Understanding is paramount, if we are to help children with Tourette’s integrate successfully at school
What is Tourette’s syndrome?
Tourette’s Syndrome is a complex tic disorder affecting 0.5 to 1.85 per cent of children in school based studies. A tic is defined as an involuntary, rapid, recurrent, non-rhythmic motor or vocal action. The tic is sudden and purposeless and can be divided into simple or complex tics. Simple motor tics are fast and meaningless and can include eye blinking, grimacing and shoulder shrugging. Complex motor tics tend to be slower and may appear purposeful, for example hopping, kissing, touching objects, echopraxia (imitating movements of other people) and copropraxia (obscene gestures). Simple vocal tics include coughing, clearing one’s throat and whistling. Complex vocal tics include repeating certain words or phrases such as “oh boy” or “all right” or repeating a phrase until it sounds “just right”.
Complex vocal tics can also include differences in articulation of speech, including variation in rhythm, tone and rate as well as coprolalia (repetitive use of obscene or socially unacceptable words or phrases). In fact, tics are common and are reported to occur in four to eighteen per cent of children. When there are multiple motor tics and one or more vocal tics this is known as Tourette’s syndrome. To be classed as Tourette’s, the tics must occur many times a day and nearly every day for more than one year, with no period of remission lasting longer than two months.
The exact cause of Tourette’s syndrome is not known, but complex interaction between genetics and brain neurochemistry and structure is believed to be implicated. Theorists have also suggested the involvement of historical infections, perinatal problems and maladaptive learning models.
Though children with Tourette’s exhibit normal intelligence patterns, there is, however, an increased prevalence of Tourette’s in children with learning difficulties or autism. Children with Tourette’s can also suffer from attention deficit disorder, obsessive compulsive disorder, and mood and anxiety disorders.
Problems at school
A lack of awareness about Tourette’s can lead to particular problems in the classroom, and many children with Tourette’s report getting into trouble at school. However, when there is understanding from school staff, students are often very appreciative. It is crucial that teachers recognise that behaviour engendered by Tourette’s is involuntary and that they make suitable allowances.
It is reported that parents often have to deal with more of the emotional and behavioural difficulties linked to Tourette’s than teachers (Christie and Jassi, 2002), while teachers more frequently report attention difficulties as the greatest area of concern. Tics can, indeed, be very disruptive and overwhelming in this respect. Differences of opinion between home and school can cause tension. Often this is manifested in discrepancies between performance at school against the ability to complete homework assignments.
It goes without saying that children with Tourette’s can be considered unusual by their peers, and this can often lead to social isolation and teasing. The frustration this causes can, in turn, lead to task avoidance. The fallout from this can often cause tremendous stress for parents.
What do children with Tourette’s say helps them?
Children with Tourette’s report that they appreciate teachers trying to understand what the condition is like for them. While Tourette’s can be disruptive for other pupils, teachers should recognise that these behaviours are involuntary. Indeed, Tourette’s affects the person with the condition much more than it affects those around them.
Providing other students in the class with appropriate knowledge and advice about Tourette’s is also helpful. This can often be incorporated into personal and social development classes. Children appreciate teachers showing patience and perseverance, which can lead to more positive school experiences. They also point to the importance of the provision of a private study area in stressful situations like examinations (Wilson and Shrimpton 2003).
Children with Tourette’s often use particular strategies to adapt to school life and to reduce anxiety and worry. Ignoring other pupil’s gazes and pre-planning changes at school are often said to be particularly helpful.
How can teachers and schools help?
The challenges children with Tourette’s face are best tackled with effective and clear communication between school and home. Psychoeducation, with the help of specialists and SENCOs, can be particularly helpful for individual problems faced by children.
Information on Tourette’s is available from charities and clinical bodies (see below), and SENCOs can put together information packs for teachers. Schools should ensure that individual education plans take full account of a pupil’s Tourette’s. The transition from Year 6 to Year 7 can be particularly challenging and may require additional planning and support.
When there are more pervasive problems with Tourette’s, input from an educational psychologist is appropriate and can be very helpful. Local education authorities can also assist in the consideration of whether a statement of special educational needs should be issued.
Practical classroom support
Specific strategies utilised by experienced teachers are known to be particularly helpful for children with Tourette’s:
- seating children with Tourette’s at the front of the classroom. This can enhance attention
- the provision of “time-out” passes. Breaks can relieve tension and ensure time for movement
- the provision of designated areas where tics are “allowed”. The suppression of tics increases anxiety and sub-optimal educational performance
- encouraging teachers to avoid responding to tics. This encourages increased normalisation
- breaking down longer assignments into shorter tasks
- removing unnecessary objects from desks
- permitting students to “fiddle” with specified objects
- the use of scribes, rulers, laptops, visual timers, grid paper, calculators, organisers and visual diaries. Such aids can be very supportive
- greater emphasis on effort over presentation in written work. This can help relieve anxiety
- the use of worksheets that require a minimum of handwriting
- pairing students with supportive and understanding “buddies”
- work contracts between teachers and student. These can outline particular expectations and provide clearer goals.
Creating the right environment of understanding in the classroom is essential and can help students with Tourette’s to develop their confidence and flourish at school. Indeed, educational input and experiences at school can have a greater impact on the student’s prognosis than any medicines or psychological therapies. If educational issues are not properly addressed, then the potential for bullying can be great, and the student is more likely to develop poor social skills, to under-achieve academically and to suffer from low self-esteem.
Uttom Chowdhury is an NHS consultant and the author of Why Do You Do That?: A Book About Tourette Syndrome for Children and Young People and Tics and Tourette Syndrome: A Handbook for Parents and Professionals.