"But Miss, I’ve got Tourette’s!”

"But Miss, I’ve got Tourette’s!”

Ruth Wadman and Georgina Jackson discuss the problems pupils with Tourette’s face in the classroom, and what schools can do to help

Tourette’s syndrome (TS) is an inherited neurological condition involving involuntary movements and vocalisations, “tics”, which persist for a year or more. As many as one school child in every hundred will have TS and boys are three to four times more likely to have TS than girls. Many will have only mild symptoms and may not have received a diagnosis. You may not think you have met a young person with TS, but you probably have.

The popular portrayal of adults with TS uttering obscene or socially inappropriate words and phrases (known as coprolalia) is unhelpful and misleading. Many children with TS find their tics lessen or disappear by the time they are 18 and only ten per cent of people with TS have coprolalia.   

Some individuals with TS do have symptoms that are disabling and that affect their education, social lives and economic prospects. However, milder symptoms often go unnoticed but still can have a detrimental impact on learning and relationships in school.

Our research, in partnership with the national charity Tourettes Action and funded by the Big Lottery Fund, has examined the personal, social and educational impact of TS. Students with TS, parents and school staff shared their experiences and insights by taking part in detailed interviews. We present some key findings from the research in this article. Crucially, our research has shown that TS is a complex condition that can be difficult to understand, and that schools can play a key role in helping students with this condition.

“A few of my teachers don’t really understand it. They don’t really know what tics I have, and some of them are like ‘stop it’ and I’m like ‘it’s a tic and I can’t help it’”. 11-year-old

Tics

Tics are sudden, rapid and uncontrollable sounds and movements. Tics can be simple, such as blinking, head jerking or coughing. Even simple tics are tiring and can cause damage to joints or self-injury. More complex tics, such as jumping and twirling, can seem purposeful but they are not. Complex vocal tics can involve uttering whole phrases that appear to be directed at others. These can be hugely embarrassing for the individual and it is important to remember that these utterances are not intentional.

“One of his tics was a racially offensive word. He didn’t even know he was saying it, and he certainly didn’t want to be saying it”. Mother

People with TS can feel an irresistible urge to tic, like the urge to scratch an itch.

“The feeling before the tic, it’s like a sneeze ‘cause you can’t really hold it back”. 16-year-old

However children, especially younger children, may not be aware of having these feelings. Some young people can hold back their tics for a period of time, but this is very effortful and feels uncomfortable.

Tics wax and wane; they can change in type, frequency and severity. They can get worse for a few weeks and then get better. Different tics can come and go for no reason.

“He tries to control his tics, but he can just get up one day and have a whole new different tic – so he has to start all over again”. Mother

Tics can be affected by periods of stress or stressful events. Many individuals report that their tics are different in different settings or at different times of day. Some students will have more tics at home than they have at school. Young people also report a reduction in tics when they take part in exercise or a pastime they enjoy such as playing music.

The changeable nature of tics can be confusing. It is important to understand exactly how TS affects the individual student.

Associated features

Most people with TS will have, or may develop, other conditions. Some students with TS will have one or two other diagnosed conditions, most commonly attention deficit hyperactivity disorder (ADHD) or obsessive compulsive disorder (OCD), but also autistic spectrum disorder (ASD). Other problems associated with TS include anxiety, self-injury, sleep disturbances and outbursts of anger. Therefore, a young person with TS may have a cocktail of symptoms.

“Teachers don’t understand the link between Tourette’s and all these other things – obsessive-compulsive stuff, attention issues and anger issues. They don’t grasp the connection and it’s a big connection”. 16-year-old

Tourette’s does not affect IQ and is not a learning disability.Tourette’s in school

TS does not affect IQ and is not a learning disability, but it can present barriers to learning. Tics tend to become most severe between the ages of ten and 12, so the transition into secondary education is a potentially difficult time. Our research focused on the experiences of students with TS in secondary school. The majority of young people we interviewed reported having difficulties concentrating in school.

“When the tics are really bad I can’t really concentrate on the work; I have to concentrate on keeping the tics in”.13-year-old.

Negative experiences with a small number of staff were, unfortunately, also a common experience. Students with forceful vocal tics can be seen as disruptive and may be told off or asked to stop tics. Young people do not find this helpful.

“He’s a clever boy and sometimes he is not able to produce very much at all but then other times he can do very well. Unfortunately we’ve had a few incidents with teachers telling him to stop ticcing or to ‘shut up’”.SENCO

TS can affect students in many different ways. Classwork, homework and examinations can all be adversely affected by tics. For example, hand or eye tics can interfere with writing, making it hard to complete work on time.

“She just couldn’t control the tics to do the homework… so we’d sit for three hours just to do a thirty minute piece of homework”. Mother

Some young people with TS will need support for learning. However, simply improving awareness and understanding of the condition in school can really help a student with TS to cope.     

Friends and peers

Most young people will have a good group of friends who understand TS and this group can help buffer against other social difficulties such as teasing. 

“He has some good friends, but when it comes to his peer group, they see him as a bit of a target because he stands out”. Father

Student with TS are vulnerable to ridicule, bullying and social exclusion but our research indicates that often this goes on unnoticed in schools.
Young people with TS also report having to deal with feelings of anxiety or feelings of anger in school, and these can also affect their relationships with others. Some students with TS may need social and/or emotional support in school.    

“He does get comments from other students and I know that they do mimic his noises, his tics – and that is something that we try to work with a lot now.”  Head of Year

Future prospects

Young people with TS worry about what will happen in the future, particularly about their employment prospects.

“I don’t want to be grown-up and still have Tourette’s ‘cause I’m scared that’ll stop me from getting a job or something”. 14-year-old

Positive work-related experiences in school can be very beneficial to young people with TS and their families.

“He had work experience and it went really, really well. I think that him and his parents were thinking is he ever going to be able to work, so work experience gave them a bit of hope”. SENCO   

How to help

TS is a complex condition and can affect young people in many different ways. Often, TS can affect students in ways that are not particularly noticeable in school.

“On the surface you wouldn’t think there was anything different about him; he’s good at hiding it. But I’ve learnt that it’s more than just tics and there is a lot of stuff going on in his head. So he may not always be fully engaged”. Teacher

Schools can find it difficult to understand which behaviours are involuntary tics and what may be more purposeful behaviours. 

“He sometimes makes animal sounds in lessons and then he gets in trouble. I need to explain that his noises are involuntary – he can’t help what he is doing”. Mother

Establishing good communication with the young person and the family can help schools to better support the student with TS:

• ask the student and the family about how TS affects him/her and how you can help
• find out what helped the student in his/her last school. Looking at how tics have been managed in the past can provide useful ideas about supporting the student
• it may be helpful to observe the student during the school day as tics can worsen in certain settings
• tics get worse when students are anxious, so good communication is crucial to explore concerns and create a sense of safety.

In the classroom:

• refrain from commenting on or responding visibly to tics whenever practical
• do not ask a student with TS not to tic
• consider appropriate behaviour management in light of the extent to which certain behaviours are not in the student’s control
• allow the student time out of lessons and a safe place to release tics, if needed
• be alert to potential mimicking, teasing and bullying
• be aware of any behavioural treatments or medication the student receives so that you can take account of any side effects and support the management strategies they have been taught.

Further information

Professor Georgina Jackson, lead investigator on the study discussed above, is Professor of Cognitive Neuropsychology, Division of Psychiatry and Applied Psychology, University of Nottingham. Dr Ruth Wadman, a Research Fellow in the department, carried out the research in schools and with families and young people:
www.nottingham.ac.uk

Advice and information on Tourette’s syndrome for teachers and parents is available from the charity Tourettes Action:
www.tourettes-action.org.uk

Source

Is there a Link Between Bipolar Disorder and Tourette's Syndrome?

Comorbidity is a common problem in dealing with any mental health problem. Bipolar disorder and Tourette's syndrome are not commonly comorbid conditions but existing cases are fascinating.

• Is there a link between bipolar disorder and tourettes? Tourette's syndrome and bipolar disorder are two very different disorders. Tourette's syndrome is a neurodevelopmental disorder characterised by the presence of multiple motor and one or more vocal and/or phonic tics. Symptoms must occur for over a year in order to receive a diagnosis.Tourette's syndrome usually begins around age six or seven and is a lifetime disorder. There is thought to be a prevalence rate of between 0.46% and 1.85% for those aged between five and 18. Bipolar disorder is an affective disorder characterised by episodes of mania or hypomania and depression. It can be recurrent or chronic.

  Comorbidity of all conditions is extremely common. Studies suggest that between 25% and 50% of people with one disorder have at least one comorbid condition. Comorbidity can be problematic as it hinders diagnosis, alters the course of a disorder and complicates treatment. Although all disorders present problems of comorbidity different disorders are more likely to be comorbid with certain disorders than others.

• Comorbidity of Bipolar Disorder

  Bipolar disorder is most commonly comorbid with substance use disorders and anxiety disorders. The epidemiologic catchment area (ECA) study found that 46% of the bipolar disorder patients included in the study reported alcohol abuse or dependence and 41% reported drug abuse or dependence. The national comorbidity survey (NCS) study found that 71% of bipolar disorder patients included the study reported at least one lifetime substance use disorder. 61.1% reported being alcohol depedent, 64.2% reported being alcohol abusers, 40.7% reported being drug dependent and 46.1% reported being drug abusers. With regards to anxiety disorders, an overwhelming 92% of bipolar disorder patients were found to have a comorbid anxiety disorder in the NCS. The ECA reported that 21% of patients had comorbid panic disorder and 21% had comorbid OCD.

Comorbidity of Tourette's Syndrome

Tourette's syndrome is most commonly comorbid with ADHD and obsessive-compulsive-disorder (OCD). In fact, a type of Tourette's named Tourette's Syndrome Plus has been suggested to describe Tourette's patients who also present with ADHD, OCD or self-harming behavior.The comorbidity rate between Tourette's and ADHD is between 60% and 80% and the disorders share an overlapping clinical spectrum. This knowledge has led to a suggestion that the disorders share a neurobiological basis. The reported comorbidity rate between Tourette's and OCD varies between 11% and 80%. The disorders share many similarities; they are both childhood onset lifelong conditions which are partly exacerbated by stress. It has been suggested that certain obsessive compulsive symptoms or behaviours represent another expression of Tourette's syndrome.

The Relationship Between Bipolar Disorder and Tourette's Syndrome

Affective disorders are also commonly comorbid with Tourette's syndrome. However, unipolar depression is far more commonly seen in cases of Tourette's syndrome than bipolar disorder. Some cases of comorbid Tourette's syndrome and bipolar disorder have been seen. Although the number of cases hinting at a link between bipolar disorder and tourettes are small, they are notable. It has been found that Tourette's syndrome plus patients (those with comorbid ADHD and/or OCD) with comorbid bipolar disorder present with peculiar features and are particularly difficult.

However, there is not thought to be a link between Tourette's syndrome and bipolar disorder per se but a link between bipolar disorder and another comorbid condition. OCD is the most likely condition to link with bipolar disorder to create these strange cases of Tourette's syndrome. Depression is the most common consequence of OCD and treatment of OCD with selective serotonin reuptake inhibitors (SSRI's) can precipitate mania. It will be interesting to follow research developments regarding the relationships and possible links among mental disorder as they are made available.

Source 

Tourette’s Syndrome: Comorbid Disorders

Tourette Syndrome (TS) often occurs with other related conditions (also called co-occurring conditions). These conditions can include:

 attention-deficit/hyperactivity disorder (ADHD) obsessive-compulsive disorder (OCD)
, Mood disorders such as depression and Bipolar Disorder and other behavioral or conduct problems,
  and non-OCD anxiety disorders

People with TS and related conditions can be at higher risk for learning, behavioral, and social problems.

The symptoms of other disorders can complicate the diagnosis and treatment of TS and create extra challenges for people with TS and their families, educators, and health professionals.

Findings from a national Centers for Disease Control and Prevention (CDC) study1 indicated that 79% of children who had been diagnosed with TS also had been diagnosed with at least one additional mental health, behavioral, or developmental condition based on parent report.

Among children with TS:

64% had ADHD.

43% had behavioral problems, such as oppositional defiant disorder (ODD) or conduct disorder (CD).

40% had anxiety problems.

36% had depression.

28% had a developmental delay

Because co-occurring conditions are so common among people with TS, it is important for doctors to assess every child with TS for other conditions and problems.

Source:http://www.cdc.gov/ncbddd/tourette/otherconcerns.html

http://www.schoolbehavior.com/disorders/tourettes-syndrome/tourettes-syndrome-comorbid-or-associated-disorders/

Bipolar Disorder

We all have our ups and downs, our "off" days and our "on" days, but if you're suffering from bipolar disorder, these peaks and valleys are more severe.The symptoms of bipolar disorder can affect your school performance and job,disrupt your daily life, and damage your relationships. And although bipolar disorder is treatable, many people don’t recognize the warning signs and get the help they need. Since bipolar disorder tends to worsen without treatment, it’s important to learn what the symptoms look like. Recognizing the problem is the first step to getting it under control.


Bipolar disorder,also known as manic–depressive disorder,bipolar affective disorder or manic depression, causes serious shifts in mood, energy, thinking, and behavior–from the highs of mania on one extreme, to the lows of depression on the other. More than just a fleeting good or bad mood, the cycles of bipolar disorder last for days, weeks, or months. And unlike ordinary mood swings, the mood changes of bipolar disorder are so intense that they interfere with your ability to function and the ability to carry out day-to-day tasks..

The elevated moods are clinically referred to as mania or, if milder, hypomania. Individuals who experience manic episodes also commonly experience depressive episodes, or symptoms, or a mixed state in which features of both mania and depression are present at the same time.These events are usually separated by periods of "normal" mood; but, in some individuals, depression and mania may rapidly alternate, which is known as rapid cycling. Extreme manic episodes can sometimes lead to such psychotic symptoms as delusions and hallucinations. The disorder has been subdivided into bipolar I, bipolar II, cyclothymia, and other types, based on the nature and severity of mood episodes experienced; the range is often described as the bipolar spectrum.


During a manic episode, a person might quit a job, charge up huge amounts to their credit cards, or feel rested after sleeping only a few hours. During a depressive episode, the same person might be too tired to get out of bed and full of self-loathing and hopelessness over being unemployed and in debt.

The causes of bipolar disorder is not completely understood, but it often runs in families. The first manic or depressive episode of bipolar disorder usually occurs in the teenage years or early adulthood. The symptoms can be subtle and confusing, so many people with bipolar disorder are overlooked or misdiagnosed–resulting in unnecessary suffering. But with proper treatment and support, you can lead a rich and fulfilling life.

Signs and Symptoms

Bipolar disorder can look very different in different people. The symptoms vary widely in their pattern, severity, and frequency. Some people are more prone to either mania or depression, while others alternate equally between the two types of episodes. Some have frequent mood disruptions, while others experience only a few over a lifetime.

There are four types of mood episodes in bipolar disorder:depression,mania, hypomania,and mixed episodes. Each type of bipolar disorder mood episode has a unique set of symptoms.

Depressive episode
Signs and symptoms of the depressive phase of bipolar disorder include persistent feelings of sadness, anxiety, guilt, anger, isolation, or hopelessness; disturbances in sleep and appetite; fatigue and loss of interest in usually enjoyable activities; problems concentrating; loneliness, self-loathing, apathy or indifference; depersonalization; loss of interest in sexual activity; shyness or social anxiety; irritability, chronic pain (with or without a known cause); lack of motivation; and morbid suicidal ideation.

In severe cases, the individual may become psychotic, a condition also known as severe bipolar depression with psychotic features. These symptoms include delusions or, less commonly, hallucinations, usually unpleasant. A major depressive episode persists for at least two weeks, and may continue for over six months if left untreated

Manic episode
In the manic phase of bipolar disorder, feelings of heightened energy, creativity, and euphoria are common. People experiencing a manic episode often talk a mile a minute, sleep very little, and are hyperactive. They may also feel like they’re all-powerful, invincible, or destined for greatness.

But while mania feels good at first, it has a tendency to spiral out of control. People often behave recklessly during a manic episode: gambling away savings, engaging in inappropriate sexual activity, or making foolish business investments, for example. They may also become angry, irritable, and aggressive–picking fights, lashing out when others don’t go along with their plans, and blaming anyone who criticizes their behavior. Some people even become delusional or start hearing voices.

HypoMania
Some people with bipolar disorder experience hypomania. During hypomanic episodes, a person may have increased energy and activity levels that are not as severe as typical mania, or he or she may have episodes that last less than a week and do not require emergency care. A person having a hypomanic episode may feel very good, be highly productive, and function well. This person may not feel that anything is wrong even as family and friends recognize the mood swings as possible bipolar disorder. Without proper treatment, however, people with hypomania may develop severe mania or depression.

Mixed Episode
A mixed state is a condition during which symptoms of mania and clinical depression occur simultaneously. Typical examples include tearfulness during a manic episode or racing thoughts during a depressive episode. Individuals may also feel incredibly frustrated in this state, since one may feel like a failure and at the same time have a flight of ideas. Mixed states are often the most dangerous period of mood disorders, during which substance abuse, panic disorder, suicidal thinking, and other complications increase greatly.

Other symptoms often include agitation, trouble sleeping, major changes in appetite, and suicide attempts. People in a mixed state may feel very sad or hopeless while feeling extremely energized.