Educational Strategies

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Edwina Reeves
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416-861-2472 TSFC E-mail: tsfc@tourette.

1 In-Service Presenter: Laura Locke TSFC National Office: TSFC Fax: TSFC TSFC Website: Calgary Support Line: Calgary Website: Educational Strategies

2 Educate as many people as possible. This includes: All teachers Office staff Substitute teachers Students Parents Tic Strategies Tic-friendly environment Graceful exits Safe haven Movement breaks, heavy muscle activities Lower stress avoid time pressures, have consistent routines Involve the student in problem solving Transitions When faced with transitions: Provide warning Provide predictable, consistent routines Practice the unexpected Allow student to leave 5 minutes early to go to next class

3 HOW TO INTERVENE IN A PROBLEM SITUATION Cooling off period. Shortly after, meet face-to-face. State concerns calmly. Identify goals, based on what can be learned from the situation (not punishment). See storms as brain overload, not as personal attacks Ensure plenty of home-school communication NEXT STEPS in a problem situation Develop a plan together. Discuss possible triggers and how to avoid these situations in the future Catch them being good Follow up. CLASSROOM BEHAVIOR MANAGEMENT PRINCIPLES Focus on what you want the student to do, not what you want the student to eliminate. Secure the student s commitment in building a new skill. Provide consistent expectations and predictable rewards; point out natural consequences. Ensure plenty of home school communication.

4 Educational Needs Students with TS might need: Accommodations in learning environment Creative modifications in assignments, testing and delivery of curriculum Extra structure and support Strategies for OCD Provide scribe support if needed Provide copies of teachers notes Use bullets for instructions instead of paragraphs Allow un-timed tests Strategies for OCD Use distraction, change in assignments, a break from work and humor to help a student get unstuck Give lots of affirmation and feedback Remember that OCD waxes and wanes Cognitive Behaviour Therapy and Exposure Response Therapy professional supervision

5 Strategies for ADHD Don t assume responses occur instinctively demonstrate Rephrase if necessary Have student repeat instructions back to you Assign a buddy Strategies for ADHD Make interactions constructive, specific and positive Be creative in seating assignment Don t sweat the small stuff Tools for OCD and ADHD Students Time Timer MP3 or IPod Gum Fidget toys Doodle Book Computer or Alpha smart

6 Homework and Assignments Home-school communication Identify purpose of assignment can it be fulfilled in different ways? Consider modifying expectations e.g. every second question Consider modifying format e.g. interview, Powerpoint, video Provide written overview of assignment Homework and Assignments Break down assignment into manageable chunks Number and sequence tasks Give explicit due dates Have a plan for completion of unfinished homework Anticipate lost/forgotten supplies and textbooks Testing Option of quieter setting Extra time Movement breaks as needed Computer Alternative grading methods eg. portfolio, oral testing, scribe, tape recorder, modified test Measure knowledge and effort, not presentation Provide a study guide

7 Computers Helps circumvent many problems Computer use increases work: quantity quality organization neatness Good for organizational deficits, perfectionism, sustaining attention, legibility, immediate feedback Outside the Classroom Be prepared to plan positive, helpful strategies for possible problematic areas, such as:»gym class» Music class»library» Assemblies»Hallways» Recess and lunch breaks»bus Self-Esteem Encourage interests in which the student excels Break up tasks to ensure many successes Empathize with the challenges they face Give a sense of control where possible Teach self-advocacy

8 A COMMON QUESTION: How do you know which behaviours are TS, and which aren t? That s a good question We should assume ALL behaviour is neurologically based. A better question might be: What is acceptable behaviour, and what is unacceptable behaviour? Basic rules, such as not harming oneself, others or property, should apply to everyone. Children do well if they can. If they can t, we need to figure out why so we can help. -Ross Greene, author The Explosive Child

9 Community Education Service To register for notification or an upcoming education session go to: For general CES enquiries Call:

10 Tourette Syndrome: Medical Treatment Tamara Pringsheim, MD FRCPC Director, Calgary Tourette and Pediatric Movement Disorder Clinic Should I be treated for TS? There is no cure for TS Treatment does not alter the course of the disorder Treatments help diminish the urge to tic Given the natural history of tics, all treatments must be periodically re-evaluated Should I Be Treated for TS? Decision to treat tics should be based on whether or not they are causing disability Are the tics interfering with enjoyment of life? Are the tics painful? Are the tics causing social problems? Embarrassment? Low self esteem? Are the tics preventing completion of school or job related activities? If tics are not disabling, treatment can be deferred

11 Traditional Antipsychotics e.g. Haloperidol, Pimozide, Fluphenazine Work by potently blocking dopamine signaling in the brain Most effective medications for diminishing tics, but use limited by side effects Possible side effects include drowsiness and movement disorders Started at bedtime and gradually increased to twice daily Usual doses Haloperidol 1 to 4 mg/day Pimozide 2 to 8 mg/day Atypical Antipsychotics e.g. Risperidone, Olanzipine, Quetiapine, Ziprasidone Work by blocking dopamine and serotonin signaling in the brain Generally very effective Potential side effects include weight gain, increased cholesterol, high blood sugars and drowsiness Started at bedtime and increased gradually to twice daily Usual dose 1 to 4 mg/day for Risperidone Alpha Adrenergic Agonists Clonidine, Guanfacine Originally used to treat high blood pressure Usual first choice of medication due to favorable side effect profile Less effective than antipsychotics in diminishing tics Can improve inattention, sleep problems and lessen anxiety in addition to improving tics Potential side effects include drowsiness and low blood pressure Started at bedtime, gradually increased to twice daily Usual dose clonidiine 0.1 to 0.3 mg/day

12 Tetrabenazine Dopamine Depletors Affects dopamine levels in the brain Side effects include drowsiness, parkinsonism, depressed mood Usual dose 25 to 150 mg per day Long Acting Benzodiazepines e.g. Clonazepam May provide modest benefit May be used in addition to another drug for added benefit Potential side effects include drowsiness and disinhibition Usual dose 0.5 to 4 mg/day in divided doses Botulinum Toxin Used only to relieve specific tics that have become disabling or painful Works by paralyzing the muscle which cause the tic e.g. head shaking tic causing neck pain, complex vocal tics (shouting, swearing) Requires injection into muscles causing the tic by a physician Injections must be repeated every 3 months

13 Deep Brain Stimulation Brain surgery Used only in cases of severely disabling TS that do not respond to medication Still in experimental stages and only done at a few centres worldwide Community Education Service To register for notification or an upcoming education session go to: For general CES enquiries ces@sacyhn.ca Call:

14 Psychological Treatment in Tourette Syndrome Bonnie Moshenko-Mitchell, Ph.D. Registered Psychologist Calgary Tourette Syndrome Clinic Psychological Treatment in Tourette Syndrome As the psychologist in the Calgary Tourette Syndrome Clinic, I address issues related to the following: Management of tics Obsessive-Compulsive Disorder Attention-Deficit/Hyperactivity Disorder Asperger Syndrome Depression Self-esteem and socialization issues Behaviour management Family functioning issues Psychological Treatment of Tics Woods and colleagues (2008) have developed a Comprehensive Behavioral Intervention for Tics (CBIT). CBIT involves the following steps: Step 1: Assess the tics Determine the onset and course of the tics Assess for premonitory urge Assess for comorbid (accompanying) conditions Assess current functioning

15 Step 2: and CBIT (Continued) Determine the antecedents consequences of the tics Tics are written on form with a variety of antecedents (places/situations) and consequences listed Goal is to indicate which antecedents make the tic worse and which consequences are applied to which tic (e.g., An antecedent may be the classroom and the consequence may be the teacher asks student to stop ) CBIT (cont d) Step 3: Provide function-based intervention strategies E.g., For the classroom example, suggestions would be to educate the teacher, address physical placement issues, address any issues with academics CBIT (cont d) Step 4: Habit Reversal Training (HRT) Awareness training Explaining awareness Describing the tic and acknowledging it Becoming aware of, describing, and acknowledging the premonitory urge, feelings, behaviours Competing Response Training Select the competing response (CR) Demonstrate the CR Practice how to use the CR

16 Treatment Issues Existing Research supports the following about therapy for tics: Tics do not increase in frequency after a period of suppression (i.e., after holding them in ) Behaviour therapy for one tic (.e., getting rid of one tic) does not make other tics worse Behaviour therapy does not cause one tic to simply be replaced by another Increasing attention to tics in the context of therapy does not make them worse Obsessive-Compulsive Disorder Disorder in which the brain gets stuck on certain thoughts, images, urges, rituals, etc., and is unable to let them go. Result is that the person with OCD experiences high levels of anxiety that in turn makes daily functioning very difficult. Common Obsessions and Compulsions (cont d) Most common obsessions in children are fear of contamination, fear of harm to self or others, and need for symmetry or exactness.

17 A Sample of Obsessions and Compulsions O: My questions need to be answered. C: I ask questions repeatedly until I get an answer I am satisfied with. O: I ll get germs when my teacher licks her finger, touches a paper, and then gives it to me. C: I look at specific kind of ceiling tile and blink in a certain way and then flick my finger in front of it. A Sample of Obsessions and Compulsions (cont d) O: I ll get germs from objects (e.g., books) that were in the bathroom. C: I need to clean objects that have been in the bathroom. O: The number 13 is very unlucky and something bad might happen if I have anything to do with it. C: I avoid writing it, put a decimal between the numbers, do not answer question #13, do not say that number. A Sample of Obsessions and Compulsions (cont d) O: It is wrong to have the cupboard doors closed in the kitchen. C: When I see a cupboard door closed, I open it. O: I m afraid the toilet will overflow/leak and turn off the fire in the basement. The gas will still be on and our house will explode C: I have to keep checking the toilets to make sure they are not overflowing or leaking

18 OCD/Tourette Syndrome Tourettic OCD? Some people with OCD describe that they perform a ritual to get a just right feeling. Some people with Tourette Syndrome describe that their tic satisfies a particular feeling Cognitive-Behavioural Therapy Evidence-based therapy is Exposure and Response Prevention (E/RP) Steps: Complete rating form. Education around OCD and the brain. Build a hierarchy. Easiest to most difficult Perform exposures to the anxiety-provoking obsession, without performing compulsion. Use corrective information and person gets used to the feared response. Anxiety goes down rewarded for not performing ritual. Resources Managing Tourette Syndrome. A Behavioral Intervention. Parent Workbook Woods, et. al. Tourette Syndrome Foundation of Canada OC Foundation Talking Back to OCD John March Helping Your Child with OCD Lee Fitzgibbons & Cherry Pedrick Freeing Your Child from Obsessive-Compulsive Disorder Tamar Chansky

19 Community Education Service To register for notification or an upcoming education session go to: For general CES enquiries Call:

Tourette Syndrome Part 1

Tourette Syndrome Part 1 Tamara Pringsheim, MD FRCPC Director, Calgary Tourette and Pediatric Movement Disorders Clinic Department of Clinical Neurosciences and Pediatrics University of Calgary Myths about