Download Writing disorders in Italian aphasic patients

Brain (1998), 121, 1721–1734
Writing disorders in Italian aphasic patients
A multiple single-case study of dysgraphia in a language with
shallow orthography
Claudio Luzzatti,1,2 Marcella Laiacona,3 Nadia Allamano,3 Antonio De Tanti4 and
Maria Grazia Inzaghi4
1Istituto
di Psicologia della Facoltà Medica, Università
degli Studi di Milano, 2Servizio di Logopedia, IRCCS
Fondazione S. Maugeri, Centro Medico di Montescano,
Pavia, 3Servizio di Neuropsicologia, Divisione di
Neurologia, IRCCS Fondazione S. Maugeri, Centro Medico
di Veruno, Novara, 4Unità di Neuropsicologia, Divisione di
Medicina Riabilitativa, Ospedale Valduce, Costa Masnaga,
Lecco, Italy
Correspondence to: Claudio Luzzatti, Istituto di Psicologia
della Facoltà Medica, Università degli Studi di Milano,
Via Tommaso Pini 1, 20134 Milano, Italy.
E-mail: [email protected]
Summary
We report results of a writing task given to 53 mildly to
moderately aphasic Italian subjects. The task was
designed to test the writing performance along the
subword-level routine for the spelling of regular words
and non-words, and along the lexical routine for the
spelling of irregular words. The aim of the study was to
identify the incidence of different dysgraphic subtypes in
Italian, a language that is considered to have shallow
orthography. Its spelling, however, is not completely free
of ambiguity. A five-part writing task was used: (i) words
with regular one-sound-to-one-grapheme conversion; (ii)
words with regular syllabic conversion; (iii) words with
ambiguous transcription; (iv) loan-words; and (v) nonwords. For regular words, the effects of word length and
word frequency, and of the variables determining the
complexity of the acoustic-to-phonological conversion
(continuant versus plosive phones; consonant-vowel
sequence versus doubled consonants or consonant
clusters) were also considered. Patients’ performances
were classified according to the presence of a dissociation
between (i) regular words and non-words, (ii) regular
words and words with unpredictable spellings, and (iii)
one-to-one and syllabic conversions. The 53 aphasic
patients span the whole spectrum of dysgraphic taxonomy.
Thirty-nine patients, in particular, manifested a
dissociated pattern of performance. Eighteen patients
showed a prevalent surface dysgraphic pattern and seven
a phonological one, while 11 patients showed a mixed
pattern (i.e. a better performance for regular words
than for ambiguous words or regular non-words). Three
patients showed a specific deficit for regular syllabic
conversion rules only. A high rate of ‘mixed dysgraphia’
suggests either a mutual interaction of the two impaired
routines when regular words are written, or two separate
functional lesions: one at the level of the auditory-tophonological conversion procedure, the other at the level
of the orthographic output lexicon.
Keywords: dysgraphia; aphasia; writing; stroke
Introduction
Over the past two decades cognitive psychologists have
proposed increasingly complex models to describe the
processes underlying the normal processing of written
language. These models were originally formulated to
describe the operations underlying word naming (Coltheart
et al., 1980; Patterson et al., 1985) and were subsequently
adapted to describe writing of words to dictation (Beauvois
and Dérouesné, 1981; Shallice, 1981; Baxter and Warrington,
1985; Harris and Coltheart, 1986; Patterson, 1986). The
models assume the need for at least two processing routes,
© Oxford University Press 1998
a lexical routine by which words are processed as a whole,
and a subword-level routine following orthographic-tophonological conversion rules in reading, and vice versa,
phonological-to-orthographic conversion rules in writing. The
need for at least two procedures was formulated for English
to explain the capacity of a literate subject to read and write
both irregular words and legal non-words (i.e. non-lexical
but phonotactically plausible phonological strings).
Two routines are assumed to be necessary for reading
aloud and writing to dictation in English, given that English
1722
C. Luzzatti et al.
is a language with a relatively irregular orthographic system.
On account of this irregularity it is often impossible to deduce
the spelling of a word from the sequence of sounds that
make it up. The claim for two routines has also been argued
on the basis of results from patients with cerebral lesions.
Focal brain damage may cause writing disorders that appear
to involve either routine selectively. Consequently, some
patients make correct use of phonological-to-orthographic
conversion rules when writing, but cannot access lexical
knowledge, and therefore regularize the spelling of irregular
words. Such a deficit is generally called ‘surface dysgraphia’.
Other patients can write words they have learned to spell in
the past, whether these be regular or irregular, but are not
able to write a legal non-word. Such a disturbance is generally
called ‘phonological dysgraphia’.
[N.B. We did not consider the possible further fractionating
of the lexical routine into a semantic lexical and a direct
phonological/orthographic lexical routine in this study.
Consequently, the possibility of a writing deficit corresponding to the isolated impairment of these subroutines (direct
dysgraphia) could not be tested.]
Not all languages with an alphabetical system of writing
are irregular like English. Some languages, such as SerboCroatian, are almost totally predictable, with regard to both
reading and writing. Others may be relatively regular in one
direction but not in the other; this is the case with French
and German, the writing of which is very often unpredictable
but reading aloud is relatively predictable. Italian is said to
be a language with a shallow orthography, where the subwordlevel routine is sufficient for the great majority of words to
be written. The phonological-to-orthographic conversion rules
are simple with a one-to-one correspondence between sound
and letter for all vowels and most consonants. As is the case
with the majority of European languages, some Italian phones
do not correspond to a single letter of the alphabet. The
transcription of these phones is generally achieved by two
or more letters. Typical examples are the phones [Q] (5 TH
of English), [X] (5 CH of German), or the different spelling
of [S] in Italian (SC6I), French (CH), English (SH) and German
(SCH). The most typical Italian phones without a one-to-one
correspondence are [ˆ] and [¥]; these are conveyed by the
letter-pairs GN and GL, respectively. Slightly different is the
realization of the velar versus palatal pairs [k] – [tS] and [g] –
[dJ]. In the first case the rule is relatively simple—one must
convert a phoneme with several letters instead of one. In
the second case a syllabic conversion is required, i.e. the
orthographic realization of a phone is determined by the
vowel that follows it ([ka], [ko], [ku] 5 CA, CO, CU; [ki], [ke] 5
CHI, CHE; [tSa], [tSo], [tSu] 5 CIA, CIO, CIU; and [tSi], [tSe] 5
CI, CE).
Finally, there are also conditions in Italian that are
unpredictable both in written-to-oral and oral-to-written
direction. Ambiguities in reading concern the site of stress
in words of three or more syllables (GONDOLA (5 gondola)
is pronounced [9gondola] and not *[gon9dola], whereas
MENTOLO (5 menthol) is stressed [men9toló] and not
*[9mentoló]). On the other hand, there are some conditions in
which a given phonological string has more than one possible
orthographic solution, though only one is correct for a certain
lexeme; ambiguities in writing often have an etymological
basis, and may apply to the pronunciation of some linguistic
areas only.
(i) The syllable [Se], for instance, is regularly transcribed
by the sequence SCE. However, there are some words in
which it is conveyed by the sequence SCIE, e.g. [Sentsa] 5
SCIENZA (5 science). The same applies to the syllables [tSe]
and [dJe] which in certain cases are transcribed by the
sequence CIE and GIE (CIELO (5 sky) instead of CELO, IGIENE
(5 hygiene) instead of IGENE).
(ii) The phonemic group [kw] may be transcribed by the
orthographic sequences QU, CU, CQU. The general rule is that
the syllables [kwa], [kwi] and [kwe] are transcribed with the
sequences QUA, QUI and QUE, e.g. QUALE (5 which), QUINDI (5
thus), QUESTO (5 this), while the syllable [kwo] is transcribed
by the sequence CUO [CUOCO (5 the cook)]. However,
exceptions exist here too, e.g. QUOTA (5 the quota).
(iii) The segments [¥] – [lj] and [ˆ] – [nj] which are
phonologically distinct in Tuscan and central-southern
pronunciation, are homophones in north-western Italian, so
much so that the spelling of words like balia [ba¥a]/[balja],
nurse (BALIA and not BAGLIA) or geranio [dJeraˆo]/[dJeranjo],
the geranium (GERANIO and not GERAGNO) is not predictable
along the phonological-to-orthographic conversion routine.
(iv) Plosive phones that are followed by the liquid
consonants ([l] and [r] or by the semiconsonant [j] are
homophones to their doubled pairs, thus rendering uncertain
the transcription of words such as [libro], book (LIBRO and
not LIBBRO), [febre], fever (FEBBRE and not FEBRE), [biblico],
biblical (BIBLICO and not BIBBLICO) and [publico], public,
(PUBBLICO and not PUBLICO).
(v) Finally, mention should be made of the spelling of
‘loan-words’ (usually from English or French) incorporated
into the Italian lexicon (e.g. BLUE-JEANS, WEEK END, etc.).
A correct use of the subword-level routine (i.e. of the
phonological-to-orthographic conversion rules) requires that
the subject first segments and identifies the phonemic string
to be converted. Such analysis seems to be adequately
represented by the information processing models in the
acoustic-to-phonological conversion. This is the routine
described by Wernicke (1885, 1886), who considered the
processing of written language as exclusively segmental, as
opposed to a purely lexical routine for the processing of oral
language (De Bleser and Luzzatti, 1989).
An acoustic-to-phonological level of analysis obviously
depends on variables determining the complexity of this
processing, such as the presence of consonant clusters,
or the phonetic characteristics of the sounds themselves.
Continuous phones, such as vowels, fricative consonants ([f],
[v], [s], [z] and [S]), liquid ([l] and ([n]), and nasal ([n] and
[m]) consonants that may be prolonged during the analysis,
are by their nature more easily segmentable and hence
Diagnosis of writing disorders
identifiable, as it is possible to analyse their audio-phonetic
(and stato-kinaesthetic) aspects at greater length.
In order to evaluate the variables individually, described
so far, a test battery was designed for the examination of
writing disturbances in adult brain-damaged subjects. Certain
phonetic/phonological variables generally overlooked in
psycholinguistic studies were added to the variables generally
considered in normal test batteries for writing deficits (length
of stimulus, lexical/non-lexical material, word frequency).
Material and methods
Subjects
Fifty-three mildly to moderately aphasic patients (30 males
and 23 females) examined at the Aphasia Units of RhoPassirana (Milano), Veruno (Novara) and Costa Masnaga
(Lecco) from 1993 to 1994 were included in the study. Their
mean (6 SD) age was 41.9 6 17.9 years and education
10.8 6 2.5 years; their mean length of illness was 13.2 6 18.3
months. Forty patients suffered from vascular cerebral
damage, 11 from traumatic brain injury and two from other
aetiologies. Type and severity of aphasia was assessed by
means of the Italian version of the Aachen Aphasia Test
(Luzzatti et al., 1994a): 14 patients were classified as Broca’s
aphasics, 21 had a fluent language disorder (11 Wernicke’s,
six anomic and four non-classifiable aphasic patients). Eight
patients could not be classified for the fluent/non-fluent
dimension, whereas 10 showed only minimal residual
language deficits. The control group included 110 healthy
adults (49 males and 61 females). Their mean age was 44.2
6 15.1 years. Only subjects with ù8 years of schooling
were included in order to be assured of a complete acquisition
of written language (mean education 13.1 6 3.7 years).
Subjects gave informed consent to participate in the study,
which had ethical approval from the S. Maugeni Foundation.
The test
The writing test used in this study is described fully in Luzzatti
et al. (1994b). It comprises the following five sections.
Section A uses regular words with complete one-soundto-one-letter correspondence.
Section B uses regular words with syllabic conversion
(e.g. [k], [g], [tS], [dJ]). The spelling of sounds [¥], [ˆ], and
syllables [tSe], [dJe] and [Se] which have two possible
orthographic solutions (see next point) was not taken into
account in this section.
Section C uses words with unpredictable transcription
along the phonological-to-orthographic conversion routine
(e.g. [¥] in [pa¥a], straw: PAGLIA and not PALIA; [ba¥a], nurse:
BALIA and not BAGLIA, or [ˆ] in [dJeˆo], genius: GENIO and
not GEGNO; [seˆo], sign: SEGNO and not SENIO).
Section D uses loan-words: foreign words which may by
now be considered as part of the Italian lexicon (e.g. bluejeans, night-club).
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Section E uses non-words with one-sound-to-one-letter
correspondence.
As the experimental subjects were natives of Lombardy
and Piedmont, in addition to the ambiguities which are
common to all Italian speaking areas (e.g. the spelling of the
syllable [kwo] or the single/doubled orthographic pair in a
plosive followed by a liquid consonant), some of the
ambiguities which are typical of the north-western Italian
pronunciation were included.
Moreover, in order to evaluate different sources of
phonetic-phonological complexity, within Section A the
following comparisons were made: (i) words made up only
of continuant sounds (fricative, liquid or nasal consonants)
with words also containing non-continuant (plosive)
consonants; (ii) words made up only of consonant-vowel
(CV) syllables with words also containing clusters or doubled
consonants; (iii) bisyllabic with polysyllabic words. Each
part of Section A used five high-frequency and five lowfrequency words (Bortolini et al., 1972). Table 1 summarizes
the different sections of the writing task (see Appendix for
the complete list of stimuli).
The mean word frequency for each section is shown
in Table 2. Regular words and words with unpredictable
transcription have a very similar frequency, whereas loanwords are less frequent. The mean word frequencies of the
five high-frequency and five low-frequency items for Section
A (regular words with complete one-sound-to-one-letter
correspondence) are also shown.
Items are almost exclusively nouns; therefore the task does
not enable us to detect word class differences. Furthermore,
the task does not consider any lexical-semantic variables
(such as the abstract/concrete dimension) that have been
shown to influence the performance along the lexical routine
(Bub and Kertesz, 1982; see also Shallice, 1988, pp. 138–142).
Words and non-words were presented separately. The 158
words were randomized for regularity, complexity, word
frequency and length, the 25 non-words for complexity and
length. The examiner read each item aloud in a neutral tone,
i.e. without emphasizing the presence of clusters, doubled
consonants or possible orthographic ambiguities. Each item
could be repeated once on request. No feedback was provided
on the adequacy of the responses. Spontaneous corrections
were accepted.
Analyses of the results and statistical methods
All the patients participating in the study suffered from a
left hemisphere lesion causing mild-to-moderate language
disorders and/or dysgraphia, but none showed a pure writing
disorder. The principal purpose of our investigation was to
detect the presence of significant differences between the
ability to spell regular words, words with unpredictable
transcription and non-words separately. The diagnostic criteria
for different types of dysgraphia concern the dissociated
(independent) impairment of performance with these different
sets of stimuli. Since the majority of the patients showed
1724
C. Luzzatti et al.
Table 1 Subtests of the writing task
A Regular words with one-sound to one-letter correspondence (n 5 80)
Examples
1
2
3
4
5
6
7
8
sole
lavoro
senso
valle
dito
prato
tappo
sponda
(Translation)
Continuance
Clusters
Doubled
consonants
Syllables
n
(sun)
(work)
(sense)
(valley)
(finger)
(meadow)
(cork)
(bank)
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Yes
No
No
Yes
No
Yes (32)
No
No
No
Yes
No
No
Yes
No
2
3/4
2
2
2
2
2
2
10
10
10
10
10
10
10
10
B Regular words (syllabic conversion rules) (n 5 15)
Example
Rule
n
9
[k], [g], [sk]; [tS], [dJ], [S]
15
gola/ghiro/valigia
(throat/dormouse/suitcase)
C Words with unpredictable transcription (n 5 55)
Examples
(translation)
Ambiguity
n
10
11
12
13
14
(scene/science)
(straw/nurse)
(sign/genius)
(book/fever)
(heart/quote/eagle)
[tS], [S] : 6 I
[¥] : GL/LI
[ˆ] : GN/NI
BR/BBR
[kw] : CU/QU
10
10
10
10
15
scena/scienza
paglia/balia
segno/genio
libro/febbre
cuore/quota/aquila
D Loan-words (n 5 8)
Examples
n
15
8
blue-jeans, night-club
E Non-words with one-sound-to-one-letter correspondence (n 5 25)
Examples
Continuance
Doubled
consonants
Syllables
n
1
2
4
4
5
Yes
Yes
Yes
No
No
No
No
Yes
No
Yes
2
3/4
2
2
2
5
5
5
5
5
nise
vimàne/ramàsola
seffa
tido
nitta
Table 2 Word frequencies in the different tasks
Stimulus
Word frequency (mean 6 SD)
Regular words (one-sound-to-one-letter correspondence)
high frequency items
low frequency items
47.39 6 69.57
91.25 6 76.42
3.52 6 4.33
Regular words (syllabic conversion)
31.47 6 40.53
Words with unpredictable transcription
47.55 6 96.49
Loan-words
(,2)
Total
43.53 6 76.86
Diagnosis of writing disorders
1725
Table 3 Performance of patients and control subjects on the five sections of the writing task (mean 6 SD)
Section
Control
subjects
(n 5 110)
All aphasic
patients
(n 5 53)
Broca’s
aphasia
(n 5 14)
Wernicke’s
aphasia
(n 5 11)
Anomic
aphasia
(n 5 6)
Residual
language
deficits
(n 5 10)
A. Regular words with one-sound-to-oneletter correspondence (n 5 80)
B. Regular words with syllabic
conversion (n 5 15)
C. Words with unpredictable transcription
(n 5 55)
D. Loan-words (n 5 8)
E. Non-words (n 5 25)
79.8 6 0.6
61.8 6 19.0
54.9 6 15.8
50.6 6 28.7
73.2 6 8.8
76.6 6 3.1
15.0 6 0.2
9.9 6 4.1
8.1 6 3.7
8.2 6 5.3
11.8 6 1.9
13.4 6 1.7
52.5 6 2.2
29.2 6 13.6
23.1 6 13.2
22.8 6 13.7
35.3 6 12.9
42.3 6 7.5
5.9 6 2.5
24.7 6 0.6
1.2 6 1.8
14.6 6 8.1
0.6 6 1.2
10.5 6 7.5
0.3 6 0.7
13.1 6 8.8
2.0 6 2.1
17.7 6 5.1
2.4 6 2.6
22.4 6 2.4
mild-to-moderate language disorders, only a few patients
showed a classical (strong) dissociation between a completely
spared and a damaged writing routine. In fact, the
dissociations shown by our patients are usually of the weak
type, i.e. there is usually poor performance on both routines,
though one routine is significantly more impaired.
Logistic regression analysis (McCullagh and Nelder, 1983)
was applied to the profile of each single subject, making it
possible to study the effects of the variables that might have
influenced performance within a linear model. The units were
the stimuli of the Test and the dependent variable for each
stimulus was two-valued (passed 5 1, failed 5 0). The
model included both categorical (e.g. words versus nonwords) and continuous variables (word frequency and item
difficulty). Difficulty (for each single item) is expressed as
the number of control subjects (out of 110) who wrote
it correctly. Each patient was classified into one of the
major dysgraphic patterns through several comparisons.
First, the four major sections of the task were checked for
an overall performance homogeneity. Then, the following
comparisons were made: (i) words with one-sound-to-oneletter correspondence and non-words with comparable
phonological and orthographic complexity; (ii) words
with unpredictable transcription and words with one-soundto-one-letter correspondence; and (iii) words with syllabic
conversion and words with one-sound-to-one-letter
correspondence. The eight loan-words were not considered
in the logistic regression analyses as they constitute a separate
and very limited set of items. Furthermore, the influence of
the different sources of complexity included in the test, such
as continuance, stimulus length and the presence of consonant
clusters, was evaluated. Comparisons were programmed as
a macro-instruction of the Generalized Linear Model program
of Aitkin et al. (1989) (GLIM 3.77). The analysis was
repeated for each of the 53 patients. As a single-case
diagnostic procedure was used, the significance level of each
comparison was set at 0.05, without adopting an overall
protection for the whole set of patients (Willmes, 1985).
The psychometric design also included covariance by item
difficulty. Any dissociation still present after this adjustment
will be stronger than—and not simply proportional to—the
difference observed among control subjects. On the contrary,
any dissociation which disappears after adjustment simply
reflects the difficulty gradient observed in the normal
control group.
Results
Control subjects
The mean scores of the 110 control subjects on the five
sections of the test, and on the eight parts of Section
A (writing of regular words with one-sound-to-one-letter
correspondence), are shown in Tables 3 and 4. Normal
subjects wrote almost all items of the task flawlessly.
However, this was not the case for the loan-word section,
where control subjects registered a lower mean performance
and a high degree of variability (5.9 6 2.5). An analysis of
the performance of the control subjects was reported in detail
in a previous paper (Luzzatti et al., 1994b). Education
significantly influences the spelling of words with
unpredictable orthography, age influences that of non-words,
and both education and age influence that of loan-words.
None of these variables, however, significantly influenced
the subjects’ performances when they were writing regular
words. An error analysis also revealed that the misspellings
of the control subjects corresponded to those predicted for
the different parts of the writing task. Normal subjects made
a very low number of errors when writing regular words and
non-words [for instance, when writing regular words they
only made 12 errors out of 8800 written words]. The analysis
was therefore made only for words with unpredictable
transcription and for loan-words. Out of 6050 words
containing a phone with an unpredictable transcription,
control subjects made 435 errors; 378 of these were of the
expected type (use of the subword-level routine instead of
the lexical one, and therefore substitution of the target with
a plausible but incorrect solution). When writing loan-words,
control subjects produced 272 errors out of 880 written
words; again, 94% of the misspellings were surface errors.
Aphasic patients
Table 3 also shows the mean performances obtained on the
five sections by the 53 aphasic patients and by the 31
1726
C. Luzzatti et al.
Fig. 1 The five sections of the writing test: score profiles (mean percentages) from control subjects and the aphasic patients who could
be classified into one of the major aphasic syndromes.
Table 4 Performance on the eight parts of Section A (regular words with one-sound-to-one-letter correspondences)*
Section A
(parts 1–8)
1
2
3
4
5
6
7
8
(e.g.
(e.g.
(e.g.
(e.g.
(e.g.
(e.g.
(e.g.
(e.g.
Control
subjects
(n 5 110)
sole, sun)
lavoro, work)
senso, sense)
valle, valley)
dito, finger)
prato, meadow)
tappo, cork)
sponda, bank)
9.97
9.97
9.95
9.97
9.97
10.00
9.97
9.99
6
6
6
6
6
6
6
6
0.2
0.2
0.3
0.2
0.2
0.0
0.2
0.1
All aphasic
patients
(n 5 53)
8.6
6.9
7.4
8.2
7.9
7.7
8.5
6.6
6
6
6
6
6
6
6
6
2.3
3.3
3.0
2.4
2.6
2.7
2.3
3.1
Broca’s
aphasia
(n 5 14)
8.0
5.9
6.2
7.4
7.6
6.8
8.1
4.9
6
6
6
6
6
6
6
6
2.5
3.1
2.6
2.3
2.4
2.7
1.8
3.1
Wernicke’s
aphasia
(n 5 11)
8.2
5.3
5.9
6.7
6.5
5.9
6.9
5.5
6
6
6
6
6
6
6
6
3.3
4.3
4.4
3.6
3.6
3.7
3.8
3.9
Anomic
aphasia
(n 5 6)
9.7
9.0
9.5
9.3
8.8
9.2
9.3
8.3
6
6
6
6
6
6
6
6
0.8
1.1
0.8
1.0
1.6
1.3
0.8
2.3
Residual
language
deficits
(n 5 10)
9.8
9.3
9.4
9.6
9.9
9.5
9.8
9.3
6
6
6
6
6
6
6
6
0.4
0.8
0.8
0.7
0.3
0.7
0.4
1.1
Data are shown as means 6 SD. *See Table 1, Section A for the eight types of words.
patients whose quantitative and qualitative performances
corresponded to that of a classic Broca’s (n 5 14), Wernicke’s
(n 5 11) and anomic (n 5 6) aphasia.
Table 4 shows the mean performance on the eight parts of
Section A (writing of regular words with one-sound-to-oneletter correspondence) for all patient groups.
The mean (percentage) score profiles of control subjects
and of the 31 patients that could be grouped according to
the major aphasic syndromes are shown in Figs 1 and 2.
Profiles of each individual subject were analysed by means
of a logistic regression analysis. Due to the high variability
shown by control subjects with loan-words, the patients’
performances in Section D were not considered in the
regression analysis. The results are given in Table 5 and
summarized in Table 6.
Eighteen patients (34%) showed predominantly a writing
impairment for words with unpredictable spelling, i.e. widespread damage to the lexical routine (surface dysgraphia),
while seven patients (13%) showed an impairment for nonwords, i.e. mainly damage to the subword-level routine
(phonological dysgraphia). Of the 18 surface dysgraphic
patients, only four (MI02, VE08, CM04 and VE12) showed
selective impairment of the lexical route and normal
performance with non-words, while only one of the seven
phonological dysgraphic patients (VE07) showed a selective
impairment of non-words (subword-level routine) and normal
spelling of regular words and of words with unpredictable
spelling. Furthermore, 11 subjects (21%) showed a peculiar
pattern of damage, characterized by an impaired writing
performance for both words with unpredictable transcription
and non-words, while they performed better on regular words
with complete one-sound-to-one-letter correspondence. The
Diagnosis of writing disorders
1727
Fig. 2 The eight parts of Section A of the writing test (regular words with one-sound-to-one-letter correspondence): score profiles from
control subjects and aphasic patients that could be classified into one of the major aphasic syndromes.
term ‘mixed dysgraphia’ will be used to designate the pattern
of disruption observed in this group of patients. Three
patients (6%) used the one-phoneme-to-one-letter conversion
flawlessly but had trouble with syllabic conversion rules.
Thirteen patients (25%) presented an undifferentiated writing
deficit on all tasks, whereas one patient (2%) had no writing
disorders. The analysis within the 80 items of Section A
showed that four patients (8%) performed better on words
composed exclusively of continuant phones (and thus more
easily analysable by the auditory-to-phonological conversion
unit) than on words also containing plosive consonants.
Furthermore, nine patients (17%) showed a length effect,
and the performance of four patients (8%) was influenced by
the presence of consonant clusters. Half of the patients (24
out of 53) showed a word-frequency effect. The rate of
patients showing a word-frequency effect varied across type
of dysgraphia: six out of the seven patients with a
phonological dysgraphia (86%), two of the three patients
with a pure syllabic conversion deficit (67%), eight of the
18 patients with a surface dysgraphia (44%), six of the 11
patients with a mixed dysgraphia (55%) and two of the 13
patients with undifferentiated writing disorder showed a
word-frequency effect; the patient with no dysgraphia did
not show a word-frequency effect. A comparison of the
rate of cases showing a word-frequency effect evidenced a
different distribution between the phonological (6/7) and
surface (8/18) dysgraphic patients (Fisher’s exact test (1), P
, 0.05).
Finally, semantic substitutions were limited to only two
patients, and even in these two cases they were few [e.g.
CM07: night-club→playboy; weekend→week-fine (Italian
translation of ’end’); VE02: babbó→papa9 (father→dad);
bació→abbració (kiss→hug)]. In both cases the phonologicalto-orthographic conversion routine was severely impaired.
However, these patients showed a different degree of damage
when writing words with unpredictable spelling. The first
patient (VE02) could still write the majority of these words,
and was therefore classified as a case of phonological
dysgraphia, whereas the second patient (CM07) had a more
conspicuous deficit of ambiguous words and was therefore
classified as a case of mixed dysgraphia, still showing,
however, a clear dissociation between ambiguous words and
non-words (42% versus 0%).
Table 6 also shows the distribution of dysgraphic disorders
according to the classic aphasia taxonomy. Types of
dysgraphia are similarly distributed along aphasic syndromes
[χ2(25) 5 15.04, not significant].
Table 7 shows the distribution of patients with dysgraphic
disorders according to aetiology. All seven of the phonological
dysgraphic patients were found within the vascular group,
while surface dysgraphia is proportionally more frequent
among patients suffering from traumatic head injury. This
difference, however, does not reach significance [χ2(5) 5
7.088, not significant].
Discussion
The purpose of the present study was to verify the diagnostic
validity of a writing task and the use of logistic regression
analysis in a psychometric single case analysis. The writing
task was administered to a sample of mildly to moderately
aphasic Italian patients. The performances of the patients
were compared to those of 110 control subjects (Luzzatti
et al., 1994b).
1728
C. Luzzatti et al.
Table 5 Classification of individual patients with multiple single-case analysis (logistic regression analysis)
Case
Words with one-sound to one-letter correspondences versus:
Other significant effects:
non-words
continuancy
length
consonant
clusters
word
frequency
.
.
.
.
.
.
.
.
.
1
.
1
.
1
.
.
.
.
.
.
1
1
1
1
1
.
1
χ2
P-value
words with
unpredictable
transcription
words with
syllabic conversion
χ2
χ2
Phonological dysgraphia
CM09
6.524
0.011
0.065
CM18
15.292
,0.0001
0.005
MI08
6.622
0.010
1.619
VE02
29.898
,0.0001
0.429
VE04
14.329
0.0001
0.558
VE07
4.984
0.026
0.132
VE18
8.479
0.004
0.034
Deficit of syllabic conversion only
CM08
0.961
1.567
CM10
1.224
0.269
3.302
MI14
0.189
0.650
Surface dysgraphia
MI07
0.883
16.680
CM05
3.129
0.077
8.624
MI02
0.585
15.358
MI12
0.154
11.043
MI15
0.635
12.607
VE08
0
48.720
MI06
0.285
8.741
CM02
0.045
21.272
CM03
0.480
21.683
CM04
0.975
9.490
VE12
0
8.729
MI03
0.065
9.194
MI04
0.439
5.333
CM16
1.235
0.266
5.083
MI10
3.741
0.053
11.174
VE06
1.282
10.720
VE13
1.608
0.205
10.060
VE16
0.373
9.467
Mixed (phonological and surface) dysgraphia
VE03
10.682
0.001
4.932
CM06
14.675
0.0001
5.201
CM07
33.764
,0.0001
8.290
CM12
12.451
0.0004
7.793
CM19
7.326
0.007
12.095
MI09
11.652
0.0006
6.082
MI11
11.395
0.0007
17.841
VE01
5.150
0.023
27.595
VE10
4.563
0.033
6.985
VE11
6.174
0.013
13.591
VE15
16.264
,0.0001
4.281
Undifferentiated writing disorders
CM01
2.092
0.148
CM11
1.017
0.313
CM13
2.035
0.154
CM14
0.831
CM15
0.050
CM17
0.055
MI05
0.775
MI13
0.200
MI16
2.888
0.089
VE05
3.002
0.083
VE09
0.002
VE14
0.015
VE17
1.791
0.181
3.430
2.039
0.670
3.668
1.827
0.389
2.302
1.212
0.041
2.005
1.957
2.739
1.897
No dysgraphia
MI01
0.164
0.136
P-value
P-value
1.299
1.491
1.291
1.265
0.215
2.961
0.988
0.254
0.222
0.256
0.261
0.211
0.069
4.937
6.198
5.555
0.026
0.013
0.018
.
.
.
.
.
1
.
.
.
1
1
.
,0.0001
0.003
,0.0001
0.0009
0.0004
,0.0001
0.003
,0.0001
,0.0001
0.002
0.003
0.002
0.021
0.024
0.0009
0.001
0.002
0.002
10.999
6.716
5.576
8.830
5.564
8.734
2.423
1.801
1.828
2.944
0
0.122
0.005
0.761
0.464
0.246
0.271
0.549
0.0009
0.010
0.018
0.003
0.018
0.003
0.120
0.180
0.176
0.086
.
.
1
1
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
1
.
.
1
1
.
1
.
.
.
.
1
.
1
.
1
.
1
.
1
0.026
0.023
0.004
0.005
0.0005
0.014
,0.0001
,0.0001
0.008
0.0002
0.039
3.899
3.100
0.003
1.769
2.167
0.328
0.849
1.509
2.677
0.179
0.987
0.048
0.078
1
.
.
.
.
.
.
.
.
1
.
.
.
1
.
.
.
.
.
1
.
.
1
.
1
.
.
.
.
.
.
.
.
.
1
1
1
.
1
1
.
.
.
1
0.064
0.153
0.059
3.740
1.219
3.644
0.164
2.408
0.290
0.014
0.108
1.366
0.051
0.656
2.889
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
1
.
.
.
1
1
.
.
.
.
.
.
.
.
.
.
.
1
.
.
.
.
.
.
.
1
.
.
.
.
.
.
.
1
.
.
.
.
.
.
.
0.203
0.512
0.055
0.176
0.129
0.271
0.157
0.162
0.098
0.168
χ2 and P-values in bold reflect significant effects.
0.007
0.085
0.184
0.141
0.219
0.102
0.053
0.270
0.056
0.121
0.243
0.089
Diagnosis of writing disorders
1729
Table 6 Type of dysgraphia by type of aphasia: distribution across the 53 aphasic patients
Broca’s
aphasia
(n 5 14)
Wernicke’s
aphasia
(n 5 11)
Anomic
aphasia
(n 5 6)
Fluent aphasia
(non-classifiable:
Wernicke’s
versus anomic)
(n 5 4)
Residual
language
deficits
(n 5 10)
Non-classifiable
(fluent versus
non-fluent
aphasia)
(n 5 8)
All patients
(n 5 53)
Phonological
dysgraphia
3
2
1
–
–
1
7
Deficit of syllabic
conversion
–
1
–
1
1
–
3
Surface
dysgraphia
5
3
3
1
4
2
18
Mixed dysgraphia
3
(phonological and
surface)
2
1
1
1
3
11
Undifferentiated
writing disorders
3
3
1
1
3
2
13
No dysgraphia
–
–
–
–
1
–
1
Table 7 Type of dysgraphia by aetiology: distribution across the 53 aphasic patients
Phonological dysgraphia
Deficit of syllabic conversion
Surface dysgraphia
Mixed dysgraphia (phonological and surface)
Undifferentiated writing disorders
No dysgraphia
Vascular
aetiology
(n 5 40)
Traumatic
aetiology
(n 5 11)
Other
aetiology
(n 5 2)
All
patients
(n 5 53)
7
3
10
10
9
1
–
–
6
1
4
–
–
–
2
–
–
–
7
3
18
11
13
1
Many contemporary models assume the existence of at
least two writing routines, one lexical and one at subwordlevel. In this framework, the first routine is the only option
possible when writing words with unpredictable or irregular
spelling, the second is the only option when writing nonwords. Italian is a language with quite regular spelling, so
that the great majority of words may be written along the
subword-level routine. For this reason, it has often been
claimed (e.g. Denes et al., 1996) that writing deficits with
features of surface dysgraphia (i.e. due to damage of the
lexical routine only) should be less frequent among Italian
patients. However, in spite of the overall regularity of
the Italian orthography, some phones have more than one
graphemic realization, though only one is correct for a
given lexeme.
On the other hand, the efficient use of the subword-level
routine requires a correct acoustic-to-phonological conversion
to allow the isolation of the single phones to be routed to
the phonological-to-orthographic conversion. The relevance
of a phonological analysis level had already been stressed
by Luria et al. (1969). These authors suggested that ‘the task
of writing a given word [whether independently or from
dictation] begins with the process of analysis of the phonetic
composition of the word, or in other words, with the breaking
down of the phonetic stream of living speech into isolated
phonemes’. This acoustic-analysis level should depend on
the variables determining the complexity of this process, i.e.
the presence of consonant clusters or the phonetic-acoustic
aspects of the single phones (e.g. plosive versus continuant).
Control subjects from the normative sample (Luzzatti et al.,
1994a, b) write all regular words almost perfectly, irrespective
of either the phonetic-acoustic aspects of the phones, or of
the presence of consonant clusters or of the type of conversion
rules (one-to-one versus syllabic rules). Older subjects made
more errors when writing loan-words which do not follow
the regular Italian orthography. This seems to be due simply
to the recent appearance of these items in the Italian lexicon
and, therefore, to a lack of acquisition of their orthography
by older subjects. The effect of age on writing non-words is,
however, more difficult to explain. On the one hand, it may
be due to a peripheral mechanism by which a loss of hearing,
however mild, can lower the performance of writing nonwords, due to the lack of lexical feedback. On the other,
impaired writing of non-words in ageing could be explained
by the results of Bisiacchi et al. (1989) which demonstrated
that the processing of non-words puts a higher load on the
1730
C. Luzzatti et al.
Fig. 3 Information-processing model of word naming, confrontation naming and writing [from Patterson
(1986), modified].
phonological short-term memory, a function that has been
shown to undergo a progressive impairment in ageing (Orsini
et al., 1987; Spinnler and Tognoni, 1987).
Aphasic patients made more errors when writing words
with unpredictable spelling and non-words. Comparing
performances on the different subtests, aphasic subgroups
(Broca’s, Wernicke’s and anomic aphasia) differ in severity,
but the profile shape is almost identical. The variables
influencing the outcome along the subword-level routine
also show a similar profile of impairment across aphasic
subgroups. Obviously, the classification of patients according
to aphasic syndromes does not imply that there is an
identical cognitive disorder in all subjects sharing the same
aphasiological label: on the contrary, a similar distribution
of dysgraphic subtypes across aphasic syndromes is a proof
of the manifold composition within these groups of subjects.
Preliminary results from a comparable study of reading
disorders (C. Luzzatti, M. Frustaci, C. Guarnaschelli,
M. Tariccó, G. Zonca, unpublished results) seem to suggest
a different pattern of impairment with respect to dysgraphia;
phonological and deep dyslexic disorders are more frequently
associated with agrammatism, while surface dyslexia is
associated with jargon aphasia. It would therefore seem that,
in Italian at least, reading and writing undergo a different
breakdown pattern.
The profiles of the individual patients were analysed with
a linear model that included the frequency of each item and
its rate of difficulty for the control subjects. The choice of
this stricter criterion calls for comment. Let us first consider
the case of word frequency. Non-words have, by definition,
a frequency value of zero. Confusion between two variables
of the model, i.e. type of items and word frequency, could
therefore be suggested. As a consequence, adjustment for
frequency could artifactually affect the word/non-word
difference and, therefore, the incidence of phonological
dysgraphia. Even if this effect is theoretically possible, we
assume that the comparison of performances with words and
non-words identifies a difference between processing routines
that cannot simply be reduced to the effect of the stimulus
frequency. In fact, this possible bias did not reduce the
Diagnosis of writing disorders
rate of dissociated patterns significantly, as the number of
phonologically dysgraphic patients before frequency
adjustment was eight, and after adjustment for frequency and
stimulus difficulty it was only reduced to seven. Furthermore,
as the items included in the different sets were matched for
word frequency, it did not affect the comparisons between
sections of the test.
A further observation concerns the policy of adjusting by
item difficulty, as assessed in control subjects. The aim of
this adjustment is obviously not to cancel the fact that words
with unpredictable transcription may be ‘more difficult’ than
regular words, but to test whether the difficulty gradient
observed in the patients was proportional to that observed in
control subjects. For the above-mentioned reasons we decided
to adopt a stricter criterion for the identification of dissociated
patterns of dysgraphia, where possible effects of interference
of the patients’ performances were partialled out by an
adjustment of the scores by item difficulty and wordfrequency effect.
The multiple analysis of single cases showed the expected
dissociation patterns. A first group of subjects showed a
pattern of deficit that corresponds to the diagnosis of surface
dysgraphia, while a second group showed a pattern
corresponding to the diagnosis of phonological dysgraphia.
A further group of subjects showed mixed damage both for
words with unpredictable spelling and for regular non-words,
but better performance for regular words. There are two
possible explanations of this mixed pattern of impairment.
According to the classical logogen model (see Fig. 3), this
pattern of disruption could be explained as being the result
of two separate functional lesions, one at the level of
the auditory-to-phonological conversion, the other of the
orthographic output lexicon; writing to dictation would
therefore be possible only for regular words along an indirect
circuit passing through the phonological output lexicon,
the phonological buffer and the phonological-to-orthographic
conversion unit. However, a pattern of disruption characterized by a selective impairment in writing words with
unpredictable spelling and non-words, with an almost
preserved spelling of regular words could also account for
the mutual interaction of the lexical and the subword-level
routines with the writing of regular words (as a consequence
of cerebral damage, both routines feed the orthographic
buffer with a blurred representation); the performance of
mixed dysgraphic patients on writing both words with
unpredictable orthography and non-words is therefore
impaired. An interaction of the two routines (‘summation’
hypothesis), however, is open to various differing
interpretations. A first hypothesis is that the two routines
already interact in normal subjects; a similar account has
been proposed for normal reading by Hillis and Caramazza
(1991). Alternatively, the interaction of the two routines may
be a compensatory phenomenon that only accounts for the
pattern of performance of mixed dysgraphic patients: while
neither of the two routines is sufficient for writing words with
unpredictable orthography and non-words, their interaction
1731
allows a better performance with the writing of regular
words. A further account assumes the so called ‘horse race’
explanation, for which each of the two routines process
regular words independently, both in normal subjects and in
mixed dysgraphic patients. Two independent race horses
would increase, a priori, the probability of better performance
in normal subjects, as well as the possibility of success in
the mixed dysgraphic patients.
In the introduction, a possible selective impairment of the
syllabic subword-level conversion rules was predicted. In
fact, three patients showed a dissociated damage of these
rules alone. Another prediction made was a possible damage
to the auditory-to-phonological conversion, a disorder that
would determine a less severe impairment of words composed
entirely of continuant phones (vowels and fricative, liquid or
nasal consonants), words that are thus more easily analysed
along the auditory-to-phonological conversion unit. This
phenomenon seems to be rare and was found in only
four cases.
A frequency effect is usually more common in phonological
than in surface dysgraphic disorders, as could be predicted
from a writing performance along the lexical routine only.
A final issue is the possible difference underlying the
process of writing in English and in a language with shallow
orthography like Italian. In a recent study, Ardila et al. (1996)
stressed the greater relevance of the subword-level routine
for the processing of written language in Spanish. However,
the writing task used by these authors did not include words
with irregular or unpredictable orthography and non-words;
unfortunately, the absence of these variables precluded, per
se, an identification of the dysgraphic patterns underlying
phonological and surface dysgraphia. The results of the
present study demonstrated that current psycholinguistic
models of written language also apply to languages with
shallow orthography. An important difference, however, is
the degree of activity of each routine; the lexical route is
crucial in languages with irregular spelling like English and
French, but less important in a language with predominantly
shallow orthography like Italian.
Acknowledgements
We wish to thank Erminio Capitani and the anonymous
referees of Brain for their helpful critical comments and
Frances Anderson and Rosemary Allpress for her careful
review of the English version of the manuscript. This research
was supported by a Grant from the Italian Ministero
dell’Università e della Ricerca Scientifica e Tecnologica
(MURST) to C.L. and from the Fondazione Valduce to
A.D.T. Portions of this paper were presented at the 15th
European Workshop on Cognitive Neuropsychology,
Bressanone, January 19–24, 1997, and at the National
Congress of the Associazione Italiana di Psicologia, Sezione
di Psicologia Sperimentale, Capri, September 22–24, 1997.
1732
C. Luzzatti et al.
References
Aitkin M, Anderson D, Francis B, Hinde J. Statistical modelling in
GLIM. Oxford: Clarendon Press; 1989.
Ardila A, Rosselli M, Ostrosky-Solis F. Agraphia in the Spanish
language. Aphasiology 1996; 10: 723–39.
Baxter DM, Warrington EK. Category specific phonological
dysgraphia. Neuropsychologia 1985; 23: 653–66.
Beauvois M-E, Dérouesné J. Lexical or orthographic agraphia.
Brain 1981; 104: 21–49.
Bisiacchi PS, Cipolotti L, Denes G. Impairment in processing
meaningless verbal material in several modalities: the relation
between short-term memory and phonological skills. Quart J Exp
Psychol 1989: 41a: 293–319.
PJ, Bruyn GW, editors. Handbook of clinical neurology, Vol. 3.
Amsterdam: North-Holland; 1969. p. 368–433.
Luzzatti C, Willmes K, De Bleser R. Aachener Aphasie Test (AAT) –
Versione Italiana. Firenze: Organizzazioni Speciali; 1994a.
Luzzatti C, Laiacona M, Allamano N, De Tanti A, Inzaghi MG,
Lorenzi L. An Italian test for the diagnosis of acquired writing
disorders: construction principles and normative data. Ricerche
Psicologia 1994b; 18: 137–60.
McCullagh P, Nelder JA. Generalised linear models. London:
Chapman and Hall; 1983.
Orsini A, Grossi D, Capitani E, Laiacona M, Papagno C, Vallar G.
Verbal and spatial immediate memory span: normative data from
1355 adults and 1112 children. Ital J Neurol Sci 1987; 8: 539–48.
Bortolini U, Tagliavini C, Zampolli A. Lessico di frequenza della
lingua Italiana Contemporanea. Milano: Garzanti; 1972.
Patterson KE. Lexical but non semantic spelling? Cogn
Neuropsychol 1986; 3: 341–67.
Bub D, Kertesz A. Deep agraphia. Brain Lang 1982; 17: 146–65.
Patterson KE, Marshall JC, Coltheart M. Surface dyslexia. London:
Lawrence Erlbaum; 1985.
Coltheart M, Patterson KE, Marshall JC. Deep dyslexia. London:
Routledge & Kegan Paul; 1980.
De Bleser R, Luzzatti C. Models of reading and writing and their
disorders in classical German aphasiology. Cogn Neuropsychol
1989; 6: 501–13.
Denes GF, Cipolotti L, Zorzi R. Dislessie e disgrafie acquisite. In:
Denes GF, Pizzamiglio L, editors. Manuale di neuropsicologia. 2nd
ed. Bologna: Zanichelli; 1996. p. 386–422. [English translation:
Aquired dyslexias and dysgraphias. In: Handbook of Clinical and
Experimental Neuropsychology. London: Psychology Press, 1998].
Harris M, Colheart M. Language processing in children and adults.
London: Routledge & Kegan Paul; 1986.
Hillis AE, Caramazza A. Mechanisms for accessing lexical
representations for output: evidence from a category-specific
semantic deficit. Brain Lang 1991; 40: 106–44.
Luria AR, Naydin VL, Tsvetkova LS, Vinarskaya EN. Restoration
of higher cortical function following local brain damage. In: Vinken
Shallice T. From neuropsychology to mental structure. Cambridge:
Cambridge University Press; 1988.
Shallice T. Phonological agraphia and the lexical route in writing.
Brain 1981; 104: 413–29.
Spinnler H, Tognoni G. Standardizzazione e taratura italiana di test
neuropsicologici. Ital J Neurol Sci 1987; 8 Suppl 8: 1–120.
Wernicke C. Nervenheilkunde. Die neueren Arbeiten über Aphasie.
Fortschr Med 1885–1886; 3: 824–30; 4: 371–7, 463–82. [English
translation by R. De Bleser. Neurology: recent contributions on
aphasia. Cogn Neuropsychol 1989; 6: 547–69].
Willmes K. An approach to analyzing a single subject’s scores
obtained in a standardized test with application to the Aachen
Aphasia Test (A.A.T.). J Clin Exp Neuropsychol 1985; 7: 331–52.
Received October 8, 1997. Revised February 1, 1998.
Second revision May 1, 1998. Accepted May 18, 1998
Diagnosis of writing disorders
Appendix
Derandomized list of the items used in the writing task [WF 5 word frequency (from Bortolini
et al., 1972)]
Section A
Part
Words
WF
Part
Words
WF
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
mare
mano
sole
muro
vino
mulo
lume
faro
filo
remo
lavoro
numero
nuvola
minerale
fenomeno
semaforo
sinonimo
sifone
visone
somaro
senso
forma
frase
marmo
nervo
frana
sfera
farsa
selva
salsa
valle
ferro
messa
sonno
villa
molla
muffa
masso
renna
223
196
173
93
78
10
10
9
5
0
267
149
27
26
21
0
0
0
0
0
123
119
34
33
19
8
0
0
0
0
83
69
47
41
30
7
5
0
0
5
5
5
5
5
5
5
5
5
5
6
6
6
6
6
6
6
6
6
6
7
7
7
7
7
7
7
7
7
7
8
8
8
8
8
8
8
8
8
8
capo
tipo
dito
coda
buco
topo
buca
baco
tubo
diga
monte
clima
festa
spesa
prato
fusto
trave
lardo
mirto
stelo
notte
letto
matto
latte
babbo
lutto
fetta
tappo
ratto
mappa
strada
fronte
stampa
sponda
nastro
crosta
tromba
frusta
fulcro
filtro
145
128
45
9
5
11
9
8
3
0
144
88
78
50
49
13
7
0
0
0
228
176
87
32
27
10
9
0
0
0
311
120
28
11
8
8
6
3
0
0
ascia
Section B
Words
WF
cane
scala
gara
gola
scopa
chiave
schifo
scheda
ghiro
ghisa
valigia
bacio
fascia
adagio
163
49
40
34
0
48
23
10
0
0
48
41
23
12
0
1733
1734
C. Luzzatti et al.
Section C
Section D
Words
WF
Words
WF
società
coscienza
scienza
igiene
usciere
ente
scena
conoscenza
ascella
macello
migliaia
paglia
aglio
caviglia
vaniglia
Italia
milione
olio
vigilia
balia
segno
compagno
ognuno
pugnale
ragno
niente
genio
geranio
paniere
cerniera
libro
litro
fibra
zebra
cetra
quattro
labbro
febbre
fabbro
spettro
quarto
aquila
squalo
quarzo
squama
liquore
quota
equo
iniquo
obliquo
cuore
scuola
scuotere
cuoio
cuoco
110
34
31
5
0
202
45
20
0
0
42
8
0
0
0
256
145
74
10
8
215
59
35
9
0
588
13
7
0
0
86
12
9
0
0
193
34
16
0
0
51
9
0
0
0
11
0
0
0
0
136
102
19
12
9
hobby
brandy
blue jeans
baby-sitter
weekend
robot
chalet
nightclub
0
0
0
0
0
0
0
0
Section E
Part
Non-words
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
5
5
5
5
5
nise
nifo
ralo
vona
relo
vimàne
forèla
rinàfo
ramàsola
lesònimo
fella
seffa
sovva
nissa
sinno
tido
pabo
bita
dute
puda
nitta
loppa
rebba
mippo
satto