics: text layout (spread out); margins (none or only one); line direction (never ascending); line , word and, letter spacing (all abnormal); nonconventional letters (many); handwriting slant (never to the right); deviation of handwriting (yes), letter size (abnormal, 3-4 cm); letter width (only wide or only narrow); continuity or flow connection (absent), shape of writing (never thread-shaped), writing speed (never slow), and strength of graphism (poor).In each sample, 1 point was accorded for every abnormal characteristic identified, yielding a graphology score ranging from 0 to 15. Patients with a score of 9 or more were considered to have ADHD.

Statistical analysis
The graphology scores of the patients with and without ADHD were summarized as mean and standard deviation and compared between the groups, total and stratified by sex.
Since scores showed a non -normal distribution, the non-parametric Mann-Whitney U test was used for data analyses. All tests were two-tailed, and the level of significance was set at p <0.05. Chi-square test was used to compare categorical variables.
The diagnostic accuracy of the graphology evaluation was examined using receiver operating characteristic (ROC) curve analysis, which depicts sensitivity by 100% specificity for every possible cutoff score, with a resulting area under the curve (AUC) ranging from 0.5 (no better than chance) to 1 (perfect diagnostic accuracy). An AUC of 0.8 or higher suggests that an instrument can be considered a useful screening tool [13].
The children with a DSM-IV/V diagnosis of ADHD had a significantly higher mean graphology score than the children in the control group (9.61+3.49 vs. 5 (Fig. 1) On separate evaluation of the individual handwriting elements, the only significant feature in girls with ADHD was line direction (never horizontal or ascending) (p <0.05; Fig. 2).
Significant features in boys with ADHD were line spacing (abnormal) and writing speed (never slow) (p <0.05).

Discussion
Although it is well known that children with ADHD have handwriting difficulties and that their handwriting improves after treatment with methylphenidate [14]. This is the first study to our knowledge to use graphology as a tool for evaluating ADHD. In support of our hypothesis, we found that graphology had a sensitivity of 75% and specificity of 76.2% for detecting ADHD.
Handwriting is a complex task requiring the integration of different components, including behavior (inattention, hyperactivity), motor planning, fine motor skills, and visual motor perception [15]. Lerer et al. [16] reported that the specific handwriting problems in children with ADHD were poor organization of written material within the space available, poor spacing within and between words, poor overall legibility, inconsistent letter size and shape, poor alignment, frequent erasures, frequent omissions of letters or words, letter inversions, poor rhythm and flow of writing, and slow speed. In our study, despite the good overall specificity and sensitivity of graphology, further analysis of the individual handwriting features evaluated yielded only a limited number of significant differences.
Among the boys, writing speed was never slow in the subjects with ADHD compared to the control group who showed more variability. This finding differed from the study of Lerer et al. [15] but was in line with the results of Adi-Japha et al. [17] who reported that the kinematic manifestations of writing deficits in children with ADHD were a fast, inaccurate, and inefficient written product accompanied by high levels of axial pen pressure. A possible explanation was the hyperactivity-associated hyperkinetic movements and lack of response inhibition characteristic of ADHD [18], leading the children to complete the task as quickly as possible. This is supported by the lack of a significant difference between the girls with and without ADHD in our cohort, as females with ADHD are known to have fewer hyperactive/impulsive symptoms and more inattentive symptoms than males [19].
Other studies suggested that children with ADHD have a less appropriate speed of execution and more motor difficulties than children without ADHD [4,20], but they did not distinguish the comorbid learning difficulties in ADHD that can cause lower writing speed [21]. Among the females, the handwriting of subjects with ADHD was never ascending

Conclusion
The handwriting of children with ADHD has specific characteristics. The use of graphology for the diagnosis of medical disorders is a highly disputed branch of handwriting analysis.
It is likely that handwriting problems in ADHD have less to do with the writing itself and more to do with factors related to motor control. Our study suggests that graphology is a promising potential auxiliary tool for use by clinicians in the diagnosis of ADHD.

Declarations
Availability of data and material: The data and materials are available upon request.