president, tsa of greater ny state, inc. how do i know

Accommodations and Techniques

for Working With Students with

Tourette Syndrome

Susan Conners

Education Specialist, Author

President, TSA of Greater NY State, Inc.

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2 Accommodations are

intended to:

Level the playing field for students with

disabilities

Address all academic, developmental, and

functional needs of the child.



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3 How do I know that my child

might need accommodations?

• A decline in grades

• Increased frustration

• Decrease in the child's self esteem

• Social difficulties

• A negative attitude about school

• School avoidance/phobia

• Behavioral issues at school

• Increase in TS symptoms due to stress or anxiety

• Difficulties at home that are a direct result of school issues



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What are my options for services

and/or accommodations?

Americans With Disabilities Act (ADA)

• Levels the playing field for students with disabilities by providing educational accommodations through a 504 Accommodation Plan (Named after section 504 of the ADA that deals with education)

• Section 504 of the Rehabilitation Act of 1973 prohibits discrimination based on disability in programs or activities receiving federal financial assistance.

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5 Individuals With Disabilities

Education Act (IDEA)

• Provides an Individualized Education Plan (IEP) -

Accommodations plus direct services of a special education

teacher or other service providers (OT, Speech, Counseling, etc.)

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6 See Presentation from January

15 Entitled 504 Accommodation

Plan Versus an IEP

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ALWAYS REMEMBER

There is a fine line between accommodating and

enabling

Accommodations cannot modify the curriculum





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8 What areas may need to be addressed by accommodations for a child with TS??

• Interfering tics

• Interfering obsessions and compulsions

• Dysgraphia (Handwriting Difficulties)

• Attention Deficits

• Short term memory deficits

• Social skills deficits

• Processing deficits

• Hyperactivity

• Behavioral issues

• Executive Dysfunction (Organizational Difficulties)



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9 Educating the Staff

Teachers need to understand all of the

complexities of TS if you want them to effectively

accommodate your child. It is essential that a 504

Plan or and IEP contain the accommodation that a

mandatory in service for all staff working with the

child be done every year at the beginning of the

school year.



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Accommodations for Tics

and Obsessions

Tics and obsessions can very much interfere with a

child’s ability to concentrate, write, read, etc. and can

be the source of great frustration for the child.

Student has a head-shaking tic that happens every few seconds that interferes with his/her ability to stay focused on the exam. It is also a tic that slows down the entire test taking process.



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11

Student has an eye blinking tic and other facial tics that make it difficult to keep his/her place and not only slows down the test taking process, but also makes it difficult to transfer answers from the test booklet to the scantronsheet with accuracy.

Student has a tic that makes him/her twist both wrists over and over again several times a minute which makes it impossible for him/her to hold a pencil and write fluidly.

Other students may tease, make fun of and imitate the tics because they don’t understand them.

Student has an obsession to count every word in every line that he/she reads. This makes test taking very slow and laborious.

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12

o Simple Motor TicsEye blinking, grimacing, nose

twitching, leg movements, shoulder

shrugs, arm and head jerks, etc.

o Complex Motor TicsHopping, clapping, throwing,

touching (self, others, objects),

funny expressions, sticking out the

tongue, kissing, pinching, tearing

paper or books, echopraxia

(repeating actions), copropraxia

(obscene gestures)

Motor Tics

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o Simple Vocal TicsWhistling, coughing, sniffling, screeching,

animal noises, grunting, throat clearing

o Complex Vocal TicsLinguistically meaningful utterances:

o Speech AtypicalitiesUnusual rhythms, tone, accents,

intensity of speech, stuttering

Vocal Tics

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14

Echolalia - involuntary repetition of someone

else’s words

Palilalia - involuntary repetition of one’s own

words

Coprolalia - involuntary utterance of curse words

or other socially inappropriate phrases or

sentences. Can seem very purposeful and

directed.

NOTE: Coprolalia is NOT necessary for a diagnosis of TS

OTHER UNUSUAL TYPES OF

VOCAL TICS

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15

Stress

Anxiety

Excitement

Fatigue

Illness

Environmental Factors

That Can Worsen TS Symptoms

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SUPPRESSION OF SYMPTOMS

Results in:

Worsening of symptoms

Inability to concentrate on task at hand

Shutting down

Fatigue and/or worsening of symptoms at end of

day

Often explosion of symptoms at home

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17

1 Need for symmetry and perfectionism

Neatness

Counting

Checking things over and over

Constant doubt or worrying

Germ obsessions

Transition Difficulties

Ritualistic behavior

Obsessive Sense of Justice

32

COMMON OBSESSIONS

AND COMPULSIONS

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18 MANAGING OCD IN THE

CLASSROOMNeurological Disorder

Driven, Perfectionistic,

Need to complete

Difficulty transitioning

Mental brakes get stuck

Assess the nature of the obsession and then brainstorm

possible solutions with the other teachers and the parents

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Accommodations for Tics and

Obsessions

Tests taken in a separate location with time limits

waived or extended.

Educate the other students who come into contact

with the child with TS. A peer in-service entitled

“Educating Classmates about TS.” is available. An

advocate from the local TSA chapter may also be

helpful.

Provide a refuge where the student may go to calm

down, release tics or obsessions. Nurse’s Office,

School Psychologist’s Office, etc.

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20 Give frequent breaks out of the classroom to release tics in a less

embarrassing environment: The bathroom, the drinking fountain, a real or

made-up errand to run.

Give the child his/her own laminated pass for a quick exit from

class when a quick break is needed.

Seat the student with TS in an area where his/her tics will be less

noticeable and embarrassing.

If tics are socially inappropriate (spitting, swearing, touching people

inappropriately), it may be necessary to brainstorm possible solutions;

e.g., a spitting tic could be resolved by allowing the child to chew gum or

have a hard candy.

Try scheduling core academics toward the beginning of the day because

tics tend to worsen when a child is tired.

SKYPE / Steno Mask

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21 Communicate with parents frequently and report

worsening tics or the development of new ones.

The use of technology is an invaluable way to

accommodate not only tics but also obsessions and

several other associated disorders.

Tablets, computers, readers, voice activated software can

be extremely helpful and can make the child much more

independent.



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Examples of particular obsessions and

compulsions and creative steps that

were taken toward a solution

A student with an obsession to count words on every line she

reads was provided with Books On Tape.

A student with a germ obsession was encouraged to carry

antiseptic hand wipes in his pocket and clean his hands

whenever he felt “contaminated.”

A student who couldn’t write without a perfectly sharpened pencil

and was always at the pencil sharpener getting the perfect point

was given a mechanical pencil.

A student with a symmetry obsession was constantly erasing his

work and doing it over because it “didn’t look right.” Allowing

him to use a computer for his work alleviated his problem.



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23 ANXIETY

Anxiety is often a difficulty for students with OCD.

You can’t always see anxiety

The school must be a place where it is safe to make

mistakes.

Punishing or ridiculing only serves to increase anxiety and

the difficulties associated with it.

Creative scheduling / partial day instruction

Change the environment

Distraction can often break an obsession and decrease

anxiety.



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24

Neurological disorder often associated with TS

Children with ADHD are often: Inattentive

Impulsive

Hyperactive

Disorganized

Socially Immature

ATTENTION DEFICIT HYPERACTIVITY

DISORDER (ADHD)

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Accommodations for ADHD /

Executive Dysfunction Disorder

Provide preferential seating in the classroom

Provide a quiet place in the classroom for

student to work independently

Allow for freedom of movement—a quick trip

to the bathroom, drinking fountain, an errand

to run

Use visual cues in addition to auditory ones.



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26

Break down assignments.

— Give one paper at a time rather than several.

— Break down all long-range assignments and projects into shorter,

more manageable parts e.g., Part 1 may be due in two days rather than

the entire project in three weeks.

Reduce the length of homework assignments—quality, not quantity is

the important thing. Give extra time on homework and projects.

Have teacher verify that assignment was written down

correctly in agenda

Use cell phone to take a picture of assignments written on

board and written notes

Allow student to leave the last class a little early in order to

pack up and organize materials.

Provide an extra set of textbooks for use at home.

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27 ADHD Accommodations

Cont’d

Color code textbook covers, notebooks, folders, etc.

Keep a supply of paper, pens, and pencils to lend students

who forget or lose such things.

Don’t penalize a student who forgets or loses basic

classroom supplies.

To make sure you get lent supplies back at the end of class,

take something of the student’s as hostage, e.g. a shoe.

Teach children basic study skills and organizational

strategies: How to sequence and break down tasks into

more manageable segments, how to prioritize for better time

management.

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Don’t assume that if the student is not sitting perfectly still and

looking you in the eye that he/she is not paying attention—the

opposite is usually true of children with ADHD.

Allow the student some sort of motor activity during times of intense

concentration; squeezing a soft ball, pencil tapping on something

soft (a sponge), foot tapping (without shoes), body-rocking, or

doodling.

When giving directions, always have the student repeat

them back to be sure they were understood

Structure assignments; Make lists that can be crossed off

when the student has finished, for longer assignments,

provide frequent breaks.

Give student a “word bank” to select from on fill-in-the-

blank tests.

Establish a method of daily communication between home

and school through an agenda book, email, etc.

Assign a “homework buddy” for the child to call on for help

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29

Students with Executive Dysfunction Disorder do much better with a

three-ring binder or trapper keeper to keep all folders together; this

can be zipped to ensure that materials are not lost.

Organize the folders in the binder by each day’s class schedule

Keep a zippered, three-hole-punched pouch in the binder and fill it

with lots of extra supplies. Check the pouch frequently and

replenish when necessary.

Weekly folder and locker clean out may be necessary and

can be part of resource room time

Email assignments in to the teacher as soon as they are

complete so they don’t get lost

Set up a calendar on a tablet / laptop / cell phone, etc. to keep

the student more organized





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30 Understanding and

Accommodating Dysgraphia

This is a non-verbal learning disability. Characteristics could include:

Slow and laborious writing

Hand and finger cramping

Sloppy handwriting – uneven spacing – irregular margins, inconsistent lettering

Inability to copy correctly from book to paper or chalkboard to paper (Visual Motor)

Difficulty with written expression - getting thoughts onto paper

Difficulty with punctuation and capitalization

Interfering tics, OCD and sensory issues

Difficulty with note-taking

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Accommodating Dysgraphia

o Have the child evaluated by an Occupational Therapist

o Use a scribe

o Have the child use a computer

o Provide OT services

o Provide notes

o Computer software that can be helpful

o Voice activated software

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32 Dysgraphia Cont’d

Tests can be given orally.

Waive or ease time limits on tests.

Standardized test answers can be written directly in the test booklet and

transferred onto the test booklet by the teacher or an aide.

Verify that all homework assignment directions are copied accurately.

Provide graph paper to help line up math problems or allow the child to

turn lined paper sideways.

Allow student to take a picture of assignments and notes on board

The use of a calculator for math can circumvent visual-motor difficulties.

Allow extra time for written work.

Scan homework and tests into a computer.

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33 Short Term Memory Deficits

o Use of a calculator

o Provide student with a word bank

o Test in small chunks

o Use of flash cards



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Behavioral Issues

Behavioral issues are most often the result of one or more of

the neurological issues:

Getting stuck / OCD

Anxiety

Frustration due to interfering tics and obsessions

Sensory overload

Being teased or bullied

It is critical that we first identify the trigger for the

behavior before the problem can be solved and the

behavior eradicated.





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35 “It’s your explanation of a

behavior that leads directly to

how you respond to it”

Dr. Ross Greene, Ph. D.

IDEA 2004 requires that an FBA (Functional

Behavioral Assessment) be conducted and a positive

behavior intervention plan be developed whenever the

behavior of a student interferes with the ability of that

student or other students to learn.

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36

Definition of FBA

An FBA is the process of determining why an

individual engages in challenging behaviors and

how the behavior relates to the environment.

I strongly recommend The Functional Behavioral

Assessment Workbook from TSA, Inc.

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Behavioral Accommodations

Allow the child to leave the classroom 2 to 3 minutes early to avoid

crowded hallways. Let a friend go with them.

Have a teacher’s aide nearby in the cafeteria to prevent confrontations.

An alternative eating site with a friend is sometimes ideal.

Seat the child up front on the school bus and educate the bus driver.

Make sure that the child is in the classroom of a structured, but flexible

teacher.

Help the child learn to remove himself/herself from the room before a

situation escalates out of control and then reward the child for doing so.

Give the child a laminated pass that will allow him to leave class for a few

minutes when he feels that a situation is escalating out of control.

Seating up front by the door will facilitate this “exit.”


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38

Behavior Cont’d

Counseling can help students to verbalize feelings prior to losing control.

Provide a refuge or safe place where the student can go to regain control.

Avoid power struggles—they escalate a bad situation.

Use humor to defuse and de-escalate the tension and as a distraction to

the situation.

Difficult behaviors may be the only way a student has to demonstrate that

there is an unresolved problem. Ask yourself if any of the following is true:

— Is the task beyond the student’s capabilities?

— Does he understand the directions?

— Does he require support with writing?

— Is the environment overwhelming?



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39

14Education, Research and Support

ÒWe must see the child

as in trouble, not the

cause of trouble.Ó

C.H.A.D.D. Educators ManualC.H.A.D.D. Educators Manual

Dr. Russell BarkleyDr. Russell Barkley

Perspective

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Sensory Processing Deficits

Constant bombardment of sensory input is neither

perceived or interpreted correctly

Have self abusive behaviors

Pick at skin, etc.

Repeatedly touch surfaces or objects that are soothing

Crave rocking or strong sensory input

Sensitive to sudden touch, the feel of certain fabrics

Need to have tags cut out of clothes or socks without seams

Very sensitive to bright or florescent lights

Can’t tolerate the texture of certain foods in their mouth

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41 Sensory Cont’d

Very sensitive to certain smells

Over reactive to certain sounds

Can experience “sensory tics” e.g. picking at scabs, biting nails, scratching oneself, self abusive behaviors

Melt down in noisy chaotic environments

Can affect any of the senses and cause great

anxiety for the child and result in

a “melt-down”.

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42 What Can Be Done About

Sensory Processing Disorder?

Sensory Evaluation by an Occupational Therapist (OT)

Sensory Therapy Techniques recommended by an OT

Environmental Modifications

Leave class 3-4 minutes early to avoid crowded

hallways

Avoid loud, chaotic environments

Find alternate place to eat lunch with a few friends

Use a headset to avoid auditory overload and

distractibility



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SOCIAL SKILLS DEFICITS

Children with social skills deficits will have difficulty:

Interacting with peers

Understanding social "rules“

Establishing eye contact

Understanding social nuances and picking up on

social cues

Perceiving the feelings of others QuickTime™ and a decompressor



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44 Children With Social Skills

Deficits Will Tend To:

Interact normally with adults but cannot do likewise with their

peers.

Experience social anxiety

Prefer activities they can do alone

Demonstrate lack of judgment

Experience social rejection

Be able to explain what they need to do in social situations but

cannot demonstrate it in the real situation.

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45 What Can Be Done About Social

Skills Deficits?

Social Skills Training

Social Skills Groups

Use of Social Stories

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Last Thoughts

See the child and not the disorder. You will miss some

incredible kids if you see just tics / obsessions /

behaviors.

ALWAYS keep your sense of humor.

Children don’t die of TS but their spirit dies

a little bit every day as they try to

maneuver a world that doesn’t understand them.



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47 Resources

Contact me for the following brochures:

• Getting Help at School - Where Do I Begin?

• The ABC’s of Special Education

• Section 504, the Americans with Disabilities Act (ADA)vs.The Individuals with Disabilities Education Act (IDEA)What is the Difference?

• Catalog of Accommodations

• Functional Behavioral Assessment Workbook

• The IEP for Students with TS - A Parent’s Guide

• The IEP for Students with TS - A Teacher’s Guide

Email me at [email protected] for

any of these resources



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48

Available at Amazon.com, Barnes and

Noble and many other bookstores

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Contact Information

Susan Conners

[email protected]

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president, tsa of greater ny state, inc. how do i know

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