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2 Look at these links Self-reports: “I was devastated when I found out I had TS. I thought I was going to be a normal boy. But I’m not. My life is awful. I feel like I’m missing out on a lot of things because of my tics. I will feel a lot better if my tics go. If they don’t I will learn to put up with them.” (Neil, 9yrs) “My teacher treats me like an angel and manages my TS really well. The other students try to be understanding as my teacher has told them all about TS.” (Neil, 9yrs) “I used to get asked why I blinked all the time and everyone used to get angry at me because I couldn’t help looking at them and I always get harassed.” Lyle who is 9 years has Aspergerg and TS, and says he feels like he’s in prison when he is at school.

3 Idea Category Tourette Syndrome (TS) is now listed as a disability under the category of Other Health Impaired (OHI).

4 Motor Characteristics MOST develop: 1.eye tic first 2.facial tics or involuntary sounds 3.others within weeks or months common examples: head jerks, grimaces, hand-to- face movements Symptoms can: 1.change over time 2.vary (frequency, type, location, or intensity) 3.increase in intensity during early adolescence (12-15 years) 4.improve in less extreme cases during adulthood

5 Communication Stuttering Coprolalia (fewer than 15% have this) –Occurs in late childhood –Most disruptive and disturbing (Jay, 2000)

6 Social Emotional Characteristics The social and emotional difficulties that accompany TS are more problematic in day-to-day adaptations than are the motor and phonic tics (Carter et al., 2000). Children are teased and made to feel stupid, different and unwanted. Peers negative responses to tics can cause anxiety, which in turn increase tics and generate self-doubt. Adolescence is a period with strong emphasis on physical attractiveness. TS results in greater psychopathology during this period than any other (Chang et al., 2004) Children also report uncomfortable, nervous, weird feelings (fear, disgust, doubt) or like they are going to explode before an onset of tics (Walter & Carter, 1997). Overall there is a higher risk of: 1.poor peer relationships 2.no relationships 3.withdrawn or aggressive social behavior

7 Academic Accommodations General Principals: 1.Tics increase as a function of stress and calling attention to tics increases them. 2. Tics decrease with relaxation or when focusing on an absorbing task (Shannon, 2003).

Accommodations 1.Model tolerance and do not allow teasing by peers 2.Try various seating arrangements (Wilson, Jeni. Shrimpton, Bradely. 2003). Allow: 1.short breaks (e.g., break long assignments into smaller parts) 2.movement around the room or outside the room (e.g., a fictitious note to the office) 3.access to a private room with a bean bag chair--have a private signal 4.exams in a private room for tension and tic release and allow more time 5.child to tape oral presentations & reports (Lue, 2001) 8

9 INTERVENTIONS Pharmacological interventions increase success (Clarke et al., 2001). 1.Anti-tic drugs block the activity of the neurotransmitter dopamine. 2.Anti-OCD drugs help to restore the brain chemical serotonin, which reduces unwanted, thoughts. (Many people choose tics over the medications because of side effects, which are sleepy, gain weight. In addition no medication has been found that eliminates tics completely.)

10 Functional Analysis of a Student with Tourette Syndrome and a Mild Intellectual Disability

years old 2. Originally diagnosed with ADHD and still carries that label 3. Diagnosed with Tourette’s in early elementary school. Showed noticeable tics such as eye blinking and barking like a dog. 4. Diagnosed in the 5 th grade as a child with a mild mental disability 5. In his school work, Chris always completes any activity or assignment given to him. Almost compulsive about completing assignments 6. Chris does not interact with his peers. Seeks adult interaction

12 1. Enjoys helping others 2. Takes initiative in completing tasks 3. Good memory 4. Good attention to details 5. Has a strong desire to learn and do what is right

13 1. Difficulty with peer relationships 2. Poor fine motor skills including handwriting 3. Struggles with math and language arts

14 1.Random talking that is unrelated to subject or task and includes asking questions about upcoming events 2.Pacing 3.Withdrawn and Pouting 4.Yelling

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16 1.Changes in students daily schedule: 2-hr. school delays, lack of aide in class, early dismissals, late bus arrivals. 2. Unstructured activities (breaks and times when waiting to load buses) 3.Structured but stressful activities: working on art project, visit to the high school, academic work in the resource room

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18 Antecedent that caused the most behavior Changes in Students Daily Schedule46% Behaviors that were seen the most Random talking/asking questions58% Pacing21% Payoffs earned the most Get self-determination (predictability)85%

19 Diagnosis of Tourette’s? Chris’ diagnosis of Tourette’s syndrome is correct. He meets all of the criteria for a diagnosis a. Although his tics have dissipated, he still shows motor tics including eye blinking and head jerking. b. Research shows that it is common for children to see a reduction in the tics as they get older. Chris’ onset was in his early elementary years. c. Chris shows TS, which includes social and academic impairments

20 Diagnosis of ADHD? Although ADHD can be a comorbid condition of TS, we must first determine whether his co-occurring learning disabilities and mild mental retardation might not better explain his inattentive behavior. Follow-up: a. Now that he is given schoolwork based on his level of reading, language, and math, Chris is able to listen and sustain attention during his academics periods. b. He remains in his seat during class, never runs about the room, does not blurt out answers, and is able to wait his turn. Conclusion: Chris is not ADHD; he has a mild intellectual disability

21 Diagnosis of OCD? Chris’s OCD is a comorbid condition of the TS Chris’ obsessions and compulsions have to do with checking, ordering, repeating, and getting things ‘just right’ rather than trivial concerns with contamination, something bad happening, or being neat and clean. Chris’s obsessive/compulsive behaviors are connected to an event in a realistic way and help him to neutralize the unpredictability of the event.

22 To address the child’s need for predictability and self-determination, teachers must provide: 1.A stable daily routine/schedule 2.Advance warning of any changes 3.Opportunities to ask questions as this is his way to reassure himself about a situation that is making him feel stressed and anxious 4.An escape, if needed, to regain control Accommodations

23 Interventions To address the Chris’ need for self-determination, Chris must learn: 1. That when he cannot regain control, to be patient and ask for short breaks 2.To use scripts to interact with his peers. (For example, Chris does not know how to initiate a conversation; he only uses statements and needs to learn to ask questions.)

24 Autism Spectrum Disorders

25 Autism Spectrum

26 Asperger Syndrome

27 Emotional Characteristics Look at this linkthis link 1.Lack of empathy 2.Low emotional maturity & do not mature socially as they age (Myles)

28 Summary: Verbal vs. Nonverbal Non-Verbal Lack of empathy Little or no ability to form friendships; naïve, inappropriate one-sided interactions Low emotional maturity & do not mature socially as they age Poor non-verbal communication Intense absorption w/ certain subjects Clumsy and ill coordinated movements Odd postures (Tony Attwood) Verbal Monotone, repetitive speech Good structural language skills Poor pragmatic everyday communication.

29 Academic Characteristics Often, academic progress in the early grades is area of relative strength; for example, rote reading and calculation skills are usually quite good, and many children can obtain “high levels of factual information” Difficulties: 1.shifting attention 2.multitasking 3.planning/organizing 4.applying information and skills across settings 5.drawing inferences and applying knowledge 6.pencil skills 7.reading comprehension 8.written language and drawing tasks can cause anxiety

30 Accommodations Provide a safe place so the child can retreat when s/he becomes over stimulated or has difficulty adjusting to a new activity. 1.Establish a schedule early on, and be consistent with it. Provide a visual representation of the daily schedule. 2.Write notes in advance for the child if the schedule is going to change for a special event. 1.Provide visual cue cards to use during instruction and teaching. 2.Set clear expectations and boundaries, and post them on the wall. 3.Provide verbal and written instructions for the child. 3.Ask questions to check the child’s understanding of the instructions. 4.Use a timer to limit perseveration/ echolalia/ singing. 5.Allow the child to earn “free time” in the child’s chosen area of interest, such as art or computers 6.Teach other children how to interact appropriately with the child with Asperger Syndrome in both academic and social settings.

31 Savant Abilities Savants are rare and have spectacular islands of brilliance, which stand in marked contrast to their disability 1.10% prevalence in autism 2.1% prevalence in those who are not autistic but had intellectual disabilities or major mental illness)

32 Cognitive Characteristics Generally they excel in one of the following areas: 1.Mathematical calculations 2.Memory feats 3.Artistic abilities 4.Musical abilities

33 Kim Peek The real Rain Man

34 Alonzo Clemons Alonzo is a savant. He is known for his sculptures.

35 Alonzo can see a fleeting image on a television screen of any animal, and in less than 20 minutes sculpt a perfect replica of that animal in three- dimensional accuracy. The wax animal is correct in each and every detail -- every fiber and muscle.

36 Richard Wawro Known world-wide, for his detailed drawings using wax oil crayons as his only medium.