"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

Tourette’s Disorder Symptoms

The essential features of Tourette’s Disorder are multiple motor tics and one or more vocal tics, expressing themselves many times a day. These may appear simultaneously or at different periods during the illness.

The anatomical location, number, frequency, complexity, and severity of the tics change over time. The tics typically involve the head and, frequently, other parts of the body, such as the torso and upper and lower limbs. The vocal tics include various words or sounds such as clicks, grunts, yelps, barks, sniffs, snorts, and coughs.

Coprolalia, a complex vocal tic involving the uttering of obscenities, is present in a few individuals (less than 10%) with this disorder.

Complex motor tics involving touching, squatting, deep knee bends, retracing steps, and twirling when walking may be present. In approximately one-half the individuals with this disorder, the first symptoms to appear are bouts of a single tic, most frequently eye blinking, less frequently tics involving another part of the face or the body. Initial symptoms can also include tongue protrusion, squatting, sniffing, hopping, skipping, throat clearing, stuttering, uttering sounds or words, and coprolalia. The other cases begin with multiple symptoms.

Specific Symptoms of Tourette’s Disorder

• Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.)
• The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.
• The disturbance causes marked distress or significant impairment in social, occupational, or other important areas of functioning.
• The onset is before age 18 years.
• The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington’s disease or postviral encephalitis).

Source

Brain stimulation gives tics to those without Tourette's

Some motor areas in the human cortex. The supplementary motor area is shown in pink. Image by: Paskari

For the first time, one of the tics that bedevil people with Tourette's has been induced in volunteers who don't themselves have the disorder, an experiment that might help us to understand and even treat the condition.

Jennifer Finis of Heinrich Heine University in Düsseldorf, Germany, and her colleagues suspected that a type of Tourette's tic called echophenomena, which involves mimicking other's movements, may be caused by over-excitation of the supplementary motor area (SMA) – a brain region involved in the initiation of movement.

To investigate further, her team used a non-invasive technique called repetitive transcranial magnetic stimulation (rTMS), which involves delivering brief but strong magnetic pulses to the scalp. By changing the frequency of rTMS, the stimulation could either inhibit or excite the SMA.

Thirty seconds after rTMS, 30 volunteers were shown video clips of someone making a spontaneous movement. Those who'd had their SMA excited were three times as likely to imitate the kind of behaviour they saw in the clips than those who'd had it suppressed.

"We suspect that this is a mechanism that might underlie tics more generally than just echophenomena in people with Tourette's syndrome," says Peter Enticott of Monash University in Melbourne, Australia, who worked on the study.

Recent studies have found mirror neurons in the human SMA (Current Biology, doi.org/dfp4j6). Mirror neurons are known to fire when we watch others perform actions. Could these SMA mirror neurons be involved in inducing echophenomena when the SMA is stimulated in volunteers without Tourette's?

"Yes, this could indeed provide an explanation," says Marcel Brass of Ghent University in Belgium, who studies echophenomena. "Alternatively, the SMA has also been related to internal control of action. So interfering with this region might make participants more susceptible to [echophenomena]."

The team is now planning to study whether inhibiting the SMA using rTMS may help reduce symptoms in people with Tourette's.

Matthias Wittfoth of the Hannover Medical School in Germany, says that he sees the findings as "a valuable first step towards the understanding of specific symptoms of people suffering from Tourette's syndrome".

But he advises caution while interpreting the results. He points out that the researchers did not use computer-assisted technology to deliver the rTMS signals precisely to the SMA, something that the researchers themselves acknowledge. "We cannot be sure that the same brain areas were stimulated in each participant," says Wittfoth. Moreover, of the 30 individuals who participated in the experiment, only seven were males. "Tourette's syndrome affects proportionally more men, thus their experimental group including mostly women does not reflect this," says Wittfoth.

Journal reference: Cortex, doi.org/jmj

Read More

Grow Cannabis Indoors