TEACHING
CHILDREN WITH TOURETTE SYNDROME
Bernadette
Knoblauch
Tourette
Syndrome (TS) is a neurological disorder characterized by repeated,
involuntary body movements (tics) such as blinking, twitching,
shoulder shrugging, or leg jerking and vocal sounds such as throat
clearing or sniffing. Symptoms typically appear before the age
of 18 and the condition occurs in all ethnic groups with males
affected 3 to 4 times more often than females. Associated conditions
can include obsessivity, attentional problems, and impulsiveness.
Since many people with TS have yet to be diagnosed, there are
no absolute figures, but the official estimate by the National
Institutes of Health is that 100,000 Americans have full-blown
TS. Symptoms include:
-
Multiple
motor and one or more vocal tics at some time during the illness,
although not necessarily simultaneously
-
The
occurrence of tics many times a day (usually in bouts) nearly
every day or intermittently throughout a span of more than
one year
-
Periodic
changes in the number, frequency, type, location, and severity
of the tics; for example, symptoms may disappear for weeks
or months at a time
-
Onset
before the age of 18.
Associated
Behaviors
Additional
problems may include:
-
Obsessions,
which consist of repetitive unwanted or bothersome thoughts
-
Compulsions
and ritualistic behaviors. Examples include touching an object
with one hand after touching it with the other hand to "even
things up," repeatedly checking to see that the flame
on the stove is turned off, or repeating a sentence many times
until it "sounds right."
-
Attention
Deficit Disorder (ADD) with or without Hyperactivity (or ADHD).
Indications of ADHD may include:
-
difficulty
with concentration; failing to finish what is started not
listening; being easily distracted; often acting before thinking;
shifting constantly from one activity to another; needing
a great deal of supervision; and general fidgeting. ADD without
hyperactivity includes all of the above symptoms except for
the high level of activity.
-
Learning
disabilities, including reading and writing difficulties,
arithmetic disorders, and perceptual problems
-
Difficulties
with impulse control, which may occasionally result in overly
aggressive behaviors or socially inappropriate acts. Defiant
and angry behaviors can also occur.
In
many cases, medication can help control the symptoms, but there
may be side effects, some of which interfere with cognitive processes.
Stimulants such as Ritalin, Cylert, and Dexedrine that are prescribed
for ADHD may increase tics, and their use is controversial. Other
types of therapy may also be helpful, including psychotherapy,
behavior modification therapy that can teach the substitution
of one tic for another that is more acceptable, and the use of
relaxation techniques, biofeedback, and excercise to reduce the
stress that often exacerbates tics.
Establishing
the Proper Learning Environment
While
school children with TS as a group have the same IQ range as the
general population, many may have some kind of learning problem.
That condition, combined with attention deficits and the problems
of dealing with frequent tics, often call for special educational
assistance. The use of tape recorders, typewriters, or computers
for reading and writing problems, untimed exams (in a private
room if vocal tics are a problem), and permission to leave the
classroom when tics become overwhelming are often helpful.
The
following are tips for dealing effectively with TS symptoms in
the classroom setting:
- Some
movements and noises can be annoying or disruptive to the
class. Please remember that they are occurring involuntarily,
and do not react with anger or annoyance! This requires patience
but reprimanding a student with TS student is like disciplining
a student with cerebral palsy for being clumsy. If the teacher
is not tolerant, others in the class may feel free to ridicule
the child with TS.
- If
some aspect of the child's tics affect the privacy or safety
of others (e.g., touching others), it is important to find
ways to work around the problem, but acceptance of the child
is critical even when the behaviors are unacceptable.
- Provide
opportunities for short breaks out of the classroom. Time
in a private place to relax and release the tics can often
reduce symptoms in class. Private time may also enhance the
student's ability to focus on schoolwork, because energy will
not be used to suppress the tics.
- Allow
the student to take tests in a private room, so energy will
not be expended on suppressing tics during a quiet time in
the classroom.
- If
tics are particularly disruptive, consider eliminating recitation
in front of the class for a while. Oral reports might be tape
recorded, so those skills can be judged without the added
stress of standing before the class.
- Work
with other students to help them understand the tics and reduce
ridicule and teasing. School counselors, psychologists, and
representatives from the local Tourette Syndrome Association
chapter can provide information and appropriate audio-visual
materials for students and staff.
Accommodations
for Writing Problems
Many
children with TS also have visual-motor integration problems.
Therefore, tasks that require seeing material, processing it,
then writing it down are often difficult and time consuming. This
problem also affects copying from the board or from a book, completing
long assignments, neatness of written work, and prescribed times
for completion of written work. Even very bright children with
TS who have no trouble grasping concepts may be unable to finish
written work because of visual-motor impairments. Sometimes it
appears as though the student is lazy or avoiding work, but in
reality the effort to record the work on paper may be overwhelming.
A
number of accommodations can be made to help children with writing
difficulties succeed in the classroom:
- Modify
written assignments by: having the child copy down and complete
every other math problem; allowing the child to present a
taped report rather than a written one; allowing a parent
to record work or act as "secretary" so the child
can dictate his ideas to facilitate concept formation. It
helps to focus on what the child has mastered rather than
the quantity of written work produced.
- Since
the student with visual-motor problems may not be able to
write quickly enough to get important information on paper,
assign a reliable "note-taking" buddy or "homework
partner" who can use carbon paper to make copies of notes
and assignments. Be sure to work this out discreetly, so the
child with TS does not feel different in yet another way.
- On
tests with computer scoring sheets, allow the student to write
on the test booklet. This helps avoid poor grades caused by
the visual confusion that can occur when using the grid answer
sheet.
- When
possible, allow as much time as needed for taking tests.
- Students
with visual-motor problems may be poor spellers. Rather than
penalizing for spelling errors, encourage proof-reading and
using a word processor with a spell checker.
- Students
with TS seem to have special problems with written math. Encourage
the use of manipulatives in teaching math and the use of a
calculator to perform rote calculations. Using grid paper
with large boxes or turning regular lined paper sideways to
form columns can also help the child maintain straight columns
when calculating.
Accommodations
for Language Problems
- Provide
visual input as well as auditory whenever possible. The student
could receive written directions as well as oral ones, or
have a copy of a lecture outline to follow while listening
to instructions. Pictures and graphs that illustrate the text
are usually quite effective.
- Give
directions one or two steps at a time. Ask the student to
repeat the instructions. Then have the student complete one
or two items and check with you to see that they have been
done properly.
- If
you notice a student mumbling while working, suggest a seat
where he will not disturb others. Sometimes quietly "reauditorizing"
instructions or information to himself can help a student
grasp and remember the assignment.
- Children
with TS may repeat their own words or those of someone else.
This may sound like stuttering but it actually involves the
utterance or words or whole phrases. Other students may exploit
this problem by whispering inappropriate things so that the
child with TS will involuntarily repeat them and get into
trouble. Be alert to this provocation.
This
urge to repeat can be seen in reading and writing activities.
Students may be unable to complete work because they "get
stuck" rereading or rewriting words or phrases over and over.
This is called "looping." The following can be helpful.
- Have
the student take a break or switch to other work.
- When
reading, give the child a note card with a cut out "window"
that displays only one word at a time. The student slides
the window along while reading so the previous word is covered
and the chances of getting stuck are reduced.
- When
writing, have the student use pencil or pen without an eraser
or allow the student to complete the work orally. Brief
reminders to move on may help.
Accommodations
for Attention Problems
- Seat
the child in front of the teacher for all instruction and
directions to minimize the visual distraction of classmates.
- Seat
the child away from windows, doors, or other sources of
distraction, i.e., where reading groups meet.
- Give
the student an "office," a quiet workplace. This
could be in a corner, the hall, or the library. This place
should not be used as a punishment, but rather a place the
student can choose to go to when focusing becomes more difficult.
- Have
the student work in short intense periods with breaks to
run an errand or simply wiggle in the seat.
- Change
tasks frequently. For example, complete five math problems,
then do some spelling, etc.
- Contract
for work to be done in advance. For example,finish a specific
number of problems by a certain reasonable time. Short assignments
with frequent checks are more effective than two or three
sheets of independent work at one time.
- With
younger children, simple gestures, such as a hand on the
student's shoulder, can be a helpful reminder to focus during
listening periods.
References
A
Physician's Guide to the Diagnosis and Treatment of Tourette Syndrome,
3rd ed., Tourette Syndrome Association, Inc., Bayside, NY. 1997.
Bronheim,
Suzanne. (1994). An Educator's Guide to Tourette Syndrome, Tourette
Syndrome Association, Inc., Bayside, NY. ED321467.
Wertheim,
Judy. (1994). Coping with Tourette Syndrome in the Classroom,
Revised. Tourette Syndrome Association, Inc., Bayside, NY. ED385075.
Reprinted
with permission by:
The
ERIC Clearinghouse on Disabilities and Gifted Education (ERIC
EC)
The Council for Exceptional Children
1110 N. Glebe Rd.
Arlington, VA 22201-5704
Toll Free: 1.800.328.0272
E-mail: ericec@cec.sped.org
Internet: http://ericec.org
October
1998
