People with dysgraphia usually can write on some level,and lack fine motor skills, finding tasks such as tying shoes difficult. It often does not affect all fine motor skills. They can also lack basic spelling skills (for example, having difficulties with the letters p, q, b, and d), and often will write the wrong word when trying to formulate thoughts (on paper). In childhood, the disorder generally emerges when the child is first introduced to writing. The child may make inappropriately sized and spaced letters, or write wrong or misspelled words despite thorough instruction. Children with the disorder may have other learning disabilities, but they usually have no social or other academic problems. Cases of dysgraphia in adults generally occur after some neurological trauma or it might be diagnosed in a person with Tourette syndrome, ADHD or an autism spectrum disorder such as Asperger's. The DSM IV identifies dysgraphia as a "Disorder of Written Expression" as "writing skills (that) ...are substantially below those expected given the person's ...age, measured intelligence, and age-appropriate education."