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Indian Pediatr 2011;48: 9 12 |
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Essential Tremors Mimicking as Dysgraphia |
Mona P Gajre and Samir H Dalwai,
Learning Disability Clinic, Division of Pediatric
Neurology and Epilepsy, Department of Pediatrics, LTMMC and LTMGH,
Sion, Mumbai, Maharashtra.
Email: [email protected]
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Essential tremor, an autosomal dominant disorder, well described in
adults, is relatively uncommon in children [1]. These children have poor
handwriting and are often mislabeled as dysgraphia.
A 13 years male was referred to the Learning Disability
Clinic with the complaint of illegible handwriting, dropping academic
grades with a possibility of dysgraphia. The handwriting fluency and
legibility deteriorated in time controlled situations such as
examinations. He was slow in copying but had no issues with concentration,
retrieval and had a good memory. Family history of tremors in father was
positive. Examination was normal except for tremors aggravated on
anti-gravity posture. Detailed exam of the motor, sensory, cerebellar
system was normal. The thyroid profile, serum ceruloplasmin, MRI brain
were normal. Weschler Intelligence Scale for Children (WISC -R) revealed a
superior intellect Full Scale IQ (FSIQ) –110.
He was administered a timed (15-20 minutes) free
writing essay to test for deficits in written language or dysgraphia. On
assessment his handwriting was tremulous, slow, and laborious and
illegibility increased progressively at the end of the task suggesting
poor mechanical writing output. To assess objectively written expression,
handwriting legibility and with a purpose to assist specialized
instruction further testing on standardized subtests of an
psychoeducational evaluation tool (WJ- III) ACH of spelling, written
expression, editing, writing samples were administered. His basic
(spelling, editing) and high order written expression skills (usage of
grammar, vocabulary, sequencing, organization of ideas) were age
appropriate but scored poorly on the writing samples subset of the
Handwriting Legibility scale and Writing Evaluation scale. He was
diagnosed as benign essential tremor with secondary mechanical poor
handwriting skills, started on propanol. Parental counseling was done and
academic accommodations sought.
Essential tremors (ET) are often stigmatized as a
disorder of the elderly and is overlooked in children. Its common in males
with a mean age of onset being 8.8 years with a high familial
preponderance [2]. It is known to cause difficulty in writing, problems
controlling utensils such as fork and become exaggerated during stress
[3]. Hands are often more affected than other parts of the body and is not
associated with any known pathology. Retrospective studies have indicated
that only a quarter of children visit a neurologist for pharmacotherapy,
propranolol being effective in 50% of children [4]. Prevalence of ET in a
study done on adults in Kolkata was 3.95 per 1000 [5]. Other causes of
tremors such as dystonic, cerebellar, postural and psychogenic need to be
differentiated form ET. Rate and accuracy in writing are crucial to
success in examinations and accommodations such as extra time, writer and
improve legibility and a good written expression. It boosts the
self-esteem of the child and allows him to explore his potential in
academics.
Acknowledgements: Dr Mamta Manglani, Dr. Sandhya
Kamath and Ms. Anagha Affreddy.
References
1. Tan E , Lum S, Prakash K. Clinical features of
childhood onset essential tremors. Eur J Neurol. 2006;13:1302-5.
2. Jankovic J, Madisetty J, Vuong K . Essential tremor
among children. Pediatrics.2004; 114:1203-5.
3. Rajput A, Robinson C, Rajput A. Essential tremor and
disability. A clinicopathologic study of 20 cases. Neurology.
2004;62:932-6.
4. Ferrara J, Jankovic J. Epidemiology and management
of essential tremor in children. Paediatr Drugs. 2009;11:293-307.
5. Das S, Banerjee T, Roy T, Raut D, Chaudhari A, Hazra A. Prevalence
of essential tremor in the city of Kolkata, India: a house- to-house
survey. Eur J Neurol. 2009;16:801-7.
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