The following is intended for teachers who must deal with a Tourette Syndrome child in the classroom, but the principles involved work equally well for the parent of a TS child at home.
O V E R V I E W
Techniques that Work
Techniques that DON'T Work
|* Set up an environment with low stimuli, much structure, routine and consistency.||* Allow the child to be over-stimulated. "Give him enough rope to hang himself!"|
|* When problems occur, do not react emotionally or get into a power struggle. Remember that the child is not thinking clearly. De-escalate the situation by removing the child. Provide positive choices. Change the scene. Redirect to a special job, etc.||* Force the "out of control" child to obey with powerful demands. Give him ultimatums such as a trip to the principle's office. Give him a "time-out" as punishment.|
|* Provide a quiet, safe place where the child can tic or exercise his TS symptoms when he needs to go. Let him be "in control" of this place, bring his school work, radio, etc.||* Send the TS child to a "time-out" room or chair until he can stop his tics, or for a "required" 15 minutes, half-hour, etc.|
|* Develop a behavior program with a strong cognitive element. Focus on a few specific behaviors. Make a contract with the child that gives him some "ownership." Build in flexibility and positive reinforcement.||* Use cost-response behavior modification. Punish the child if he is not performing up to expectations. Reward him only if he accomplishes predetermined goals.|
|* Create flexible expectations based on waxing and waning of symptoms. Always find something to praise or reward the child for.||* When behaviors wax, come down on the child hard with negative criticism. Point out how well he did last month! Make him feel shamed for not "keeping it up!"|
A calm, moderately structured classroom is best suited for the TS child. The goal is to build inhibitory control. The program should provide positive role modeling, much adult supervision, and much positive reinforcement and building of self-esteem. TS children typically feel more confident and secure and can perform better with adults than with their peers. Adults should be seen as regular partners in helping the children to develop coping skills and to build self-control. We also need to set realistic expectations for the children to develop these skills. These goals have to be seen in terms of years, not weeks or months. Experience has shown that 75% of TS children do improve during adolescence. The neurological system does some self-correcting or "catching up" during puberty. At around age 14 or 15 we begin to see age-appropriate self-control choices being made. Maturity is the key factor in behavioral improvement, which again may be different from the typical EBD child. The key ingredient to success is positive self-esteem.
Role-playing may be used as a consequence for inappropriate behavior with TS children. They often do not know appropriate responses, as they do not process incoming information in a normal way. Giving honest feedback about behavior, without value judgement or anger, may helf the children process what has happened. Using logical and natural consequences (without shame or blame) and working it through cognitively with the child builds awareness of responsibility in the child. Use problems as teaching opportunities!
"Time-out" needs to be seen as a privilege, not a punishment. It can be used to prevent escalating behavior. The child should have the choice to use his "office" or quiet place when he needs it. This builds personal power and responsibility for his disorder.
We have to work with the child to accept his Tourette Syndrome, and to learn to compensate for areas of difficulty. Obsessive-compulisve symptoms or ADD symptoms need to be addressed from the neurological perspective. POHI teachers (teachers of the Physically or Other Health Impaired) are best trained to address the needs of the TS child. They are trained with a neurological perspective, teaching children to cope with their lifelong disability. The EBD (Emotional Behavioral Disorder) philosophy, in contrast, tries to change behavior in children who are able to control it.
In summary, goals for the TS child with associated behavioral problems include building self-esteem, building a sense of personal power, building success, learning responsibility for behavior, learning self-management skills and developing lifetime coping skills. With proper medication, positive school programming and maturity, we will see successful results.