Hand-writing is still a core aspect of the national curriculum in the UK. Indeed, the new curriculum, implemented in 2014, focuses even more on hand-writing skills, linking a child’s handwriting to composition and spelling ability. However, other countries such as the USA have dropped handwriting skill from the curriculum as questions have been raised about the importance of hand-writing within a digital age. Think about how often do adults even write with a pen these days and is it not likely that the need to write with a pen will even decrease further when children will grow up?

Writing is a task that requires a number of cognitive processes to come together

One of the arguments put forward as to why handwriting is still important is that handwriting allows children to “feel” the letters and that this ‘learning by doing’ aids children’s spelling abilities.

However, handwriting does not only require complex motor abilities, it is also a complex cognitive skill. When writing with a pen a child engages at least in the following cognitive processes:

1) thinking of the sound they are going to write (verbal working memory)

2) retrieve appropriate visual representation of the sound from memory (visuo-spatial working memory)

3) find appropriate place on paper to start writing (visuo-spatial awareness) whilst remembering to hold the pen correctly (motor skills) and remembering the visual representation of the sound (verbal working memory and visuo-spatial working memory)

4) keep track of how to write the sound (visuo-spatial awareness)

repeat these steps for next sound.

Hence, writing with a pen requires a lot of 1) working memory abilities (processing more than 1 thing/information at the same time in the brain), 2) motor abilities, 3) visuo-spatial abilities. All of these are generally areas of difficulty for children with WS.

In comparison, writing with a keyboard on a computer involves the following:

1) think of sound you are going to write

2) retrieve appropriate visual representation of the sound from memory

3) find appropriate sound on computer (visuo-spatial ability but can memorised) and press button

repeat for next sound.

Therefore, writing with a keyboard limits the amount of cognitive processing (less working memory demands) and minimises motor demands and visuo-spatial demands. This may be beneficial for children with WS, especially when they are asked to write longer texts as even though some children with WS write, their writing can be slow and laborious. In addition, writing longer texts or a story requires children to keep in memory even more information as well as story structure etc, placing an even greater demand on children’s working memory abilities. However, it has been argued that as computers auto-correct and have spell checks, writing with a keyboard may limit children’s spelling abilities. In addition, we can question whether limitations or difficulties, such as handwriting, should be avoided by using a keyboard or receive more attention, practice and support instead.

Writing is important for children: children who read and write more get to develop their language abilities more and better language abilities lead to better writing abilities. However, children who have motor difficulties, as well as working memory and visuo-spatial difficulties, might benefit more from writing with a keyboard than writing with a pen, at least when writing longer texts.

Comorbidity Williams syndrome and Autism spectrum disorders

Comorbidity is the presence of a developmental disorder co-occurring with another one. It is often claimed that those with Williams syndrome (WS) and those with Autism spectrum disorders (ASD) show opposite social and communication difficulties. Yet, the comorbidity between WS and ASD is higher than expected, even though the exact rate of dual diagnosis is currently unclear. A number of parents have asked me how a comorbid diagnosis for ASD in WS can be made. Therefore, below I have outlined some of the similarities and differences that are commonly observed in those with WS and ASD (but this list is not exhaustive). Although all children are different, these are the typical behaviours that one would observe for each developmental disorder. As you can see from the table, there is quite a lot of overlap between the two disorders, which makes it harder to make a comorbid diagnosis of ASD and WS.

As can be seen from the table children with WS often show socio-communication difficulties that overlap with ASD. However, those with WS who receive a dual diagnosis for ASD show more features that are typically only seen in ASD, especially eye contact avoidance, atypical intonation, and low social approach.

Further reading

Klein-Tasman BP, Phillips KD, Lord CE, Mervis CB, Gallo F. Overlap with the Autism Spectrum in Young Children with Williams Syndrome. Journal of developmental and behavioral pediatrics : JDBP. 2009;30(4):289-299. doi:10.1097/DBP.0b013e3181ad1f9a.

Asada K, Itakura S. Social Phenotypes of Autism Spectrum Disorders and Williams Syndrome: Similarities and Differences. Frontiers in Psychology. 2012;3:247. doi:10.3389/fpsyg.2012.00247.

By Dr Jo Van Herwegen

Children with WS are often delayed in their learning and most require specialist support (including speech and language therapy, physio therapy, occupational therapy, music therapy). I would say that all children with WS would benefit from 1-to-1 support to help their learning and to follow instructions. Besides that support, children with WS might benefit from the following strategies and approaches to support their learning and inclusion in the classroom:

Language development: Although language abilities generally are a strength in older children with WS, almost all young children with WS show a significant delay at the start of language development. In addition, children with WS often show better vocabulary compared to language comprehension. Therefore, the following adjustments should be made:

• Make instructions short or break them down into smaller chunks.
• Make eye contact and clearly say the child’s name before giving an instruction, as children with WS often miss that the instruction applies to them too when given in a group.
• Seeing their affinity with music, songs can help gain attention from children with WS and be used to teach children new facts and materials.
• Make sure objects and concepts are accessible/visible when talking about them and avoid abstract concepts.
• When explaining things always give the same example/explanation to start with and then expand with others, children with WS find it difficult to see similarities and analogies between things so explaining things in a different way might confuse them and hinder their learning.
• Grammatical understanding (especially prepositions such as “on”, “beside”, “between”) is often poor and people with WS might confuse sentences such as “the cat chases the dog” and “the dog chases the cat”. So always check the child with WS has understood what is expected from them.
• Figurative language or analogies are often used to explain new concepts. Yet, children with WS find figurative language, such as metaphors (i.e. the brain is like a computer), and analogies difficult to understand. So it is best to use more concrete language.

Peer relationships: Relationships with peers often stay superficial and people with WS tend to seek out social interactions with adults, instead of peers, even when older. In addition, individuals with WS may lack theory of mind abilities (understanding what others may be feeling or thinking) and may thus not able to respond appropriately to other people or in social situations. Therefore, the educational programme for children with WS should include some naturalistic play scenarios that include components of theory of mind as well as social situations and Social Stories that allow them to develop their social skills and establish friendships with peers.

Learning environment: Due to their distractibility and complex sensory needs, it is important that children with WS can receive some 1-to-1 teaching in a quiet room as this will allow them to concentrate better but also provide some vital time out from all the sensory input. This is important as too much sensory input can interfere with processing and the consolidation of the information being taught and lead to high levels of anxiety.

Managing behavioural and anxiety problems: Although most young children with WS are happy, people with WS are at an increased risk for high levels of anxiety and phobias. These tend to become worse with chronological age and at times of transition. These high anxiety levels can lead to outbursts of aggression or difficult behaviour. A fixed or predictable routine (e.g. a time schedule) is definitely recommended to reduce anxiety. In addition, using the same well-known support workers and preparing children with WS for any transitions might be needed.

Motor skills: Due to their low muscle tone, limited working memory abilities, and poor visuo-spatial awareness, writing with a pen is often a slow and laborious process in children with WS. Instead, the use of an iPad or keyboard would allow children with WS to develop their literacy (as well as language and learning).

The use of outdoor activities (such as climbing and balance activities) will help develop gross motor abilities. Furthermore, research has shown that people with WS have very poor visuo-spatial and navigation abilities but that exploration through self-locomotion can improve spatial abilities, spatial language as well as navigation abilities which in turn will aid independence long term.

General information processing and learning in WS: Research has shown that children with WS do not necessary integrate new information into their existing knowledge and theories. This means that it might be difficult for them to retrieve facts or they might take a long time to learn new things. A lot of repetition and explicitly showing children how new information relates to things they already know might be required. In addition, individuals with WS have a local processing information style which means that they will see/hear/focus on details at the expense of the wider context. So for example, when looking at a picture they may focus on certain details but not see how items go together. Similarly, when listening to a story they may remember details without understanding the wider context of the story or main storyline. Making children explicitly link information will therefore be essential. In addition, teaching children to group objects and semantic knowledge into categories will be required.

Reading development: Reading abilities have been found to be delayed in children with WS. And there is a lot of variability in the reading abilities of children with WS with some children being quite fluent readers and others struggling to read. This is mainly because many children find it difficult to learn the letter-sound combinations. In addition, many individuals with WS who do read quite fluently still find it difficult to understand what they are reading and show reading comprehension difficulties.

Reading difficulties are caused by visuo-spatial difficulties as well as poor working memory abilities.  Therefore, a phonological reading approach may not always work for children with WS and it is important that phonics lessons are combined with whole word reading and vocabulary lessons (for example such as in the Reading and Language Intervention or RLI for children with Down syndrome).

Mathematical development: Our research has also shown that, although children with WS know the counting names very well, their understanding of mathematical concepts is very delayed. Number abilities relate to domain specific abilities (such as approximate number abilities (ANS) or ability to see where there are more or less items as well as the number line) and some domain general abilities (including working memory (WM) and language abilities). Our research has shown that the ANS abilities in WS are impaired from infancy onwards and that individuals with WS have difficulties with WM. These difficulties can explain why, although they are very good at counting, people with WS fail to understand the meaning of counting or to complete formal mathematical tasks.

Due to the rarity of the disorder (about 1 in 20 000 life births), there are currently no intervention or training programmes that are aimed at WS specifically. However, children with WS often show language and attention difficulties that are similar to children with more common disorders such as Down syndrome (DS). In addition, although children with WS are very sociable, they also show social difficulties and anxiety issues that are common in children with Autism Spectrum Disorders (ASD). Therefore, children with WS might benefit from training programmes that have been found to be successful for children with DS and ASD.

The information provided here is very general and might not apply to all children or all ages. However, hopefully this summary provides some further information about what kind of support and strategies might be helpful for children with WS.

Some key references:

Brock J. Language abilities in Williams syndrome: a critical review. Dev Psychopathol. 2007;19: 97-127.

Martens MA, Wilson SJ, Reutens DC. Research Review: Williams syndrome: a critical review of the cognitive, behavioural, and neuroanatomical phenotype. J Child Psychol Psychiatry. 2008;49:576-608.

Thomas MSC, Van Herwegen J. Williams syndrome and language development. In:  Brooks P, Kempe V, Golson JG, editors. Encyclopedia of Language Development. Sage Publications;2014: 667-669.

Van Herwegen J, Rundblad G, Davelaar EJ, Annaz D. Variability and standardised test profiles in typically developing children and children with Williams syndrome. Br J Dev Psychol. 2011;29:883-894.

Van Herwegen, J. & Simms, V. (2020). Mathematical development in Williams syndrome: A systematic review. Research in Developmental Disabilities. Special Issue