¶ … Education
Behavioral Issue -- Tourette's Syndrome
Demographics: Male, 13 years old, Chinese heritage, healthy otherwise, scores in 90th percentile in most intelligence tests; non-violent, intensely curious, we will call him Lon
Tourette's syndrome, also commonly known as GTS or TS, in an inherited neuropsychiatric disorder with onset in childhood. The syndrome manifests itself by intermittent (called waxing and waning) motor and vocal tics. It is part of a spectrum of tic disorders. It was once considered a rare syndrome that only manifested itself with exclamations of bizarre or obscene words or inappropriate and derogatory remarks, known as coprolalia. However, we now know that this particular symptom is fairly rare and, in fact, Tourette's is quite common, about 10 children per 1,000 have some form of tic disorder (Lombroso and Scahill, 2008).
Genetics, environment, nervousness, and new situations often play a role in Tourette's, but the exact cause is unknown. Medication is not usually necessary unless the tics get out of control and disrupt breathing. There is actually no effective medicine that works on every case of tics, but there are medications and therapies that can reduce their severity. Often, relaxation or biofeedback therapy, combined with reassurance and a safe environment are all that is necessary, and certainly education and understanding the disorder is paramount, particularly with younger children who are often frightened by the tic; or are chastised or teased because of it (Tourette's Syndrome Fact Sheet, 2010).
Part 1 -- Socio-cultural assessment -- Lon is a 13-year-old male of Chinese heritage; his parents were born in Australia, and his grandparents immigrated in the early 1950s. Lon has 2 brothers and 1 sister, all younger than him. His family situation is stable, both parents are university educated; his father is a civil engineer and his mother an accountant. He consistently tests in the higher percentiles of achievement tests, is pleasant, outgoing, loves to read and play soccer, and in every way simply a normal early teen who happens to be intelligent and afflicted with an annoying disorder.
For Lon, his tics are complex, but rarely present. He has repetitive eye blinking, facial grimacing, shoulder shrugging, and jerking. Often these are congruent with repetitive throat-clearing, sniffing, and grunting sounds. Although not part of the rare population that utters obscene expletives, Lu's tics do sometimes cause disruption in class, and sometimes cause him to be ostracized because other students are afraid of him during an episode.
Lon's tics come and go; it is difficult to accurately predict them. They are often worse with excitement or anxiety, better during calm and focused activities. Certain physical experiences sometimes trigger or worsen his tics -- wearing a turtleneck or tie often accentuates nick ticks; hearing members of the class cough or sniff with a cold sometimes triggers similar sounds. Loud, raucous music or cacophony in class is another identified trigger.
The Applied Behavioral Analysis (ABA) approach is the science of both predicting and controlling human behaviors. In the case of Lu, it is important then to analyze and note what particular environmental factors influence the onset of a tic episode, what behavioral or environmental factors mitigate the situation, and the other interventions that have been tried or should be tried to help ease the discomfort within Lon's academic world. His current teachers are not very comfortable when Lon has his episodes; Lon's parents and physician have all talked with the school and new teachers, as they do each year.
Current paradigm:
Issue
Behavioral Manifestation
Current Reactive Strategy
Tic Episode Low
Most tics suppressed or camouflaged; tends to be light blinking of eyes, no sounds, some involuntary limb movement; repressing tics causes Lon to build up stress; if stress not released these usually move into a medium or high outbreak.
Either ignore, or depending on time of day, Lon will often see if he can go for a quick walk or jog; sometimes light physical activity, even as simple as throwing a ball, helps.
Tic Episode Medium
Episodic and usually environmentally caused; stress prior to an exam; loud noises in classroom; exposure to certain types of music; oddly, certain smells; manifests with more tic episodes and some Attention Deficit issues.
Teacher usually isolates Lon or has him go to an unused room or the library. The excuse is that "his tics make everyone uncomfortable."
Tic Episode High
Rare, typically 1-2 times per school year; brought on because of intense stress, anger, conflict with another student; sometimes illness or other high stress factors
Usually Lon is asked to go to the nurse's office where he is given a hot towel, the room is darkened, and he is asked to relax. Sometimes he is able to take a short nap.
Again, using an Applied Behavioral Approach to his situation, we can easily find other, more proactive approaches to his issue.
Behavioral Intervention Strategy:
Issue
Manifestation
ABT Construct
New Paradigm
Tic Episode Low
Most tics suppressed or camouflaged; tends to be light blinking of eyes, no sounds, some involuntary limb movement; repressing tics causes Lon to build up stress; if stress not released these usually move into a medium or high outbreak.
Task analysis; tasks at hand are broken into component parts so task is the focus; can use behavioral scripting, "If I do this, this should happen." A bit like a self-imposed dialog with oneself.
Self-administered; If Lon feels an episode coming on, he immediately goes into a mode in which he dialogs with himself; taking his mind off the tics and focusing on whatever task is at hand through self-dialog.
Tic Episode Low
Most tics suppressed or camouflaged; tends to be light blinking of eyes, no sounds, some involuntary limb movement; repressing tics causes Lon to build up stress; if stress not released these usually move into a medium or high outbreak.
Chaining of Behavior; task a begets task b, and so on. If there is a task involving mathematics, then chain it to a word problem and extrapolate; expand the universe to prevent the unwanted behavior.
An extension of the above, or if simple dialog does not work; expand the universe to be more of a multi-dimensional dialog. "This math problem is telling me this…. So, I know there are some real-world examples of this." Essentially, focusing on a far broader picture in order to train the mind to move elsewhere.
Tic Episode Medium
Episodic and usually environmentally caused; stress prior to an exam; loud noises in classroom; exposure to certain types of music; oddly, certain smells; manifests with more tic episodes and some Attention Deficit issues.
Prompting -- Cue or assistance to encourage desired response; categorized from least to most intrusive.
Prearranged with teacher or classmate; if Lon cannot handle his tic, a partner will be engaged to provide aural or visual clues to help Lon focus externally. The focus and activities should be of a relatively calming nature.
Tic Episode Medium
Episodic and usually environmentally caused; stress prior to an exam; loud noises in classroom; exposure to certain types of music; oddly, certain smells; manifests with more tic episodes and some Attention Deficit issues.
Shaping -- Gradually modifying behavior through numerous interactions with predetermined helpers.
Extension of the above; classmate could be allowed to go for a walk with Lon and redirect him from thinking about the tics; walk until the behavioral urge passes.
Tic Episode High
Rare, typically 1-2 times per school year; brought on because of intense stress, anger, conflict with another student; sometimes illness or other high stress factors
Redirection -- completely change the environment in a positive way; have a preset plan that includes aural and visual calmers.
Have a preset location either within the classroom, in the library, or even in a private conference room in which Lon can hook up his headphones and laptop; whichever is more comfortable to Lon. Headphone play calming or nature music; and either dark glasses to block out ambient light, or glasses that diminish all light so Lon can rest.
Tic Episode High
Rare, typically 1-2 times per school year; brought on because of intense stress, anger, conflict with another student; sometimes illness or other high stress factors
Meditation or Biofeedback techniques under professional supervision; ideally in nursing office or, if severity warrants, home.
Simple light-sound biofeedback machine in which Lon chooses a program, and allows the combination of light and sound to refocus into more relaxed mental state, eventually bringing him down to at least the theta state.
(Sources: Cooper, Heron and Heward, 2007; (Steege, Mac, Perry and Longenecker, 2007; Spotts and Atkins, 1998; Brenninkmeijer, 2010).
Literature Review -- Globally, the number one factor in the school system is discipline and classroom management. Concern about discipline follows two major templates: 1) if students are not behaving they are not learning and not preparing for exams and thus effective teaching is not happening, and 2) misbehavior in the classroom is often indicative of futhre problems in society. Surprisingly teachers (80%) did not think discipline was a serious issue. The data shows that it is more media and outside perceptions that color perceptions in many schools; certainly, in some countries and in some areas, certain schools are quite rough and do have discipline problems; but in many, discipline simply involves regulating classroom behavior and holding students accountable for assignments (Fields, 2000).
Issues of resistance are also high on the list of concerns about the school system, with the popular view being that race and economic class are the primary motivators and influencers of the way students resist teacher authority, assignments, and classroom/school activities. Definant behavior is increasing in some demographic areas, and seems to peak in secondary school. Often, disaffected or disadvantaged students are more defiant, sometimes due to that being the only psychological way they feel any control in their lives. Definance in the form of student conflicts exists, just as it would in the adult world, with the difference being that students do not yet have developed frontal-coretex areas, and therefore lose control more often. Understanding the link between psychological issues and definance often gives educators a better way to deal with individual problems (McFarland, 2001).
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