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Teaching Children with Tourette
The ERIC Clearinghouse on Disabilities and Gifted Education (ERIC EC)
ERIC EC Digest #E570
Author: Bernadette Knoblauch
Tourette Syndrome (TS) is a neurological disorder
characterized by repeated, involuntary body movements (tics)
such as blinking, twitching, shoulder shrugging, or leg jerking
and vocal sounds such as throat clearing or sniffing.
Symptoms typically appear before the age of 18 and the
condition occurs in all ethnic groups with males affected 3 to
4 times more often than females. Associated conditions can
include obsessivity, attentional problems, and impulsiveness.
Since many people with TS have yet to be diagnosed, there
are no absolute figures, but the official estimate by the
National Institutes of Health is that 100,000 Americans have
full-blown TS. Symptoms include:
- Multiple motor and one or more vocal tics at some time
during the illness, although not necessarily simultaneously
- The occurrence of tics many times a day (usually in bouts)
nearly every day or intermittently throughout a span of more than
- Periodic changes in the number, frequency, type, location,
and severity of the tics; for example, symptoms may disappear for
weeks or months at a time
- Onset before the age of 18.
Additional problems may include:
In many cases, medication can help control the symptoms,
but there may be side effects, some of which interfere with
cognitive processes. Stimulants such as Ritalin, Cylert, and
Dexedrine that are prescribed for ADHD may increase tics,
and their use is controversial. Other types of therapy may also
be helpful, including psychotherapy, behavior modification
therapy that can teach the substitution of one tic for another
that is more acceptable, and the use of relaxation techniques,
biofeedback, and excercise to reduce the stress that often
- Obsessions, which consist of repetitive unwanted or
- Compulsions and ritualistic behaviors. Examples include
touching an object with one hand after touching it with the
other hand to "even things up," repeatedly checking to see
that the flame on the stove is turned off, or repeating a
sentence many times until it "sounds right."
- Attention Deficit Disorder (ADD) with or without
Hyperactivity (or ADHD). Indications of ADHD may include:
- difficulty with concentration; failing to finish what is
started not listening; being easily distracted; often acting
before thinking; shifting constantly from one activity to
another; needing a great deal of supervision; and general
fidgeting. ADD without hyperactivity includes all of the above
symptoms except for the high level of activity.
- Learning disabilities, including reading and writing
difficulties, arithmetic disorders, and perceptual problems
- Difficulties with impulse control, which may occasionally
result in overly aggressive behaviors or socially inappropriate
acts. Defiant and angry behaviors can also occur.
Establishing the Proper Learning Environment
While school children with TS as a group have the same IQ
range as the general population, many may have some kind
of learning problem. That condition, combined with attention
deficits and the problems of dealing with frequent tics, often
call for special educational assistance. The use of tape
recorders, typewriters, or computers for reading and writing
problems, untimed exams (in a private room if vocal tics are
a problem), and permission to leave the classroom when tics
become overwhelming are often helpful.
The following are tips for dealing effectively with TS
symptoms in the classroom setting:
- Some movements and noises can be annoying or disruptive
to the class. Please remember that they are occurring
involuntarily, and do not react with anger or annoyance! This
requires patience but reprimanding a student with TS student is
like disciplining a student with cerebral palsy for being clumsy.
If the teacher is not tolerant, others in the class may feel free
to ridicule the child with TS.
- If some aspect of the child's tics affect the privacy or
safety of others (e.g., touching others), it is important to find
ways to work around the problem, but acceptance of the child is
critical even when the behaviors are unacceptable.
- Provide opportunities for short breaks out of the classroom.
Time in a private place to relax and release the tics can often
reduce symptoms in class. Private time may also enhance the
student's ability to focus on schoolwork, because energy will not
be used to suppress the tics.
- Allow the student to take tests in a private room, so energy
will not be expended on suppressing tics during a quiet time in
- If tics are particularly disruptive, consider eliminating
recitation in front of the class for a while. Oral reports might
be tape recorded, so those skills can be judged without the added
stress of standing before the class.
- Work with other students to help them understand the tics
and reduce ridicule and teasing. School counselors,
psychologists, and representatives from the local Tourette
Syndrome Association chapter can provide information and
appropriate audio-visual materials for students and
Accommodations for Writing Problems
Many children with TS also have visual-motor integration
problems. Therefore, tasks that require seeing material,
processing it, then writing it down are often difficult and time
consuming. This problem also affects copying from the board
or from a book, completing long assignments, neatness of
written work, and prescribed times for completion of written
work. Even very bright children with TS who have no trouble
grasping concepts may be unable to finish written work
because of visual-motor impairments. Sometimes it appears
as though the student is lazy or avoiding work, but in reality
the effort to record the work on paper may be overwhelming.
A number of accommodations can be made to help children
with writing difficulties succeed in the classroom:
- Modify written assignments by: having the child copy down
complete every other math problem; allowing the child to present
a taped report rather than a written one; allowing a parent to
record work or act as "secretary" so the child can dictate his
ideas to facilitate concept formation. It helps to focus on what
the child has mastered rather than the quantity of written work
- Since the student with visual-motor problems may not be able
to write quickly enough to get important information on paper,
assign a reliable "note-taking" buddy or "homework partner" who
can use carbon paper to make copies of notes and assignments. Be
sure to work this out discreetly, so the child with TS does not
feel different in yet another way.
- On tests with computer scoring sheets, allow the student to
write on the test booklet. This helps avoid poor grades caused
by the visual confusion that can occur when using the grid answer
- When possible, allow as much time as needed for taking tests.
- Students with visual-motor problems may be poor spellers.
Rather than penalizing for spelling errors, encourage
proof-reading and using a word processor with a spell checker.
- Students with TS seem to have special problems with written
math. Encourage the use of manipulatives in teaching math and the
use of a calculator to perform rote calculations. Using grid
paper with large boxes or turning regular lined paper sideways to
form columns can also help the child maintain straight columns
Accommodations for Language Problems
- Provide visual input as well as auditory whenever
possible. The student could receive written directions as well as
oral ones, or have a copy of a lecture outline to follow while
listening to instructions. Pictures and graphs that illustrate
the text are usually quite effective.
- Give directions one or two steps at a time. Ask the student
to repeat the instructions. Then have the student complete one
or two items and check with you to see that they have been done
- If you notice a student mumbling while working, suggest a
seat where he will not disturb others. Sometimes quietly
"reauditorizing" instructions or information to himself can help
a student grasp and remember the assignment.
- Children with TS may repeat their own words or those of
someone else. This may sound like stuttering but it actually
involves the utterance or words or whole phrases. Other
students may exploit this problem by whispering inappropriate
things so that the child with TS will involuntarily repeat them
and get into trouble. Be alert to this provocation.
This urge to repeat can be seen in reading and writing
activities. Students may be unable to complete work because they
"get stuck" rereading or rewriting words or phrases over and
over. This is called "looping." The following can be
- Have the student take a break or switch to other work.
- When reading, give the child a note card with a cut out
"window" that displays only one word at a time. The student
slides the window along while reading so the previous word
is covered and the chances of getting stuck are reduced.
- When writing, have the student use pencil or pen without an
eraser or allow the student to complete the work orally. Brief
reminders to move on may help.
Accommodations for Attention Problems
- Seat the child in front of the teacher for all
instruction and directions to minimize the visual distraction of
- Seat the child away from windows, doors, or other sources of
distraction, i.e., where reading groups meet.
- Give the student an "office," a quiet workplace. This could
be in a corner, the hall, or the library. This place should not
be used as a punishment, but rather a place the student can
choose to go to when focusing becomes more difficult.
- Have the student work in short intense periods with breaks to
run an errand or simply wiggle in the seat.
- Change tasks frequently. For example, complete five math
problems, then do some spelling, etc.
- Contract for work to be done in advance. For example,finish a
specific number of problems by a certain reasonable time. Short
assignments with frequent checks are more effective than two or
three sheets of independent work at one time.
- With younger children, simple gestures, such as a hand on the
student's shoulder, can be a helpful reminder to focus during
A Physician's Guide to the Diagnosis and Treatment of Tourette Syndrome, 3rd ed., Tourette
Syndrome Association, Inc., Bayside, NY. 1997.
Bronheim, Suzanne. (1994). An Educator's Guide to Tourette
Syndrome, Tourette Syndrome Association, Inc., Bayside,
Wertheim, Judy. (1994). Coping with Tourette Syndrome in
the Classroom, Revised. Tourette Syndrome Association,
Inc., Bayside, NY. ED385075.
This digest was adapted with permission from the Tourette
Syndrome Association, Inc.
ERIC Digests are in the public domain and may be freely
reproduced and disseminated, but please acknowledge your source. This publication
was prepared with funding from the U.S. Department of Education, Office of Educational
Research and Improvement, under Contract No. RI93002005. The opinions expressed in
this report do not necessarily reflect the positions or policies of OERI or the Department
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