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Vocabulary
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Tics are repetitive brief, stereotypical movements or vocalizations
SLD is specific learning disability (e.g., in math, reading)
TS is tourette syndrome
Invariant mean without change
Prescient feelings are warning signs that are thought to be
perceptive or clairvoyant
Copralalia is using obscene or socially inappropriate words
Palilalia--the repetition or echoing of one's own spoken words, and
may sound like stuttering.”Do my work work work”
Echopraxia is involuntary repetition or imitation of the observed
movements of another
Echolalia is the repetition or echoing of the last sounds, words,
phrases of another; these can be immediate or delayed
Dopamine is a chemical which helps transmit signals from one
nerve cell in the brain to the next.
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Look at these links
•http://www.tsa-usa.org/
•http://www.tsa-usa.org/news/HBO_Release_apr06_update.htm
Self-reports:
“I was devastated when I found out I had TS. I thought I was going to be a
normal boy. But I’m not. My life is awful. I feel like I’m missing out on a lot of
things because of my tics. I will feel a lot better if my tics go. If they don’t I
will learn to put up with them.” (Neil, 9yrs)
“My teacher treats me like an angel and manages my TS really well. The
other students try to be understanding as my teacher has told them all about
TS.” (Neil, 9yrs)
“I used to get asked why I blinked all the time and everyone used to get angry
at me because I couldn’t help looking at them and I always get harassed.”
Lyle who is 9 years has Aspergerg and TS, and says he feels like he’s in
prison when he is at school.
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Definition
A physical disorder of the brain characterized by multiform,
frequently changing motor and phonic tics:
1. involuntary movements (motor tics)
2. involuntary vocalizations (vocal tics)
First described by Gilles de la Tourette:
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Tourette Syndrome (TS)
Diagnostic Criteria
DSM IV diagnostic criteria:
1. Presence of both motor and phonic (vocal) tics
2. Occurrences many times a day, nearly every day,
usually in clusters, for longer than 1 year and not due to
substance abuse or medications
3. Onset before 18 years
4. The disturbance is not due to the direct effects of a
substance or general medical condition (must rule out
TBI, brain tumors, epilepsy, autistic disorders, muscular
dystrophy, CP, Parkinson’s, etc.)
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Idea Category
• Tourette Syndrome (TS) is now listed as a disability under the
category of Other Health Impaired (OHI).
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Prevalence
1. 1 in 1000 children; 10 times more
frequent in childhood than adulthood.
2. Symptoms visible by 7, but signs as
early as 2-5 years (Crawford et al.,
2005)
3. Boys outnumber girls 3 to 1(Clarke et
al., 2001)
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CO-OCCURRENCE
When TS accompanied by other disorders it is
called Tourette’s Plus (Lue, 2001).
1. 50% have OCD symptoms
2. 50% have ADHD
3. 25-35% have tantrums and aggression
(aggression occurs more frequently in TS, if the
child already has hyperactivity, impulsivity, or
ADHD)
4. 33% have SLD
Boys more likely to have tics, and girls to have OCD
symptoms;
Sleep disorders are fairly common
– Frequent awakenings
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– Walking or talking in one’s sleep
ETIOLOGY
1. Heredity:
50-70% of diagnoses of TS have hereditary
base
With one parent with TS, a child has a 50% chance of inheriting
TS
Identical twins may have tics that differ in intensity and frequency
and non-genetic factors underlie these differences.
2. Biochemistry:
An excess of, or oversensitivity, to dopamine.
3. Environmental factors:
a. Caffeinated beverages, cough syrup, recreational
drugs, diet medication, hay fever, allergies, or viral
illnesses increase tics, which occur less frequently
during sleep or activities that absorb the child’s
concentration.
b. Anxiety, anger, fear, or frustration increases tics
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MOTOR CHARACTERISTICS
Motor tics
are defined as purposeless movements
that range from simple to complex:
MOTOR Simple:
1. blinking eyes (most
common)
2. jerking neck
3. shrugging shoulders
4. flipping head
5. kicking
6. tensing muscles
7. sticking tongue out
8. finger movements
MOTOR: Complex:
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3.
4.
5.
6.
facial gestures (eye rolling)
grooming behaviors
smelling things
touching (other people or things),
tapping
jumping, squatting, retracing steps,
deep knee bends, twirling when
walking
7. hitting, biting
8. rarely are there self injurious actions
such as hitting or biting one’s self.
9. Echopraxia
10.Copropraxia (Woods et al., 2003)
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Motor Characteristics
MOST develop:
1. eye tic first
2. facial tics or involuntary sounds
3. others within weeks or months
• common examples: head jerks, grimaces, hand-toface movements
Symptoms can:
1. change over time
2. vary (frequency, type, location, or intensity)
3. increase in intensity during early adolescence (12-15
years)
4. improve in less extreme cases during adulthood
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VERBAL CHARACTERISTICS
VOCAL: Simple:
1. throat-clearing
2. sniffing
3. coughing
4. grunting
5. spitting
6. yelling
7. belching
VOCAL: Complex:
1. animal sounds
2. repeating words or
phrases out of
context “oh boy” “I
don’t know”
3. Coprolalia
4. Palilalia
5. Echolalia
They may “hear” a word or sound coming into their
mind and feel they have to ‘say” it.
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Communication
• Stuttering
• Coprolalia (fewer than 15% have this)
– Occurs in late childhood
– Most disruptive and disturbing (Jay, 2000)
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Social Emotional Characteristics
•The social and emotional difficulties that accompany TS are more
problematic in day-to-day adaptations than are the motor and phonic
tics (Carter et al., 2000). Children are teased and made to feel
stupid, different and unwanted. Peers negative responses to tics can
cause anxiety, which in turn increase tics and generate self-doubt.
Adolescence is a period with strong emphasis on physical
attractiveness. TS results in greater psychopathology during this
period than any other (Chang et al., 2004)
•Children also report uncomfortable, nervous, weird feelings (fear,
disgust, doubt) or like they are going to explode before an onset of
tics (Walter & Carter, 1997).
•Overall there is a higher risk of:
1.poor peer relationships
2.no relationships
3.withdrawn or aggressive social behavior
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Cognitive Characteristics
Same IQ
Visual-Motor and Perceptual Difficulties
1. Writing difficulties
2. Perceptual problems
(Chui et al., 2000; Shannon, 2003))
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Academic Characteristics
Tics potentially affect control of muscles involved
in task performance.
Children are able to suppress for limited periods of
time, which increases as they age, but it does
take great effort away from the task at hand (Walter
& Carter, 1997)
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Academic cont.
Tics can make simple routine activities difficult
(Chui et al., 2000)
Difficulties with:
1.organization
2.long written assignments
3.copying from the black board
4. completing assignments on time and neatly (Walter & Carter, 1997)
More likely to have SLDs:
1.Reading difficulties
2.Mathematical difficulties
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Academic Accommodations
General Principals:
1.Tics increase as a function of stress and calling
attention to tics increases them.
2. Tics decrease with relaxation or when focusing
on an absorbing task (Shannon, 2003).
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Accommodations
1.
2.
Model tolerance and do not allow teasing by peers
Try various seating arrangements
(Wilson, Jeni. Shrimpton, Bradely. 2003).
Allow:
1.
2.
3.
4.
5.
short breaks (e.g., break long assignments into smaller
parts)
movement around the room or outside the room (e.g., a
fictitious note to the office)
access to a private room with a bean bag chair--have a
private signal
exams in a private room for tension and tic release and
allow more time
child to tape oral presentations & reports (Lue, 2001)
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INTERVENTIONS
Pharmacological interventions increase success
(Clarke et al., 2001).
1. Anti-tic drugs block the activity of the
neurotransmitter dopamine.
2. Anti-OCD drugs help to restore the brain
chemical serotonin, which reduces unwanted,
thoughts.
(Many people choose tics over the medications
because of side effects, which are sleepy, gain
weight. In addition no medication has been found
that eliminates tics completely.)
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Functional Analysis of a Student with
Tourette Syndrome and a Mild
Intellectual Disability
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1.
2.
16 years old
3.
Diagnosed with Tourette’s in early elementary
school. Showed noticeable tics such as eye
blinking and barking like a dog.
4.
Diagnosed in the 5th grade as a child with a mild
mental disability
5.
In his school work, Chris always completes any
activity or assignment given to him. Almost
compulsive about completing assignments
6.
Chris does not interact with his peers. Seeks adult
interaction
Originally diagnosed with ADHD and still carries
that label
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1. Enjoys helping others
2. Takes initiative in completing
tasks
3. Good memory
4. Good attention to details
5. Has a strong desire to learn and
do what is right
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1. Difficulty with peer relationships
2. Poor fine motor skills including
handwriting
3. Struggles with math and language
arts
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1. Random talking that is
unrelated to subject or task
and includes asking
questions about upcoming
events
2. Pacing
3. Withdrawn and Pouting
4. Yelling
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1. Changes in students daily schedule: 2-hr.
school delays, lack of aide in class, early
dismissals, late bus arrivals.
2. Unstructured activities (breaks and times
when waiting to load buses)
3. Structured but stressful activities: working
on art project, visit to the high school,
academic work in the resource room
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Antecedent that caused the most behavior
Changes in Students Daily Schedule
46%
Behaviors that were seen the most
Random talking/asking questions
58%
Pacing
21%
Payoffs earned the most
Get self-determination (predictability)
85%
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Diagnosis of Tourette’s?
•Chris’ diagnosis of Tourette’s syndrome is correct.
•He meets all of the criteria for a diagnosis
a. Although his tics have dissipated, he still shows motor tics including
eye blinking and head jerking.
b. Research shows that it is common for children to see a reduction in
the tics as they get older. Chris’ onset was in his early elementary
years.
c. Chris shows TS, which includes social and academic impairments
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Diagnosis of ADHD?
Although ADHD can be a comorbid condition of TS, we must first
determine whether his co-occurring learning disabilities and mild
mental retardation might not better explain his inattentive
behavior.
Follow-up:
a. Now that he is given schoolwork based on his level of
reading, language, and math, Chris is able to listen and sustain
attention during his academics periods.
b. He remains in his seat during class, never runs about the
room, does not blurt out answers, and is able to wait his turn.
Conclusion: Chris is not ADHD; he has a mild intellectual
disability
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Diagnosis of OCD?
Chris’s OCD is a comorbid condition of the TS
•Chris’ obsessions and compulsions have to do with checking,
ordering, repeating, and getting things ‘just right’ rather than
trivial concerns with contamination, something bad happening, or
being neat and clean.
•Chris’s obsessive/compulsive behaviors are connected to an
event in a realistic way and help him to neutralize the
unpredictability of the event.
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Accommodations
To address the child’s need for predictability and
self-determination, teachers must provide:
1. A stable daily routine/schedule
2. Advance warning of any changes
3. Opportunities to ask questions as this is his way
to reassure himself about a situation that is
making him feel stressed and anxious
4. An escape, if needed, to regain control
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Interventions
To address the Chris’ need for self-determination, Chris
must learn:
1. That when he cannot regain control, to be patient
and ask for short breaks
2. To use scripts to interact with his peers. (For
example, Chris does not know how to initiate a
conversation; he only uses statements and needs to
learn to ask questions.)
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References
Bagheri, M. M., Kerbeshian, J., & Burd, L. (1999). Recognition and management of Tourette’s
syndrome and tic disorders. American Family Physician, 59, 2263-2274.
Budman, Cathy, (2000, Oct.). Explosive outbursts in children with Tourette’s Disorder. Journal of
the American Academy of Child and Adolescent Psychiatry, (need volume and page
numbers)
Carter, A., O’Donnell, D., Schultz, R., Scahill, L., Leckman, J., & Pauls, D., (2000). Social and
emotional adjustment in children affected with Gilles de la Tourette’s Syndrome:
Associations with ADHD and family functioning. Journal of Child Psychiatry, 41, need page
numbers
Chang, H., Tu, M., & Wang, H., (2004). Tourette’s Syndrome: Psychopathology in adolescents.
Psychiatry and Clinical Neurosciences, 58, 353-358.
Chiu, N., Chang, Y., Lee, B., Huang, C., & Wang, S., (2001). Differences in Tc-HMPAO brain
SPET perfusion imaging between Tourette’s Syndrome and chronic tic disorder in children.
European Journal of Nuclear Medicine, 28, need page numbers
Chowdhury, Uttom, & Christie, Deborah, (2002, Sept.). Tourette's Syndrome: A training day for
teachers. British Journal of Special Education, 29, 123-26.
Clarke, M., Bray, M., Kehle, T., & Truscott, S., (2001). A school-based intervention designed to
reduce the frequency of tics in children with Tourette’s Syndrome. School Psychology
Review, 30, need page numbers
Crawford, S., Channon, S., & Robertson, M., (2005). Tourette’s Syndrome: Performance on tests
of behavioral inhibition, working memory and gambling. Journal of Child Psychology and
Psychiatry, 46,1327-1336
Evidente, Gerald Virgillio, (2000, October). Is it a tic or Tourette’s? Postgraduate Medicine
Online, 108, need page numbers
Hendren, Glen, (2002). Tourette's Syndrome: A new look at an old condition. Journal of
Rehabilitation, Need Volume and April-June need page numbers
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References cont.
Jay, T., (2000). Why we curse. Philadelphia, PA: Benjamins, need edition and page numbers?
Lue, M. S., (2001). A Survey of Communication Disorders for the Classroom Teacher. Needham Heights, MA: Allyn, need
edition and page numbers?
Rowland, Belinda, (need year). Tourette's Syndrome. Gale Encyclopedia of Alternative Medicine, (need edition and page
numbers)
Shannon, J. B., (2003). Movement Disorders Sourcebook. Detroit, MI: Omnigraphics, need edition and page numbers?
Sukhodolsky, Denis (2003, Jan.). Disruptive behavior in children with Tourette’s Syndrome: Association with ADHD
comorbidity, tic severity, and functional impairment. Journal of the American Academy of Children and Adloescent
Psychiatry, (need edition and page numbers)
Truscott, S. (2001). A school-based intervention designed to reduce the frequency of tics in children with Tourette’s
Syndrome. School Psychology Review, 30, 11-21.
Van Borsel, John, & Vanryckeghem, Martine, (2000, May). Dysfluency and phonic tics in Tourette's Syndrome: A case
report. Journal of Communication Disorders, 33(3), pp. 227-240.
Walter, A. L., & Carter, A. S., (1997). Gilles de la Tourette’s Syndrome in childhood: A guide for school professionals.
School Psychology Review, 26 (1), need page numbers
Wilson, Jeni, & Shrimpton, Bradley (2003). Planning learning for students with Tourette's Syndrome. Student Disability
Conference.
Wodrich, David (1998, autumn). Tourette’s Syndrome and tics relevance for school psychologists. Journal of School
Psychology, 36(3), pp. 281-294.
Woods, D. W., Koch, M., & Miltenberger, R. G., (2003). The Impact of tic sverity on the effects of peer education about
Tourette’s Syndrome. Journal of Developmental and Physical Disabilities, 15 (1), page numbers
Woods, D. W., Twohig, M. P., Flessner, C. A., & Roloff, T. J., (2003). Treatment of vocal tics in children with Tourette's
Syndrome: Investigating the efficacy of habit reversal. Journal of Applied Behavior Analysis, 36, pp. 109-112.
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