By: Dr. Meir Flancbaum
Sam is a bright, considerate, athletic middle school student, but he dreads going to school. Throughout his day, unintended movement and noises known as tics occur so frequently that it is difficult for him to concentrate in class. Sam has a disorder characterized by motor and phonic tics.
While Sam’s close friends and family have always understood and accepted his noises and twitches, lately he has become the target of bullies. They mimic his tics repeatedly, tell him to “shut up,” or call him insulting names, such as “Tourette’s boy.” As Sam’s tics have begun to interfere with his day-to-day life, his once high self esteem has plummeted, along with his grades. His parents and teachers have noticed he is spending more time by himself, and they are worried.
Tips for Teachers
- Education increases acceptance: When a child in the class has Tourette syndrome, educate the other students about the disorder. Consider having the child make a short presentation or having a professional come address the class.
- Youth with TS are just like everybody else: If a child’s tics are noticeable, but only minimally interfering, the best strategy is just to ignore them.
- Behavior Therapy: If tics are more severe, the most effective course of action is to refer the child to habit reversal therapy, where he or she will learn skills to control tics during instructional periods. As a teacher, you can serve as the child’s “coach,” when he implements strategies in the classroom.
- Give breaks: If a child has severe bouts during class, consider offering him or her short, pre-arranged breaks that will ensure it is not misinterpreted as a punishment or a way to avoid work.
- Avoid telling a child to suppress his tics: This will likely trigger anxiety and stress, which increases a child’s urge to tic.
- Set a good example: Taking a supportive and accepting stance regarding a child’s tics demonstrates how you want his or her peers to respond.
Many people assume that tics are quite rare, and confuse them with Tourette syndrome (TS), but current research suggests that tics affect 12-18% of school-age children. Tourette syndrome, in contrast, is significantly less common: Actual diagnoses are being made in between one and ten cases per thousand individuals.
Tics are short, repetitive, stereotypic movements of muscles or vocalizations, including blinking, facial grimacing, leg twitching, sniffling, grunting or throat clearing. When a particular tic involves multiple muscle groups, such as extending one’s arm and then making a fist, it is called a complex tic. Only when an individual has multiple motor and at least one phonic tic, will he or she be diagnosed with Tourette syndrome.
Many young people with tics may not be bothered by them, so it is essential to wait and watch to see if they cause any interference at home or at school. Parents and teachers should remain vigilant, however, to make sure tics do not worsen with a child’s changing circumstances or age.
Stress can exacerbate the expression of tics, particularly in middle and high school, as social awareness and pressure mounts, thereby reducing a child’s ability to control tics, and causing serious self-esteem problems. Staying alert and watchful to see if the tics become more disruptive is critical. The child may become distressed by them if they interfere with completing school work, cause body soreness, or trigger feelings of embarrassment, especially if, like Sam, one is teased or bullied as a result.
If it seems like the tics are becoming a problem, the first place to start is by increasing parents’, teachers’ and the child’s knowledge of tics, the course of the disorder, what makes them worse, and treatment options. Simply doing this can help adults feel more comfortable around youth with tics and empowered to get them the help they need. Attending a consultation or in-service trainings about tics and related disorders can help reach this goal, too.
Most important: Never punish a child as a result of his or her tics. In fact, the stress a child experiences in response to such reprimands will very likely make the tics worse.
For decades, the treatment of choice for tic disorders, including Tourette syndrome, has been medication. While medications can be effective, many parents prefer their children not take them, unless necessary, either on principle or due to concerns about adverse side effects.
Recently, there has been a resurgence of research supporting a behavior therapy for tics called Habit Reversal Training (HRT), which can be implemented alone or in conjunction with medication management.
HRT is a behavior therapy designed to help individuals reduce their tics. The first step is to teach individuals to become more aware of their tics, and specifically, the warning signs, which immediately precede them. Though tics may seem to come out of the blue, a behavior therapist can help someone learn to detect them before they happen. Next, individuals are taught to engage in an exact, specific behavior—called a competing response—that is incompatible with exhibiting the tic. The goal of this treatment is to try and teach the brain to resist the urge to tic, even when it thinks that it must. Eventually, the urge to tic may even go away. In addition to HRT, treatment will typically include relaxation training and strategies to reduce stressful situations that can make tics worse.
The most important support a child can receive is from the caring adults who recognize the tics have become a problem and that help is needed, and who then follow through with effective therapies to ensure the child can get on with living his or her life.
Meir Flancbaum, PsyD, is a post-doctoral fellow at Behavior Therapy Associates in Somerset, New Jersey, where he provides clinical treatment, school-based consultation, and training workshops. He specializes in the treatment of youth with Tourette syndrome and associated disorders, including disruptive behavior and anxiety, as well as trichotillomania, or hair pulling. Dr. Flancbaum also conducts research on behavioral treatment for tics at Rutgers University.
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