What SLPs Need to Know:
Agraphia

 10 min read

Writing is a fundamental skill we begin learning in our early school days. As adults, we write every day for different purposes: to make notes and lists, enter events on the calendar, text our friends and family, and communicate at work. Writing, whether by hand or typing, becomes second nature for many people, requiring little mental or physical effort.

Unfortunately, writing is often negatively affected by a stroke, brain injury, and neurodegenerative conditions. This loss of writing ability is called agraphia. It can have a sudden onset or decline over time in the case of dementia. Losing the ability to write can impact communication, independence, and self-esteem. While it’s often not the first thing that brings patients to speech therapy, working to improve writing can make a big difference in quality of life.

To better understand what happens when writing goes wrong, it helps to examine how we write normally. According to the dual-route model of spelling, we use one of two ways to write or type words (Rapcsak et al., 2007):

There are also the motor and visuospatial components of writing to consider, such as forming letter shapes, spacing out words, writing in a straight line, and keyboard movements. Writing is a complex process from beginning to end, making it sensitive to brain damage.

Agraphia: A Writing Impairment

Not all agraphia types are created equal. One stems from problems with the physical act of writing, and the other is tied to language and cognition. It’s important to spot the difference in clinical practice.

Peripheral Agraphia: Impaired Motor Processes

Cortical lesions or peripheral nerve and muscle damage can result in peripheral agraphia (Tiu, 2022). It involves impaired motor planning and motor skills needed for the physical act of writing letter shapes (allographs) and typing. Peripheral agraphia is sometimes called non-linguistic agraphia, since it doesn’t revolve around the cognitive-linguistic processes needed for writing.

Someone with peripheral agraphia might write distorted letters without significant spelling errors (Magrassi et al., 2010). There are different subtypes, like apraxic agraphia and visuospatial agraphia. Occupational therapists would likely take the lead on peripheral agraphia cases, but SLPs should be aware of them to make the appropriate referrals.

Central Agraphia: Impaired Cognitive & Language Processes

Any lesion involving the cortical language areas, or their associated subcortical structures, can cause central agraphia (Tiu, 2022). Clinicians will notice errors in both oral spelling and writing since the agraphia stems from impaired cognitive and linguistic processes (Magrassi et al., 2010).
 
Central agraphia often coexists with other language difficulties as a symptom of aphasia. It can mimic characteristics of the spoken language impairment, like agrammatism in Broca’s aphasia or jargon in Wernicke’s aphasia, called non-fluent agraphia and fluent agraphia, respectively (Tiu, 2022). It can co-occur with an acquired reading impairment with or without aphasia, referred to as agraphia with alexia. Clinicians may encounter different types of central agraphia, keeping in mind that patients may not fit neatly into one box.
 
Agraphia can occur in total isolation as well, while other areas of language remain intact. This is called pure agraphia, but it’s not very common compared to the other presentations (Lees, 2022).

Agraphia & Electronic Communication

In an interview study by Kjellén et al. (2016), many people with aphasia said they prefer to type on a computer than write by hand, even though those with aphasia usually type slower, use less complex syntax, and have less output compared to those without aphasia (Azios et al., 2023). Writing goals often include emailing, texting, social media, and assistive technology (Menger et al., 2024). These forms of electronic communication have pros and cons for those with dystextia, a loss of texting ability or a change in texting style.

Benefits of Electronic Communication:

• More time to read, process, and formulate responses compared to voice calls
• Messages are saved to help remember conversation details
• Spelling errors, grammar errors, and abbreviations are generally acceptable; not all errors need to be corrected
• Emojis, images, and GIFs can support written messages
• Spell check, autocorrect, and predictive text can reduce errors
• Communication breakdowns are less likely

Challenges of Electronic Communication:

• Typing still requires lexical and non-lexical retrieval
• There are increased demands on spatiomotor knowledge when using a keyboard
• Texting may be more complex than handwriting
• There are different typing patterns on a phone and a computer keyboard, both requiring motor skills that might be impaired after a stroke

(Azios et al., 2023; Lee & Churney, 2022; Menger et al., 2024; Thiel et al., 2013; Beeson, 2014)

Treating Agraphia

Multiple therapy protocols involve some combination of anagramming, copying, and recalling words. This lexical-semantic approach can improve written naming for trained words.

Target words for these treatments should be functional and personally relevant, since generalization to untrained words is limited based on research findings.

A phonological approach can be used if the sublexical route (or the phoneme-to-grapheme conversion) is impaired. Sound-letter and letter-sound correspondences are trained using a hierarchical approach described by Beeson et al. (2010). Studies have found improved phonological processing and spelling using this phonological approach.

Learn more about the phonological approach in this How-To article.

For patients with milder deficits, these treatments target writing at the sentence level:

If a patient can write at the sentence level but struggles with longer passages, consider using assistive technology in your sessions. Moss et al. (2024) had patients with acquired agraphia use speech-to-text and text-to-speech software for 7-10 hours weekly. They found significant improvements in narrative writing and social networking after training. Gains didn’t generalize to handwriting, suggesting this approach can help patients compensate for writing deficits but doesn’t restore skills.