Difficulty consistently inhibiting thoughts and/or actions. Inappropriate statements or behaviors result from the student’s inability to consistently apply “mental brakes” – the child can’t stop himself consistently from expressing behaviors, thoughts, or displaying actions that someone else might be able to control. Behaviors might seem to be excessive silliness, being sassy, free-associative comments, emotional outbursts, contextual swearing, blurting out, inappropriate comments, explosive anger, and oppositional defiance.
For those with dysinhibition, a sign saying “Don’t Touch, Wet Paint” is an invitation to touch the paint. Obeying the sign means inhibiting the very behavior suggested by the sign. Inhibiting behaviors is challenging for all children, but presents a far greater challenge for students with TS due to their impulsivity and inconsistent ability to apply their mental brakes. This is not purposeful disobedience,
but the inconsistent dysfunction of a brain affected by the chemical imbalances that cause TS.
A second grader’s teachers had a difficult time believing that every time the child said something inappropriate or acted in an impulsive manner that it was a “tic”. Tourette Syndrome is more than tics, and many of a student’s ‘behaviors’ can be “symptoms” rather than tics. Verbal and physical tics are not the only symptoms of TS. Many students, whether they have severe or mild physical and vocal “tics”, also have significant difficulty with invisible (but extremely disruptive) dysinhibition. When a student is told that his turn on the computer is over and he makes an inappropriate remark, it may be due to his having TS. In these instances, it is best to use ‘planned ignorance’, but then include counseling support to help him recognize that his ‘brakes’ don’t always work well. Then, teach him strategies that allow a more appropriate response. Since his actions are due to a neurological disorder and are not purposeful, this may require a great deal of practice and patience.
2. OPPOSITIONAL BEHAVIORS
Many students with TS have a secondary diagnosis of Oppositional Defiant Disorder (ODD). Dr. Ross Greene refers to these children as being chronically inflexible and will typically display ODD behavior. The support team must look for the underlying difficulties such as OCD, ADHD, tics, processing difficulties, written language deficits, and sensory issues which prevent the child from expressing his needs or responding appropriately. For example, a student who becomes oppositional only during a task requiring writing may be communicating through his behavior that he is not capable of writing. If a student displays defiant behavior in a particular setting, this may indicate that he is somehow overwhelmed in this setting.. Dr. Ross Greene’s books “The Explosive Child” and “Lost at School” are excellent resources.
3. IMMATURE BEHAVIORS
Does the student get along well with peers? Does he have friends? Are his social skills on the same level as those of his peer group?
Frequently students with TS act in an immature fashion and display behaviors that are typical of much younger students, even though they may have more advanced academic abilities. Dealing with ongoing frustration or anxiety may have caused delays in developing skills necessary to inhibit inappropriate behaviors. The child then displays behaviors that are not age appropriate, which are often perceived by adults as being purposeful. It’s also not unusual for the child to get along with either younger children or with adults better than with children their own age. Immature behaviors are frequently seen in children with TS, and should be perceived as a component of the disability, and not manipulative and purposeful misbehavior.
4. REFUSING SUPPORTS AND ACCOMMODATIONS
A student may refuse supports and accommodations because he doesn’t want to be singled out as being different.
Guidance, support and patience by parents and educators may be able to overcome the child’s resistance. A positive and proactive plan should include discussions with the student emphasizing that “fair is not always equal, and equal is not always fair.” Because the child requires different supports, it’s not “bad” or “weird” but simply “fair” for his situation.
5. OBSESSIVE COMPULSIVE BEHAVIORS
Obsessive-Compulsive Behaviors are characterized by recurrent, unwanted thoughts and images (obsessions), and/or repetitive behaviors (compulsions) which the person hopes will prevent the obsessive thoughts or make them stop. Performing the “rituals” provides only temporary relief and not performing them significantly increases anxiety.
OCD has been shown to be a common related disorder for people with TS. Providing appropriate educational supports is significantly complicated for students with TS and OCD because it is often
difficult to tell the difference between complex tics and obsessive-compulsive behaviors.
Students may experience a wide variety of difficulties due to OCD including, but not limited to, rigid thinking, perfection, difficult transitions, poor social interactions, inability to respond in an appropriate manner, beginning and/or completing work, etc. Unrecognized symptoms often results in punishment, an increase in the student’s anxiety, drop in grades and behaviors which are interpreted
to be opposition defiant, disrespectful and/or lazy.
A small percentage of children with TS have outbursts of uncontrollable anger often referred toin the TS community as “rage, as a symptom of TS. Generally, but not always, this is displayed in the home setting more frequently than at school. Usually the child or adult might yell, throw things, perhaps call names, all in a manner that seems unprecipitated. This symptom is neither the fault of the child nor the parents. As it can seem dramatic, many parents blame themselves. In certain school or other systems, they may also be blamed by professionals, friends and family. The matter merits further
exploration by school teams, teachers and families. The R.A.G.E. (Repeated Anger Generated Episodes) brochure (Publication M-357, or downloadable publication M-357DD) available for a nominal charge in TAA’s online store is an excellent resource for professionals and for parents with children with these symptoms. It will help them understand that there’s no one to blame, and which strategies to employ for children who have neurologically based rage. Sometimes a change in routine or expectation of an event for a child who is inflexible may set off an episode. In fact, experience shows that typical interventions (including negative consequences) only serve to increase these rage episodes. It is critically important that adults in the life of a child with TS become aware of what reduces or increases the child’s explosive responses. In addition, children who are affected by the devastating symptom of neurological rage need trusted adults who can provide care with flexibility and calmness.
7. ‘FIGHT OR FLIGHT’
In general, students with TS have a heightened response to their environment. A teacher’s volatile manner may cause the student to become overwhelmed – which may escalate into a ‘flight or fight’ response by the student with TS. It’s important that the student be placed with teachers who can remain calm in a difficult situation.
8. DIFFICULTIES WITH TRANSITIONS
Very often individuals with TS have problems with transitions – they are internally driven to complete the current task or stay in the current environment and not move on. For the student with TS and additional anxiety caused by obsessive-compulsive behaviors, transition difficulties can be exacerbated. Transition strategies can be written into the IEP for teachers to follow. If a strategy hasn’t yet been established, the current teacher may need to experiment with different ways of preparing the student for approaching transitions.
9. USE OF INAPPROPRIATE LANGUAGE (Coprolalia)
Coprolalia is a symptom of Tourette Syndrome characterized by unwelcome, unwanted and uncontrollable utterances of words or phrases that are not appropriate. Commonly, people come to know coprolalia as the “swearing tic”. Certainly this symptom is mocked in moves and other media.
Many people believe that a person must have coprolalia in order to have a diagnosis of Tourette Syndrome. In fact, only a small minority have this symptom. Ironically, while this is the most recognizable symptom, it’s also the symptom that is most misunderstood. It’s the symptom most responsible for students being removed from class, receiving detention or suspension, and being moved to a more restrictive environment. Coprolalia is any socially inappropriate sound, word, phrase or group of words. A limitless variety of sounds, simple phrases or words can also be coprolalia. Examples: ‘elephant’, ‘toys’, ‘coffee’, ‘shut up’, ‘jerk’, ‘donkeys have knees’ could be examples of coprolalia.
A common misunderstanding is that in order for ‘inappropriate words or sounds’ to be a symptom of TS, they must be said “out of the blue” and must be repetitive in nature. This leads to the mistaken belief that if a student swears once and/or at an “appropriate” time, then it is not due to TS and therefore deserves punishment. Coprolalia can be one word, a string of words, or a phrase, said many times or said once but repeated over time. However, TS symptoms, including coprolalia are different for every individual, inconsistent, change periodically, wax and wane and are increased by stress.
The inconsistency of a child with TS to inhibit the use of inappropriate behaviors and statements adds to the difficulty of understanding the symptoms of this disorder. For example:
A polite 4th grade girl was being punished for being disrespectful to her teacher. The teacher reported that every time she said that the class was going to have a test or homework, the girl would say ‘shut up’. There is no denying that this was inappropriate. However, it is also a symptom of the TS. It is easy to recognize that when the teacher told the class there was going to be homework or a test, most likely there were other students who were thinking ‘shut up’ ― or worse. These students were able to stop from expressing these thoughts because they didn’t have affected brain processes which reduced their ability to inhibit saying what they were thinking. The little girl with TS was not able to inhibit blurting out inappropriate statements that appeared to be purposeful. Stress makes symptoms worse which increases her inability to inhibit in a stressful or undesirable situation. Stress increases the likelihood of symptoms of dysinhibition and decreases the ability to inhibit ‘inappropriate’ behaviors and statements. Difficulty inhibiting verbal expressions may result in the occurrence of the more easily recognized swearing vocal tic for a small percentage of students with TS.