Slide ______1 Managing Tourette ______Syndrome in the Classroom ______

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Susan Conners, M. Ed. ______Author President, TSA of ______Greater NY State ______

Slide ______2 Haim Ginott ______

I’ve come to the conclusion that I am the ______decisive element in the classroom. It’s my personal approach that creates the climate. It’s my daily mood that makes the weather. ______As a teacher, I possess a tremendous power to make a child’s life miserable or joyous. I ______can be a tool of torture or an instrument of inspiration. I can humiliate or honor, hurt or heal. In all situations, it is my response that ______decides whether a crisis will be escalated or de-escalated and a child humanized or de- humanized ______

Slide ______3 If I had but one life to give for my country, it would be ______Billy in the third row. ______

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Slide ______4 Tics ______An Involuntary, repetitive ______motor movement or vocalization ______

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Slide ______5 Multiple Motor Tics Simple Motor Tics ______Eye blinking, grimacing, nose twitching, leg movements, shoulder ______shrugs, arm and head jerks, etc.

Complex Motor Tics ______Hopping, clapping, throwing, touching (self, others, objects), ______funny expressions, sticking out the tongue, kissing, pinching, tearing paper or books, echopraxia ______(repeating actions), copropraxia (obscene gestures) ______

Slide ______6 Vocal Tics Simple Vocal Tics ______Whistling, coughing, sniffling, screeching, animal noises, grunting, throat clearing ______Complex Vocal Tics Linguistically meaningful utterances: “I’ve got it.” ______“Oh boy.” “Now you’ve seen it.” ______Speech Atypicalities Unusual rhythms, tone, accents, ______intensity of speech, stuttering ______

Slide ______OTHER UNUSUAL TYPES OF 7 VOCAL TICS ______

 Echolalia - involuntary repetition of someone ______else’s words  Palilalia - involuntary repetition of one’s own ______words  Coprolalia - involuntary utterance of curse words ______or other socially inappropriate phrases or sentences ______NOTE: Coprolalia is NOT necessary for a diagnosis of TS

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Slide ______8 Waxing and Waning ______

 Tics naturally wax and wane, change in ______nature and in severity  Tics change much more frequently in ______childhood than adulthood  Tics typically seem to worsen during pre- ______puberty and puberty

 Many people with TS experience a lessening of tics in adulthood ______

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Slide ______9 Environmental Factors That Can Worsen TS Symptoms ______

 Stress ______ Anxiety ______ Excitement

 Fatigue ______ Illness ______

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Slide ______10 SUPPRESSION OF ______SYMPTOMS Results in: ______

. Worsening of symptoms . Inability to concentrate on task at hand ______. Shutting down . Fatigue and/or worsening of symptoms at end of day ______. Often explosion of symptoms at home ______

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Slide ______11 CLASSROOM SUGGESTIONS ______Even tics which appear to the onlooker to be very mild can be very interfering (e.g. eye rolling, head shaking). Vocal and motor tics can create tremendous social stresses for the student ______

 Frequent breaks ______ Preferential seating

 Assessing interference of individual tics for accommodations ______

 Educate classroom about TS

 SKYPE ______

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Slide ______12 ASSOCIATED DISORDERS ______

TS is a Neurobiological spectrum ______disorder - almost always accompanied by other neurological ______conditions ______

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Slide ______MOST COMMON ASSOCIATED 13 DISORDERS ______An extremely large number of people with TS are also diagnosed with the ______following: ______ Obsessive-Compulsive Disorder  Attention Deficit Hyperactivity ______Disorder ______ Learning Disabilities

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Slide OTHER FREQUENTLY OCCURRING ______14 ASSOCIATED ISSUES ______

In addition, students may exhibit other ______neurobiological symptoms, including:  Executive dysfunction  Depression ______ Anxiety disorders  Sleep disorders ______ Fine-motor difficulties (Dysgraphia)  Aggressive and/or explosive behavior ______ Sensory defensiveness  Social Skills Deficits ______

Slide ______15 ______OCD “Tics of the Mind” ______

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Your body tics and ______your mind tics QuickTime™ and a decompressor are needed to see this picture. ______

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Slide COMMON OBSESSIONS ______16 AND COMPULSIONS ______ Need for symmetry and perfectionism ______ Neatness  Counting ______ Checking things over and over  Constant doubt or worrying ______ Germ obsessions 1  Transition Difficulties 3 ______ Ritualistic behavior  Obsessive Sense of Justice 2 ______

Slide ______17 MANAGING OCD IN THE CLASSROOM ______

 An obsession with erasing words slows down writing. May need writing accommodations. ______ Counting compulsion - May need books on tape or a scribe.

 Time limits waived and extended time on tests. ______

 Advanced warning for any changes  Distraction and humor ______ Look for red flags for OCD and……. ______

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Slide ______18 Red Flags for OCD ______

______Writing and erasing

Continually sharpening pencil Difficulty with transitions ______Unable to tolerate any changes Repeated hand washing ______Perfectionism

Not able to turn in papers/tests for fear of mistakes ______Repeated checking Asking constant questions ______

Slide ______19 OBSESSIVE-COMPULSIVE ______DISORDER (OCD) ______ Neurological Disorder  Driven, Perfectionistic, ______ Need to complete ______ Difficulty transitioning  Mental brakes get stuck ______

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Slide ______20 ATTENTION ______DEFICIT ______HYPERACTIVITY ______DISORDER ______(ADHD) ______

Slide ______21 PORTRAIT OF A HYPERACTIVE CHILD ______

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Slide ATTENTION DEFICIT HYPERACTIVITY ______22 DISORDER (ADHD) ______ Often interpreted exclusively as a behavior problem ______ Children with ADHD are often:

• Inattentive ______• Impulsive • Hyperactive ______• Disorganized • Socially Immature ______

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Slide ______23 INATTENTIVE ______

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QuickTime™ and a  TIFF (Uncompressed) decompressor Very distractible are needed to see this picture.

 Difficulty sustaining attention ______

 Distracted by even the smallest extraneous noise ______ Difficulty staying on task ______

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Slide ______24 IMPULSIVE ______

______ Blurt out without being called on  Fail to think before acting ______ Do dangerous things without thinking of consequences ______

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Slide ______25 HYPERACTIVE ______

. Can’t sit still for long periods of time ______. Need constant movement - finger or toe tapping, squeezing something, chewing gum or something crunchy ______

. Lose control easily ______

I can’t sit still ______

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Slide ______26 DISORGANIZED / EXECUTIVE ______DYSFUNCTION ______

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Slide ______COMMON DIFFICULTIES FOR 27 STUDENTS WITH EXECUTIVE ______DYSFUNCTION  Keeping track of their belongings ______ Organizing their materials

 Getting started on a task/staying on task

 Breaking down long assignments/projects

 Sequencing information ______

 Forming goals

 Writing down homework assignments  Managing their time ______ Losing everything

 Coming to class unprepared  Having disorganized desks and lockers ______ Failing to finish anything

 Difficulty managing workload  Becoming quickly overwhelmed ______

Slide ______28 ______

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Before Medication After Medication ______

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Slide ______29 SOCIALLY IMMATURE ______

 Children with ADHD are often socially immature ______ Social/emotional age is often about 2/3 of their actual chronological age (Dr. Ross Greene) ______ Difficulty with social ` interactions with children their own age ______ Prefer playing with younger children

 Respond in a manner that is not age appropriate ______ Don’t pick up on social cues

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Slide ______CLASSROOM SUGGESTIONS 30 FOR ADHD ______ Assistance from teacher with managing workload

 Creative Methods for keeping track of assignments

 Teacher signing assignment book

 E-mailing assignments home ______

 Emailing completed assignments to teacher

 Leaving message on home voicemail  Extra set of books at home ______ Taking picture of assignment on board

 Breaking down assignments (chunking)

 Reducing workload – Quality VS Quantity  Preferential seating ______ Use of technology

 Testing in a separate location

 Use of a headset

 Freedom of movement ______

 Frequent breaks

 Social skills training / groups ______Slide ______Fine Motor/Visual Motor Impairment 31 Dysgraphia ______This is a non-verbal learning disability. Characteristics could include:

 Slow and laborious writing ______

 Hand and finger cramping

 Sloppy handwriting – uneven spacing – irregular margins, inconsistent lettering ______

 Inability to copy correctly from book to paper or chalkboard to paper (Visual Motor)

 Difficulty with written expression - getting thoughts onto paper ______

 Difficulty with punctuation and capitalization

 Interfering tics, OCD and sensory issues

 Difficulty with note-taking ______

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Slide ______WHAT TO DO ABOUT 32 DYSGRAPHIA ______

 Have the child evaluated by an Occupational Therapist

 Use a scribe ______

 Use a computer/word processor

 Provide OT services  Classroom notes provided ______ Computer software that can be helpful (Inspiration)

 Voice activated software / Dragon Speak / Dragon Dictation ______

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Slide ______33 BEHAVIORS ASSOCIATED WITH TS ______ Some students with TS and ADHD exhibit a short fuse and a low frustration tolerance that can lead to all-out loss of control. They may go into ______uncontrollable rages/storms for what appears to be no reason ______ These behaviors are often the result of one or more of their neurological disorders  This can often lead to a diagnosis of an emotional ______disorder and/or Oppositional Defiant Disorder (ODD) ______

______Slide ______34 ______“It’s your explanation of a behavior that leads ______directly to how you ______respond to it” ______Dr. Ross Greene, Ph. D. ______

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Slide ______35 A FUNCTIONAL BEHAVIORAL ______ASSESMENT MUST BE CONDUCTED AND A ______POSITIVE BEHAVIOR INTERVENTION PLAN ______DEVELOPED IF A CHILD’S BEHAVIOR IMPEDES THE ______LEARNING OF THAT CHILD OR ANOTHER CHILD ______

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Slide ______36 FUNCTIONAL BEHAVIORAL ASSESSMENTS ______

______The function of the behavior of a child with these complex disorders is not always what it appears TS and all of its related disorders directly affect ______behaviors  It is critical to ascertain how the behavior relates to ______the neurobehavioral disorder in order to provide an appropriate and effective behavior plan ______

______Slide ______37 QuickTime™ and a decompressor A Workbook are needed to see this picture. ______for Conducting a Functional Behavioral ______Assessment and Writing a Positive Behavior ______Intervention Plan for a Student with Tourette Syndrome ______

By Susan Conners and Kathy Giordano ______

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Slide ______38 ______

______What can we do FOR the child PRIOR to the behavior ______instead of what do we do TO the child AFTER the ______behavior has occurred? ______

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Slide ______Perspective 39 ______ÒWe must see the child as in trouble, not the ______cause of trouble.Ó ______C.H.A.D.D. Educators Manual Dr. Russell Barkley ______

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Education, Research and Support 14 ______Slide ______SENSORY PROCESSING DISORDER 40 Constant bombardment of sensory input ______Hyposensitivity

 Appear sluggish

 Have self abusive behaviors ______

 Pick at skin, etc.

 Repeatedly touch surfaces or objects that are soothing  Crave rocking or strong sensory input ______Hypersensitivity . Sensitive to sudden touch, the feel of certain fabrics . Need to have tags cut out of clothes or socks without seams ______. Very sensitive to bright or florescent lights . Can’t tolerate the texture of certain foods in their mouth . Very sensitive to certain smells ______. Over reactive to certain sounds . Melt down in noisy chaotic environments ______

Slide ______41 What Can Be Done About Sensory ______Processing Disorder? ______ Sensory evaluation and therapy techniques by an OT

 Environmental Modifications ______o Leave class 3-4 minutes early to avoid crowded hallways

o Avoid loud, chaotic environments

o Find alternate place to eat lunch with a ______few friends

o Use a headset to avoid auditory overload and distractibility ______o Preferential seating on school bus

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Slide Possible Co-Morbid ______Memory Disorders 42 Deficits OBSESSIVE COMPULSIVE ______10 DISORDER EXECUTIVE SOCIAL OR BEHAVIOR DYSFUNCTION 9 SKILLS 5 2 ______DEFICITS TOURETTE 3 SYNDROME Dysgraphia SENSORY handwriting ______PROCESSING 1 problems 8 AD/HD PROCESSING Anxiety 6 4 ______DEFICITS Inflexible DYSINHIBITION 12 7 15 Learning Aspergers ______Disability 14 BIPOLAR 13 Syndrome 11 ______Slide ______STRENGTHS 43 Articulate Good sense of ______humor Charming Creative ______TOURETTE Artistic SYNDROME Musical ______

Extremely Knowledgeable Honest ______Bright Focused Theatrical ______

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Slide ______44 Keep a Sense of Humor ______

______1. QuickTime™ and a Tourette Tics me off decompressor are needed to see this picture. 2. Sometimes I feel like a tic, sometimes I don’t ______3. Pop, pop, tic, tic, oh what a relief it is! ______4. I do not obsess, I do not obsess, I do not obsess ______5. We do ticcin’ right 6. I do solemnly swear….. ______

Slide ______45 ______

QuickTime™ and a ______decompressor are needed to see this picture. ______

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______Available at Amazon.com, Borders, Barnes and Noble and many other bookstores ______Slide ______46 Useful Resources ______

The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, ______Chronically Inflexible Children Dr. Ross Greene, Harper Collins Publishers, 2010 ______Lost at School: Why Our Kids with Behavioral Challenges are Falling Through the Cracks and How We Can Help Them Dr. Ross Greene, Scribner, 2009 ______

The Out of Sync Child Kranowitz, Carol Stock, A Skylight Press Book/A ______Perigee Book, 2005 (For children with sensory issues) ______

Slide ______47 Useful Resources Continued ______

Front of the Class ______Brad Cohen and Lisa Wysocky, St. Martin's Griffin, November 2008 ______Executive Skills in Children and Adolescents: A Practical Guide to Assessment and Intervention Peg Dawson ______Eddy, The Guilford Press; 1 edition , 2003 ______

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Slide ______BOOKS FOR CHILDREN 48 Quit It ______Marcia By lick, Yearling, 2004

A Test of Will ______Diane Schrader-Smith, 2002

VIDEOS ______

I Have Tourette’s but Tourette’s Doesn’t ______Have Me – HBO Network, 2005 (wonderful for a peer in-service) ______A Teacher Looks at Tourette – an educator’s in service DVD, Tourette Syndrome Association, Inc. ______Slide ______49 Contact Information ______

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Susan Conners [email protected] ______

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