Health and safety recommendations for both the tourette syndrome (TS) and tourette syndrome plus associated disorders - ADHD, OCD (TS+) student and those in their environment

Time Away (Detours)

  • Predetermined behaviour plan
  • Ideally a quiet place not associated with discipline
  • Private
  • Out of the view of other students
  • An environment that can reduce over stimulation and possible ridicule

Use Of Positive Language

  • Not uncommon for TS/TS+ students to experience difficulty controlling their impulses
  • Often prohibiting a particular behaviour will only guarantee it, request the desired behaviour

    Sample:

    Don’t say - “Please stop touching walls.”
    Say -  “Please keep your hands on your desk.”

    Don’t say - “Please stop making noise.”
    Say - “Please look at me quietly”

  • Tone should be unassuming and the statement should not be one that may generate a contradictory response
  • Positive language requires patience and practice but is a proven effective tool

Attention shortcomings

  • Attention shortcomings cause students to often miss physical cues regarding their environment and body language of those around them
  • When it is necessary to discipline the student, don’t assume he/she knows what the appropriate behaviour is
  • Explain and demonstrate the desired behaviour, action or response, if you expect appropriate behaviours in the future
  • Attention deficits can result in students hearing without listening – to ensure the student hears and remembers, have them repeat your instructions back to you
  • Teacher may have to rehearse or walk the student through a specific task, for example, a student who consistently gets into trouble during unstructured times will not learn correct behaviour simply through a detention – staff needs to find out what is happening during this time and develop strategies and skills to help the student be successful

Zero tolerance policies

  • TS/TS+ symptoms can cause a student to violate school policies/rules without intent
  • Neurological symptoms and personal knowledge of the TS/TS+ student need to be taken into consideration
  • Essential to establish a safety plan – individualized and easy to implement
  • Parent contact number, availability important, current list of medications provided (if possible) in case of an emergency

Don’t sweat the small stuff!

  • Choose your battles and address the issues that genuinely require intervention
  • Increased stress will not only increase tic symptoms but quite possibly cause behavioural issues

Recognizing and responding positively to behavioural issues

  • Some challenging and difficult behavioural issues can be attributed to symptoms of TS+, and some are not TS related
  • Recognizing and responding positively to challenging behaviour is the most effective way to de-escalate a situation
  • Teachers need to respond to difficult behaviours regardless of its origin
  • Responses need to be consistent, supportive, and positively model appropriate behaviour
  • Stay calm – this helps the student become calm
  • Don’t take it personally – helps avoid a power struggle, decreases your stress and the student’s stress
  • You are in control of your own responses – be a role model

Don’t intellectualize the situation – there are many factors over which you as the adult have little or no control

  • The symptoms of TS/TS+
  • Medication side effects
  • Displaced anger
  • Hunger, thirst, sleep deprivation caused by the disorder or medications

Be positive and proactive – listen to the student, look for clues of potential crises; pay close attention to:

  • Body language
  • Facial expressions
  • Verbal and nonverbal communications

Recognizing signs of anxiety before a crisis begins

  • Increase or decrease in vocal and/or motor tics
  • Fidgeting or unrest
  • Challenging, rude comments
  • Confrontational tone
  • Passivity
  • Redness around eyes and ears
  • Heavy breathing

Verbal outbursts

  • Many volatile situations can be de-escalated by listening to the student, validating his/her concerns, calmly suggesting an option (time away or detour, movement break)
  • Implement Support Plan
  • Access resource room

Physical outbursts

  • Each school should have a predetermined safety plan in effect
  • Stay calm, supportive, non-confrontational, and implement the predetermined safety plan

    Safety plan should include:

    • Classroom teacher(s)
    • Student’s E.A.
    • School administration
    • School staff near the student’s classroom
    • Parent(s)/guardian

Consequences

  • Should be logically related to the behaviour and as short term as possible
  • Avoid angry retribution – teach the skill that is missing
  • Try to catch the student before they make a mistake or become agitated – help them think and plan

Classroom strategies

Mobility

  • TS/TS+ students require opportunities for movement
  • Depending upon age, location of classroom, and student ability, consideration should be given to:
    • Use of a hall pass or Detour card
    • Use student as messenger when need for movement is obvious – make sure all staff are aware of this
    • Negotiate acceptable mobility options with student
    • Allow student use of quiet, squeezable stress reducing fidget items
    • Chewing gum

Recess/lunch/unstructured times

  • Recess and lunch can be the most challenging “subjects” at school
  • Unsupervised social interaction can prove very stressful and overwhelming to students with sensory overload, social skills deficits, who are prone to be teased or bullied when releasing suppressed tics or compulsions, and are tired due to disrupted sleep cycles

Tests/exams

  • Allow additional time for testing
  • Consider testing early in the day when student may be more alert and medications are not wearing off
  • Alternative setting
  • Consider removing wall clocks
  • Allow for breaks and movement
  • Allow for oral testing
  • Allow for scribe
  • Consider exemptions from standardized tests
  • Be aware bubble sheets may be impossible for some students

Organizational skills

  • School by its very structure has many organizational demands, limited movement, prolonged listening demands, extensive writing requirements, and rule oriented behavioural expectations
  • All of these can conflict with the symptoms and learning difficulties for many students with TS/TS+
  • Be aware that noticeable independence can take a long time
  • The teacher(s) should consider:
    • Clear consistent realistic rules and expectations
    • Keep to a clearly established daily routine
    • Keep a supply of pens, pencils, paper available
    • Cues and reminders prior to transition periods
    • Consider colour coding binders, texts
    • Set regular times to tidy up the binder
    • Write due dates on assignments
    • Establish a consistent location at home and school to store completed work, backpack, etc.
    • Establish a daily communication book between home and school (have a back up)
    • Chunk work where possible
    • Provide study outlines
    • Teach the student how to break down information to study
    • Encourage short breaks after 10 – 15 minute intervals of prolonged study
    • Encourage study buddies

Affective and cognitive support

Modifications/accommodations

  • Need to be individualized, doable and fluid

Communication

  • Ongoing, honest, communication between home and school is essential

IEP (individual education plan)

  • Informal or formal I.E.P. dependent upon student’s needs and practice of School/School Board
  • I.E.P. should be reviewed and updated as necessary each term to reflect new goals

School/system team

  • School/system Program Development Team (PDT) requires a working knowledge of the student’s needs, strengths, weaknesses, effective action plan that is current and open to change with an eye to the future

Goals

  • Realistic, measurable goals

Support team

Parents

  • Communicate your knowledge of your child, observations, techniques that seem to work, what doesn’t work
  • Inform the school of medication(s), side effects, target most common concerns – homework, “storms”, and sleep disturbances
  • Communicate to the school if homework affects your life negatively

Teacher

  • Communication observations, what’s working, what’s not – report any side effects of medication
  • Set the mood, encourage tolerance, acceptance, remain positive
  • Be cognizant of the possibility of tic suppression – speak with parents – is child exploding at home

Educational assistant

  • Due to the one on one or small group nature of the relationship, many students strike a strong bond with the E.A.
  • Positive E.A./parent relationship is needed for success
  • E.A. should be included in any Program Development Team (PDT) meetings related to I.P.R.C. format

Resource teacher/L.S.T./TOSA

  • Usually the individual within a school with the additional skills and training in special education
  • Often responsible for sharing success strategies to classroom teacher and E.A.

School administration

  • Know your school’s administration
  • Develop a positive relationship
  • Make sure it is understood you are your child’s advocate and want to work with the school team to develop the best learning environment for your child

Physician

  • Provide “release of information” documents so the school can provide and receive information in order to better monitor medication(s)

School psychologist

  • Can provide important information for the teacher/PDT around general intellectual ability, other cognitive functions, and areas of strength
  • Can help in determining a student’s social abilities, and help determine how much of a social problem is due to cognitive difficulties
  • Students with TS/TS+ require a formal psychological assessment in executive functioning, memory, fine motor performance and learning disabilities because so many of them have deficits in these areas
  • The psychological evaluation and written report can provide a “road map” to help plan the student’s education
  • The psychological evaluation can also recommend a need for further evaluation by other professionals (O.T., Speech Language) and are a major factor in the development of an I.E.P.

Occupational therapist

  • Assess the student’s performance and provide treatment and recommendations as necessary, usually focussed on
    • Productivity
    • Leisure and Vocational Interests
    • Fine and Gross Motor skills
    • Self-Care
  • O.T. can also be a valuable resource for students with sensory integration dysfunction

Speech and language pathologist

  • Provide information regarding the student’s speech, receptive and expressive language
  • Evaluate articulation, voice, fluency, vocabulary, grammar, and how language is used in social situations
  • Pragmatic skills (social situations) are very important as it is “not what you say, it is how you say it”.
  • Eye contact, volume of voice, tone of voice, staying on topic, physical boundaries, body language, maintaining, and ending a conversation are essential for school and life in general

TS+ obsessive compulsive disorder (OCD)

  • “Just Right”, “Just So”
    • Compulsions are more common in people who have TS Syndrome and Obsessive Compulsive Disorder
  • TIC Suppression and Obsessions
    • Suppression of compulsions usually cause an increase in anxiety, obsessions and fatigue
  • Punitive Responses
    • Only increase the cycle of OCD (i.e. school tardiness is often related to compulsions that have to be done “just so” before they leave for school)
  • Communication with Parents
    • Keep an open line of communication with parents – be observant and don’t be afraid to tell them if you find the students OCD symptoms are causing a major disruption to his/her health or school performance

Strategies for compulstions affecting note taking, essays, written tests

  • Choice
    • Allow student to choose, when possible whether to print or write, use pen, pencil or coloured pencil
    • Provide assistive technology options
    • Oral presentations
    • Provide copies of teacher notes
    • Provide a scribe
    • Limit the number of corrections to that which the student can manage
    • Do not ask for hand written work to be redone
  • Use of adaptive technology-laptop, iPAD, scanner/printer, computer software to promote skill development
  • Determine what is acceptable
    • Academically-individualize expectations for the end product of the academic task
    • Know that corrections to work can be a trigger for OCD behaviour
    • Behaviourally-avoid expectations that feed into OCD’s rules

Strategies for compulsions affecting reading

For Assisted Reading

  • Audio books
  • Listening-allow student to be read to

For Independent Reading

  • Chunking
  • Highlighting - highlight important sections of longer text

Supports for compulsions affecting mathematics

  • Graph paper
  • Chunking
  • Reduced workload
  • Additional time for tests
  • Reducing distractions by providing
  • use of a calculator
  • use of headphones
  • use of a matrix, number line, or other visual and concrete strategies

Additional strategies for OCD

  • Allow for added time, extensions
  • Be proactive to de-escalate or distract OCD behaviour
  • Have a prearranged cue established to allow for a break or change in activity