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NeuroRehabilitation 34 (2014) 29–37 DOI:10.3233/NRE-131007 IOS Press

Expressive writing in people with traumatic brain injury and learning disability Lisa Wheelera , Sherry Nickersona,∗ , Kayla Longa and Rebecca Silverb a Towson

University, Towson, MD, USA University, Syracuse, NY, USA

b Syracuse

Abstract. BACKGROUND: There is a dearth of systematic studies of expressive writing disorder (EWD) in persons with Traumatic Brain Injury (TBI). It is unclear if TBI survivors’ written expression differs significantly from that experienced by persons with learning disabilities. It is also unclear which cognitive or neuropsychological variables predict problems with expressive writing (EW) or the EWD. OBJECTIVE: This study investigated the EW skill, and the EWD in adults with mild traumatic brain injuries (TBI) relative to those with learning disabilities (LD). It also determined which of several cognitive variables predicted EW and EWD. METHODS: Principle Component Analysis (PCA) of writing samples from 28 LD participants and 28 TBI survivors revealed four components of expressive writing skills: Reading Ease, Sentence Fluency, Grammar and Spelling, and Paragraph Fluency. RESULTS: There were no significant differences between the LD and TBI groups on any of the expressive writing components. Several neuropsychological variables predicted skills of written expression. The best predictors included measures of spatial perception, verbal IQ, working memory, and visual memory. CONCLUSIONS: TBI survivors and persons with LD do not differ markedly in terms of expressive writing skill. Measures of spatial perception, visual memory, verbal intelligence, and working memory predict writing skill in both groups. Several therapeutic interventions are suggested that are specifically designed to improve deficits in expressive writing skills in individuals with TBI and LD. Keywords: Writing disorder, expressive writing skill, TBI, cognition

1. Introduction The ability to write well has become more important as the emphasis on electronic written expression becomes more prevalent (Berninger et al., 1998; Borkowski & Thorpe, 1994). Written expression is vital to many important aspects of daily life. For example, it is an essential skill for conducting personal business, such as filling out job or college applications, note taking, text messaging, and replying to emails. Despite the necessity for writing skills at work, in school and in everyday life, many people find it difficult to write their ∗ Address

for correspondence: Sherry Nickerson, Towson University, 17905 Bunker Hill Road, Towson, MD 21120, USA. Tel.: +1 443 803 1619; E-mail: [email protected].

thoughts effectively; this is especially difficult for those with poor organizational skills. Injuries affecting the frontal lobes often result in organizational deficits that render brain injury survivors particularly susceptible to problems with written expression (Lezak, Howieson, & Loring, 2004; Savage et al., 2005). While persons with learning disabilities (LD) have been the primary focus of research investigating expressive writing disorders (Butler, Elaschuk, & Poole, 2000; Wong, Wong, Darlington, & Jones, 1991; Wong, 2000), few studies have addressed these issues with TBI survivors. The purpose of this investigation was to investigate the neuropsychological predictors of expressive writing skill among individuals with TBI relative to those who have learning disabilities.

1053-8135/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved

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1.1. What is expressive writing skill? Graham and Harris (1989) defined expressive writing as “writing for the purpose of displaying knowledge or supporting self-expression and is accomplished by generating content, developing an ongoing frame for the story, and planning in advance of writing”. Wong et al. (1991) identified two orders of expressive writing skill. Lower order skills include spelling, punctuation, and grammar; higher order skills include planning, organizing text, and implementing strategies. Early research regarding expressive writing problems focused on lower order skills; however, the advent of technological aids such as spellcheck and grammar check on computers have made lower order errors easy to recognize and to correct. More recently, research in this area has shifted to exploring higher order (cognitive and metacognitive) aspects of writing skill such as the ability to structure writing and to plan a coherent outline (Wong et al., 1991). There are few generally accepted measures of written language. For example, the Woodcock-Johnson Psychoeducational Battery-Revised (1989) includes several subscales that measure writing ability. However, this test does not measure writing free form text. Additionally, the Test of Written Language (Hammell & Larsen, 1996) assesses writing skill by analyzing written descriptions of pictorial sequences. It is therefore unclear how well this test format mimics everyday writing. A larger problem with both tests is that they measure writing skill in terms of standardized scores, percentiles, and grade levels of the written materials but fail to take into consideration other variables such as the proper usage of adjectives and adverbs, jargon, number of paragraphs, and word fluency. There is no measure of sentence construction, style, or parsimony of language, all of which are necessary components of effective written expression. However, perhaps the biggest problem with these tests is that they do not measure expressive writing in a naturalistic setting in which an individual would simply write a series of paragraphs in their typical style. The creation of software programs that analyze freely written text has made evaluation of natural writing possible. For example, RightWriter® (www.rightwriter.com) and Grammarly (www.grammarly.com) analyze a variety of features of written language and provide a comprehensive analysis of the various aspects of a person’s written expression. These measures include several commonly used readability formulae such as the Dale-Chall Index (Dale & Chall, 1948), the

Gunning FOG index (Flesch, 1948), and the McLaughlin SMOG index (1969) (See DOD MIL – M – 38784B for a complete description of these indices). The Department of Defense uses the Flesch index (Flesch, 1948) to evaluate the readability of its documents. This index is the overall reading grade level that a reader must have to understand the text. Other measures such as the FleschKincaid index (Kincaid, Fishburne, & Chissom, 1975) are hybrid versions of the original Flesch formula. The advantage of these scoring systems is that they can be applied to freely written text similar to what occurs in everyday life. 1.2. What is expressive writing disorder? Short (1992) considered reading, writing, and arithmetic disorders to be part of larger language-based developmental problems with cognition and language. Whitehurst et al. (1988) defined an expressive language disorder as a condition characterized by developmentally delayed expressive language skills (e.g., written expression) relative to the person’s receptive language skills (e.g., reading comprehension) and IQ. Giordano (1984) defined a writing disorder as an inability to communicate functionally through writing. While these definitions outline the substance of the expressive writing disorder, they do not provide a functional definition that can be used to identify someone who has an expressive writing deficit. The diagnostic and Statistical Manual of Mental Disorders (DSM-V) defines the disorder as a type of specific learning disability that is characterized by “poor spelling, punctuation, and grammar as well as lack of clarity and organization of written expression” (DSM V, 2013). The DSM-V definition is, perhaps, the most commonly used functional method for diagnosing a writing disorder. It identifies those with below average written language skill as measured by standardized tests relative to the standard scores on other measures of intelligence. By this definition, a person with standard scores on tests of expressive writing that were significantly below their measured IQ levels falls into the category of expressive writing disorder. The disorder would interfere with their ability to function academically or vocationally and it cannot be attributed to other factors such as overall low IQ. 1.3. Neuropsychological predictors of expressive writing disorder Connor (1991) defined writing as the ability to integrate semantic, sensory, and motor areas of the brain.

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Because of the reduced speed and limited capacity for information processing caused by brain injury, the ability to regulate the integration of these skills may be exacerbated in brain-injured individuals (Goodglass & Kaplan, 1983). Parente and Hermann (2010) identified decreases in cognitive flexibility and divergent thinking skills in individuals with damage to the frontal lobes which creates problems with attention, limited memory, and decreased capacity for abstract thinking. Lezak (1995) identified several consequences of brain damage that may affect a person’s writing skill. For example, many brain-injured individuals are physically unable to write because of spasticity, tremors, or paresis. Mildly brain injured individuals have also shown cognitive deficits that potentially interfere with writing skill (Lewis & Murdoch, 2011). For example, Lewis and Murdock (2011) found 35% of individuals diagnosed with mild traumatic brain injury (mTBI) showed difficulties with visual processing, learning, memory, selective attention, and executive function 6 months post injury. There are also visuoperceptual deficits that affect the quality of handwriting and diminished quantity of written material. These problems may result from or be exacerbated by aphasia, a condition that includes word-finding problems, word substitutions, and an inability to maintain concentration and focus for long periods (Lezak, 1995). O’Donnell, Romero and Licht (1990) investigated language deficits in young adults with and without LD or TBI. Using the Aphasia Screening Test (Enderby, Wood, Wade, & Hewer, 1986), they found little difference between the LD and TBI samples; however, both groups showed many more errors when compared to the non-disabled group (O’Donnell et al., 1990). Significant correlations between errors made on the Aphasia Screening Test and performance on the spelling subtest of the Wide Range Achievement Test suggests that aphasia may also affect other aspects of a survivor’s expressive writing skill (O’Donnell et al., 1990). Mayes and Calhone’s (2007) research differentiated “typical” adolescents from adolescents diagnosed with ADHD, autism, anxiety, depression, and ODD, regarding the amount of neuropsychological deficits each group displayed. The results were similar to those reported by O’Donnell et al. (1990). The not-disabled or “typical” adolescents outperformed the disabled adolescents on performance tests of learning, attention, graphomotor skill, and processing speed. On tests of written expression, adolescents with ADHD and autism demonstrated worse performance compared to both the control and the other disorders group (Mayes and Calhone, 2007).

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Ewing-Cobbs, Levin, Eisenberg and Fletcher (1987) found that early onset TBI produces more severe language deficits, including written language, later in life. These authors showed that brain injuries occurring before adolescence resulted in more severely disrupted written language relative to those whose brain injuries occurred during adolescence. Docking and Murdoch (2007) studied a child pre and post mTBI and found that 11 months post injury, the child showed significant issues with expressive language. Additionally, Catroppa and Anderson (2004) determined that both moderate and severe TBI in childhood resulted in some degree of residual impairment at 24 months post-injury. Levander, Levander and Schalling (1989) found that gender was a significant predictor of expressive writing skill. Females scored significantly higher relative to men on measures of reading comprehension, spelling and writing fluency. Men performed better on tests requiring right hemisphere functioning and perceptual motor skill while women outperformed men on tests that required left hemisphere skills such as fluency, articulation, and grammar. 1.4. Causes of writing disorder Rosenbuth and Reed (1992) suggested that writing dysfluency results from the feeling that writing is overwhelming which produces anxiety. Moran (1987) indicated that writers with learning disabilities lacked internalized models of written composition resulting in difficulty constructing and remembering visual images of written content. Consequently, persons with LD are unable to plan or revise their writing (Newcomer & Barenbaum, 1991; Thomas, Englert, & Gregg, 1987) which results in “knowledge telling” (Thomas et al., 1987; Thomas, 1996; Whitehurst et al., 1988) instead of an organized narrative. Specifically, those with poor writing skills write everything they know about a given subject without concern for organization or flow. Goodglass and Kaplan (1983) emphasized the role of memory as a component of expressive writing. These authors suggest that difficulty with writing may result from failure to recall the motor movements necessary to produce alphabetical syntax, a problem defined as “written word-finding disorder”. Lane and Lewandowski (1994) showed that if you remove the lower level mechanical aspects of writing, such as spelling, penmanship, capitalization, and punctuation, writers would be able to devote greater resources to planning and idea generation. Some researchers (Butler, Elaschuk, & Poole, 2000; Thomas et al., 1987;

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Wong, 2000) believe that expressive writing deficits derive from underlying cognitive deficits. For example, a TBI survivor with damaged frontal lobes may have difficulty setting goals, brainstorming, sequencing ideas, and organizing and planning. Some survivors may have difficulty activating prior knowledge and sustaining thoughts in memory about various topics; these deficits create additional problems such as redundant thought content and early termination of sentences or paragraphs (Whitehurst et al., 1988; Connor, 1991). This brief literature review reveals several unanswered questions. First, because of a dearth of systematic studies of expressive writing disorder with TBI survivors, it is unclear what aspects of freely written text could define the expressive writing difficulties of persons with LD or TBI. Second, there is no clear evidence that problems with written expression after brain injury are any different from those experienced by persons with learning disabilities. Third, most studies of the relationship between cognition and expressive writing with non-injured groups have identified visual imagery, memory, perceptual-motor skill, attention, and concentration as significant predictors (Butler, Elaschuk, & Poole, 2000; Wong, Wong, Darlington, & Jones, 1991; Wong, 2000). However, it is unclear which of these variables predict expressive writing difficulties with LD or TBI persons. The following experiment was designed to investigate whether different measures of freely written text could be combined into meaningful clusters that would define an expressive writing disorder in persons with LD and TBI. The study also assessed whether persons with LD or TBI differed with respect to these clusters of measures. The experiment also evaluated which of several cognitive variables predicted the expressive writing skill and the expressive writing disorder.

had varying degrees of injury, however, all TBI participants experienced at least a 2-week coma following initial head trauma. None of the participants with brain injuries had any documented prior history of learning disabilities. The average Full Scale IQ for the LD participants was 93 (Sd = 13). The Average IQ for the TBI survivors was 92 (Sd = 14). 2.2. Procedure The last task of the psychological evaluation involved generating a writing sample in which each participant spent 10 minutes writing a paragraph that expressed his or her vocational interests. The writing samples were then analyzed using the RightWriter® (www.right-writer.com) computer software package to determine the level of expressive writing skill. This software computed the total word count or fluency, as well as the number of grammatical errors and several measures of readability including the FleshKincaid index of readability (http://www.standardsschmandards.com/exhibits/rix/) which is the academic grade level required of the reader to understand the written text. The RightWriter® program computes this measure as part of its output. The Flesh-Kincaid index was first converted into standard scores with a mean of 100 and a standard deviation of 15 to match that of the Wechsler distribution. The difference between the person’s Flesh-Kincaid index minus their score on the Wechsler Adult Intelligence Scale (Wechsler, 2008 – http://www.pearsonassessments.com) provided an index of expressive writing disorder. A negative score on this variable indicated that the persons’ measured verbal IQ exceeded his or her written language ability.

3. Results 2. Method 3.1. Data reduction 2.1. Participants Participants included 28 adults with a diagnosed LD and 28 with TBI. The data were part of psychological evaluations performed individually by a licensed psychologist. The research was approved by the Towson University IRB committee. Each participant in the LD condition had a documented history of special education training, an Individualized Educational Plan, and a documented diagnosis of learning disorder (De La Paz & Graham, 1997). Participants in the TBI condition

Our first goal was to analyze the output from the The RightWriter® software to create clusters of correlated variables that would characterize written expression in the LD and TBI groups. Therefore, analysis began by extracting the principal components (PCs) of the measures of writing skill from the TBI and LD groups separately. Each analysis produced four PCs that accounted for approximately 90% of the total variance in the TBI sample and 86% of the total variance in the LD sample. The four extracted components (see

L. Wheeler et al. / Expressive writing disorder Table 1 Cognitive predictors of writing communication Reading ease

Sentence fluency

Grammar/ spelling

Paragraph fluency

Block design

Verbal IQ

Working memory

Visual memory picture completion Rey figure copy

R2 = 0.30

R2 = 0.30

R2 = 0.30

R2 = 0.54

∗∗ Variables included in each model were significant at the 0.001 level

or less to correct for the number of significance tests performed.

Table 1) were quite similar in each sample; the similarity suggested that the components of written expression did not differ between them. In each analysis, the first PC was a global measure of Reading Ease that included all of the reading level indices plus the average number of words per sentence. Specifically, the PC included the Flesch-Kincaid index of readability (Kincaid et al., 1975), the Flesch index (Flesch, 1948), the Gunning Fog index (Gunning, 1952) and the Reading Ease index (Flesch, 1948) plus the average number of words per sentence. The second component measured Sentence Fluency and included the number of sentences, the average number of syllables per word, the total number of words, the average number of sentences per paragraph, and the number of three syllable words used. The third component described the participant’s level of Grammar and Spelling skill. This component included the total number of spelling errors and the number of grammatical errors in the paragraph. The fourth component was a measure of Paragraph Fluency, which included the number of paragraphs the participant generated within the 10-minute period and the average number of sentences per paragraph. 3.2. Discriminating the LD and TBI groups The next step was to determine if the LD and TBI groups differed with respect to these components of writing skill. Discriminant analysis did not indicate any significant differences between the groups on any of the four factors. The next stage of the analysis assessed the predictors of writing skill. Four separate linear regression analyses were performed to determine which cognitive variables predicted the Reading Ease, Sentence Fluency, Grammar and Spelling, and Paragraph Fluency component scores. These analyses used all of the cognitive variables as predictors of each component score. The analyses were clearly post-hoc; therefore the tests of the individual predictors included a Bonferonni

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correction for the number of significance tests performed. Generally, this approach required testing each predictor with a 0.001 criterion for significant entry into the prediction model. The analysis of the Reading Ease component yielded a multiple R2 of 0.30 and one significant predictor, the Block Design subtests of the Wechsler Intelligence Scale. Those participants who scored higher on the Block Design subtest also produced writing samples that required a higher level of education to comprehend it. The Verbal IQ from the Wechsler scale was the only variable that predicted the Sentence Fluency component (R2 = 0.30). Those participants with higher verbal IQs produced more sentences and sentences that were more complex. The Working Memory measure from the Wechsler scales was the only significant predictor of the Grammar and Spelling component (R2 = 0.30). Higher scores on this subtest yielded lower grammar and spelling errors. Three variables predicted the Paragraph Fluency component (R2 = 0.54). This group of predictors included the Picture Completion subtest from the Wechsler Scales, performance on the Rey Figure Copy test (Rey, 1941) and the Immediate Visual Memory subtest from the Wechsler Memory Scale. Better performance on any of these tests predicted greater paragraph production. 3.3. Predicting expressive writing disorder The difference between the Flesh-Kincaid readability index (Kincaid, Fishburne, & Chissom, 1975) minus the Verbal IQ is one index of expressive writing difficulty. We initially transformed the Flesh-Kincaid index into a Wechsler standard scores system (mean = 100, Sd = 15) then subtracted the two to produce a difference score for each participant. Subtracting the Verbal IQ from the Flesh-Kincaid index measured the extent of the EWD. If the score was zero or greater, there was no evidence of an expressive writing disorder because the persons’ measured writing skill was was comparable to or better than their measured IQ. If the score was less than zero, then the measured writing skill level was less than would be expected from the person’s measured intelligence indicating some degree of EWD. The results indicated that the block design subtest from the Wechsler scales was the only significant predictor (R2 = 0.54) of the discrepancy score. Higher scores on this subtest resulted in less discrepancy between the IQ and Flesh-Kincaid indices. Additional analysis of differences between the TBI and LD groups on the expressive writing disorder index did not show any significant differences.

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A second EWD measure was created using grade levels from the writing samples and from the Wide Range Achievement Test. This measure involved subtracting the participants’ terminal grade level from his or her Flesh-Kincaid reading grade level index. If the score was zero or greater there was no evidence of an expressive writing disorder because the persons’ measured writing skill was at or above their measured grade level. If the score was less than zero, then the measured writing skill level was less than their measured grade level, indicating some degree of expressive writing disorder. The various psychometric measures were then used to predict this index. The linear regression analysis indicated that performance on the Rey Complex Figure was the only significant predictor by post-hoc criteria (R2 = 0.28). Those participants who scored higher on the Rey copy task had less of a discrepancy between their terminal grade placement and their Flesh-Kincaid writing index or a positive score. This model accounted for approximately 20% of the variance in the outcome measure. Additional analysis of differences between the TBI and LD groups on the expressive writing disorder index did not show any significant differences.

4. Discussion There are three major findings in these data. First, the PCA identified four aspects of expressive writing that were generally consistent across these two disability groups. Second, LD and TBI survivors did not differ markedly in their expressive writing skill or in their level of expressive writing disorder. Third, there were several cognitive variables that predicted the components. These variables include measures of spatial processing, working memory, visual memory, and verbal intelligence. Measures of visual perception predicted the indices of writing disorder. These data revealed four components of expressive writing: Reading Ease (the requisite grade level necessary to read the text), Sentence Fluency, the person’s Grammatical and Spelling skill, and the number of paragraphs the person can write per unit of time. These four components accounted for between 80–90 percent of the total variance in the writing sample data in either group. It is possible that different measures of expressive writing would factor into different components however, within this experimental context that involved free form writing, and these four components comprised the majority (80–90%) of what we call expressive writing.

Most of the cognitive variables that predicted the expressive writing components and the EWD indices involved some form of visual or spatial processing. The Block Design and Picture Completion subtests from the Wechsler Intelligence Scale measure non-verbal logic, the ability to perceive a larger object from parts, and ability to perceive missing critical details. These intellectual qualities may underlie a survivor’s ability to visualize a concept that he or she is trying to describe. The Rey Complex Figure Copy task and the Visual Reproduction tasks measure visual perception and visual memory. These two aspects of cognition seem to be necessary to generate larger collections of sentences that describe a common theme. Only two of the six significant predictors involved verbal processing. Higher verbal intelligence was necessary to generate more sentences and more complex sentence structures. Higher functioning working memory was necessary to reduce grammar and spelling errors. Several previously reported findings in the literature were supported in these data. Generally, visual imagery, memory, perceptual-motor skill, verbal intelligence have all been identified as significant predictors of expressive writing in non-disability samples. The fact that most of the significant predictors of written expression in this study involve visual and spatial processing or visual memory is consistent with Levander et al. (1989) who suggested that a person’s ability to remember a visual image of the content of the paragraph predicts his or her expressive writing skill. Goodglass and Kaplan (1983) also emphasized the effect of memory on expressive writing. However, these data suggest that visual rather than verbal memory has the predominant effect on writing skill. These results provide partial support for Wong’s (2000) categorization of writing as a two-stage process. The PCA showed that three of the components involved syntactical processing whereas one (Reading Ease) required a deeper level of thought. These results are also consistent with those of Enderby, Wood, Wade, & Hewer (1986) who did not find any differences between LD and TBI samples. 4.1. Improving expressive writing These results indicate several therapeutic interventions that may be useful for improving expressive writing skills. 4.1.1. Hand-eye coordination Performance on Rey Complex Figure copy task, a measure of perceptual-motor functioning which was a

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part of our initial assessment, predicted paragraph fluency and one of the EWD measures in this study. This finding suggests that the person’s perceptual-motor and hand-eye coordination are important aspects of the ability to produce quantities of written text. Therapy to improve a person’s writing skill, such as practice writing upper and lower case letters, drawing symbols, or practice writing motions common to a variety of letters and numbers, may help to improve the mechanics of writing. Occupational therapy to improve coordination in the arm and hand may also help to increase fluency and readability of the text. 4.1.2. Visual/spatial processing Visual memory also predicted paragraph fluency in the current study and a measure of spatial processing predicted the Reading Ease component. These results suggest that teaching a person to visualize an idea would improve both paragraph fluency and the quality of the content. Perhaps the person could diagram the concept before writing. This technique consolidates the idea into a visual image that the person can recall as a unit and visualize as they write. Mental imagery training may therefore help the person to form a visual picture of the idea they are trying to express in writing. 4.1.3. Improve working memory Results indicate that the ability to manipulate information in memory predicted the ability to reduce spelling and grammatical errors in written text. Although tasks that require mental control, such as practice doing mental math or doing anagram solutions may help the person to concentrate, simple drill and practice spelling words and recognizing grammatical errors is perhaps the most expedient way to improve writing skill. 4.1.4. Improve detail perception The picture completion subtest, a measure of detail perception, predicted the paragraph fluency and grammar/spelling component. Detail perception is part of the ability to find errors in written work, spelling errors, or contextual errors, such as paragraph indentations, paragraph breaks, and inaccurate word usage. Detail perception can be trained using flawed sentences. For example, sentences patterned after those on the editing portion of the Woodcock-Johnson Psychoeducational battery (1989) would be useful. These questions require a person to proofread or edit a sentence or paragraph containing grammatical errors. Teaching basic rhymes such as, “I before e except after c . . . ” is a

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way to check common spelling or grammar flaws as well. 4.1.5. Prosthetic aids Several prosthetic aids are especially helpful in locating grammatical errors. For example, spelling, grammar, and punctuation checkers are available on most word processors. These programs locate grammatical errors in text, provide suggestions for corrections, and may be adjusted for a variety of different writing styles. Persons with learning disabilities or brain injuries can learn to use these packages with a minimum of training. Websites like www.grammarly.com and software packages like RightWriter® may also be quite useful. 4.1.6. Developing goals Thomas et al. (1987) pointed out that skilled writers develop goals to guide writing and then generate and organize writing to meet those goals. Several authors have proposed interventions that generally involve goal setting, as a way to improve writing skill (Butler, Elaschuk, & Poole, 2000; Wong et al., 1991; Ferreti, MacArthur, & Dowdy, 2000; Troia, Graham, & Harris, 1999; De La Paz & Graham, 1997). For example, when Troia et al. (1999) explicitly instructed students with LD to set goals, brainstorm new ideas, and to sequence their ideas prior to writing, there written communication improved significantly. 4.1.7. General academic skill training Although not specifically implicated in these results, general academic training will improve the person’s vocabulary, ability to outline, to diagram sentences, and to abstract the main idea from text therefore improving written expression. Clearly, the extent of a person’s vocabulary affects the quality of his or her written expression and options in describing ideas. The sentence quality depends upon grammatical correctness. Practice diagramming sentences can ensure that the sentence structures are correct. Finally, practice reading text passages and then describing the main point helps the person to focus on the main idea. All of these activities improve overall academic performance which will easily transfer to specific academic skills like expressive writing. Declaration of interest The authors declare that there is no conflict of interest.

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