Working Effectively With Students With Tourette Syndrome Unit

TOURETTE SYNDROME

WorkingEffectively With Students With Tourette Syndrome

Unit

Outline

Introduction:This section gives a general background of Tourret Syndrome. Itexplains the typology of this disorder, its comorbidities and briefhistory in its management. Towards the end of this section, a thesisstatement is indicated showing what this paper intends to achieve.

Literaturereview: This is the main section of this paper. It discusses severalresearch studies pertinent to increasing the effectiveness ofeducators in working with TS learners. The articles are borrowed fromthe field clinical psychology and educational psychology.

Itis divided into several subheadings each detailing a specificapproach and its efficiency in managing TS learners and the conditionitself.

Discussion:This section offers a general overview of the research studiesexamined in the literature reviews. It ties ideas together for easierdigestion by showing that not one single approach is self sufficientbut managing TS learners require a multipronged approach utilizingthe best of each approach.

Conclusion:This section offers the final views of the research and makes finalconcluding remarks.

Tourettesyndrome (TS) is a chronic neurological disorder affecting the brainand nervous system by causing tics – repeated, uncontrollablemovements or involuntary vocal sounds. The syndrome is named afterthe pioneering French neurologist Dr. Georges Gilles de la Tourettewho first reported the syndrome in 1885 in an elderly patient beforeobserving the same in other patients. In most cases, comorbidconditions include attention-deficit hyperactivity disorder (ADHD),obsessive compulsive disorder (OCD) and autistic spectrum disorder(ASD) which can all complicate diagnoses and management of thedisorder. Co-existent psychopathologies include depression, anxiety,oppositional defiant disorder (ODD), conduct disorder (CD) andpersonality disorders (PDs) (Hwang et al 2012). The diagnosis mayalso be hindered by repressed symptoms and signs.

Allthese comorbid disorders have far reaching impacts on the quality oflife of the affected individuals and in this case social, emotional,psychological and educational needs. Continued research in thisdisorder has eased the diagnosis process which solely relies onclinical diagnosis as no medical tests are available that can detectthe condition. As a chronic disorder whose severity tends to reduceonce a person attains adult age, research and management of thedisorder that affects 1% the global population largely targetschildren who also register average intellectual ability butexperience a wide range of challenges in pursuit of education(Robertson 2011). The disorder is managed largely throughpharmacotherapy and behavior intervention measures each with itsadvantages and disadvantages.

Forexample, the use of antipsychotics in children is not recommended dueto adverse side-effects and even the results very weak (Robertson2011). Some side effects include unacceptable sedation, weight gain,cognitive dulling, and mild motor functioning impairment (Piacentiniet al 2010). Additionally, pharmacotherapy is not recommended forpeople with mild symptoms (Frank and Cavanna 2013). Behavioralintervention methods on the other have minimal side effects and shownmore promising results. There are several behavioral interventionmethods all grouped under Comprehensive Behavioral Intervention forTics (CBIT). In severe cases of TS, surgery is an option specificallyaimed at addressing given symptoms such as involuntary movement(ibid). It is these symptoms that psychologists and clinicians areeager to address that create a new set of needs for children livingwith TS in school, out of school and at home. Given that childrenliving with TS age spend considerable amount at a school peers andteachers have a central role in enforcing and supporting behavioralintervention programs. Ideally the school environment should enablesuch children deal with the psychological and social ramifications oftheir condition.

Additionally,educators have a prerogative to safeguard patients’ dignity bycreating a suitable environment for learning that respects theirspecial needs and fosters inclusion. At the minimum, they shouldprevent any possible discrimination, stigmatization or peervictimization against TS learners. This paper therefore assesses therole and place of teachers in working effectively with learners withTS syndrome in shaping their behavior as a treatment option and alsocatering to their special needs. The paper will summarize findingsfrom various studies on TS and the best ways that teachers cancontribute towards enabling education and life of children with TSovercome the psychological and social ramifications of theircondition.

Literaturereview

Behavioralinterventions

Continuedresearch in TS management has developed several behavioralintervention approaches. Frank and Cavanna (2013) carried out asystematic review to identify the current evidence based behavioralintervention approaches used in managing TS. Their review identifiedHRT, massed negative practice (MNP), contingency management (CM),supportive psychotherapy (SP), assertiveness training (AT), exposurewith response prevention (ERP), self-monitoring (SM),cognitive-behavioral therapy (CBT), relaxation therapy (RT),tension-reduction technique and biofeedback training (BT) as the mainbehavioral intervention methods currently in use. All these methodshave their strengths and weaknesses and all apply optimally indifferent contexts. Educators can borrow from these approaches indevising approaches that will shape the behavior of students with TSand play a therapists role in the classroom environment.Additionally, teacher’s knowledge of the disorder, its treatmentoptions, its social implication on afflicted students and its effecton peers equips them with the knowledge about the special needs ofaffected students.

HabitReversal Therapy

HRTis one of the most popular behavioral intervention methods inmanaging TS and tics. The intervention is based on the knowledge ofneurological background of tics but also acknowledges the role ofsituational and environmental factors in influencing tics (Piacentiniet al 2010). Habit reversal is applied in therapeutic contexts tohelp patients stop repetitive behavior such as tics which isbothersome and does not serve any adaptive purpose for theindividuals. For the patients, they are unaware of these habits andhence have no capacity stop them unaided because these habits are soingrained and repetitive in such a manner they are a disorder. Thesebehaviors are usually a response to certain stimuli such as feelinguncomfortable or uneasy. HR therefore seeks to replace theserepetitive and bothersome behaviors with less bothersome responses tosuch stimuli.

Toadminister HRT, therapists must create a plan and rationale thatstarts by first examining the tics or other repetitive behaviors. Thehistory, precipitating factors, and frequency of occurrence must beself reported by patients. Through HRT, patients are required to keepa log detailing the place, precipitating factor and time of day toenable the patients to bring these behaviors to their consciousness.Therapists therefore encourage and support the patients withidentifying tics and choosing alternative less bothersome behavior toreplace tics (Piacentini et al 2010). Teachers have a role to playespecially in identifying the triggering contexts and situations forthese tics and avoid them. They therefore have a moral andprofessional obligation to steer off these situations to enable thatthey do not interfere with learning for the affected student and forpeers in the classroom (Dolowitz 2014). For instance, in the study bySalmon and Kirby (2009), the authors noted that in both studysubjects, a boy and a girl, being told they were wrong in any givensituation triggered their explosive outbursts. Therefore, teachersshould learn alternative ways to relay such information.

Supportivepsychotherapy (SP),

SPhas grown in popularity in recent years as an alternative topharmacotherapy and HRT. SP is used to basically reinforce apatient’s capacity to deal with stressors and other stimuli thatprovoke tics or repetitive behavior. However, SP is not only uniqueto TS but is also used in managing other neurological disorders. Thiskind of therapy is short term and does not engage in probing apatient’s history or underlying factors that stimulate tics.Ideally, therapists offer attentive listening and encourage patientsto express their thoughts and feelings and also offer understandingas a means to buttress self esteem and instill hope. This way thepatients chart his or her own chart in treatment and recovery withthe therapist only offering hope, support and being an attentivelistener. As such, it can be perceived as an all embracing templatein which more definite techniques of therapy can be implanted (Misch2000). The fact that it does not employ specialized training to be agood listener shows that teachers can play the peripheral role ofbeing a therapist to TS learners by listening to them and offeringthem space and chance to express themselves and be understood(Dolowitz 2014).

However,the number or randomized controlled trials carried out to assess SP’seffectiveness is relatively low and the samples used is relativelysmall at less than 50 (Piacentini 2010). However, popularity of theoption is being buoyed by success in the few cases carried out(Roberston 2012). One such study was carried out by Piacentini andcolleagues (2010) that compared behavioral intervention withsupportive therapy and education through a sample of 126 youngsters.The participants were aged between 9-17 years and were recruited inDecember 2004 and observed through to May 2007. The interventioncomprised of eight sessions spread out over a 10-week period. Thestudy was implemented in three sites namely: Johns Hopkins School ofMedicine, the University of California at Los Angeles, and theUniversity of Wisconsin–Milwaukee. Under HRT, therapist providedinformation on management to tics directly to subject and parents. InSP and education group, therapists were restricted of offeringgeneral information on TS and allowing parent and subject to interactopenly under a therapist’s presence.

Inboth interventions, behavior therapy and SP, there was markedreduction in tics severity. However, behavior therapy recorded moreimprovement with 52.5% reduction in tics compared to 18.5% reductionin the control group receiving supportive therapy and education. Theresults thus indicate that although SP is growing in use, it stillremains inferior to behavioral interventions such as HRT (Piacentiniet al 2010). Possible explanation for such a huge variance isineffective supportive therapy and education approach which is one ofthe study core weaknesses. The SP and education intervention wasintentionally watered down as it did not highlight how therapistsprovided support to enable subjects deal effectively with stressorsthat trigger tics as is required of SP.

Exposurewith response prevention (ERP),

ERPis also a common behavioral intervention treatment for neurologicaldisorders including TS. However, this method is commonly associatedwith treatment of OCD. In the recent past, the method has been widelyapplied in the treatment of TS and is widely compared and contrastedin terms of result to HRT (Robertson 2011). As the name suggests, themethod involves two main activities. The exposure part entails invivo (direct) or imagined controlled exposure of a patient to stimulithat trigger tics such as anxiety causing situations. Repeatedcontrolled exposure allows patients to get used to the situationthereby causing less anxiety or decreased stimulating effect. Theresponse prevention part pertains to alternative behaviors thatpatients are introduced to with a view to prevent them reacting in abothersome repetitive manner of tics. The objective being that duringboth in vivo and imagined exposure, patients will stay exposedwithout triggering tics (Wetterneck and Woods 2006).

Onestudy by Wetterneck and Woods (2006) sought t assess this approachusing a case study approach of one child. The boy, of Caucasianethnicity and of normal intellectual capacity, had been displayingsymptoms of TS syndrome since the age of 8. Diagnosis before thestudy commenced only identified TS thereby ruling out the commonco-occurring OCD. Three core repetitive behaviors were observed inthe subject notably evening up, arranging and symmetry. In thiscontext, evening up was recorded as the repetitive behavior of movingsimilar objects in a manner that they match in terms of function,orientation and location. Arranging was identified as placing mixedobjects into unique categories while symmetry was identified asmoving a given category of items such as books to retain symmetrysuch as arranging them by dimensions or by size.

TheERP intervention involved in this research involved both exposure andresponse prevention on the three noted repetitive behaviors. Exposureinvolved creating stimulating environments at the subject’s homefor five minutes for 2-3 times per week. Proceedings were recorded onvideo camera with full awareness of the subject. An independentevaluator then asked questions relating to the subject’s perceivedlevel of discomfort created by the exposure every single minute on ascale of 0-10 (10 being highest distress). The frequency ofcompletion of target behavior was noted. The exercise continued for1-2 times every week and at three month follow-up. The interventionor response prevention was carried out in a clinic setting(Wetterneck &amp Woods 2006). The settings of any interventioninfluence patient’s response due to availability or absence ofcertain environment triggers (Robertson 2011). Two to three 20-minutesessions were offered per week. The sessions involved giving thesubject instructions on how to resist performing the noted repetitivebehavior in that situation. Alternative behaviors were suggested withthe subject learning to apply them over time after exposure tostimuli. Results showed significant drop in all three repetitivebehaviors after three sessions. Discomfort levels in each of theeliciting environments dropped from an average of 1.25 to zero.

Thisresearch and intervention are well articulated can be easilyreplicated in the classroom situation by teachers and even parents athome. The study successfully makes clear that though teachers are notspecifically trained in addressing such behaviors that might bedisruptive to the learning process, they can help enforce thebehavior by pointing out these issues (Wetterneck &amp Woods 2006).The research is easy to follow as it does not use complicatedassessment tools but rather relies on simple observations. However,the design of the research that involved asking questions everyminute in the eliciting environment could trigger anxiety and thuspossible new tics interfering with the findings.

Socialintervention

Thesocial and psychological implication of TS can be very traumatizingfor the learners. This situation calls for specialized attention fromteachers and educators. Conville (2011) writes that misconceptionssurrounding TS and tics beget bias, mistreatment, misunderstanding,discrimination and further psychological trauma in the afflictedpersons. Therefore, educators must by necessity first employstrategies in education to create awareness and knowledge about TSand demystify symptoms in order to create a hospitable environment.One of the strategies suggested by Lerclerc et al (2011) involve amultifunctional approach that combines both clinical measures andsocial measures to manage explosive outburst in children with TS.Their study assessed an innovative cognitive-behavioral interventionapproach for decreasing frequency and intensity of explosive outburstin two TS subjects.

Thefirst subject was a boy named Tim aged 10 who has been diagnosed withTS and ADHD. He exhibited emotional outbursts (EO) characterized byinsulting and yelling 3-5 times a week. Other observable ticsincluding opening eyes wide, smelling fingers and symmetry rituals.The second subject was an 11 year old girl named Kate. She has beendiagnosed with TS. She exhibited EO 2-3 times per week characterizedby biting and hitting. Visible tics were blinking and visualcontractions. The two subjects were require to keep a journal abouttheir tics and EOs on frequency and triggers. They were later exposedto eight 90-min therapy sessions conducted by a professionalpsychotherapist. A treatment manual was developed with the assistanceof the participants’ parents and teachers who filled outquestionnaires. The therapy sessions thus informed by theself-reports sought to explain EO, offer practical exercises toreplace EOs, games and role plays and situational monitoring.Teachers were also heavily involved outside the therapy session inreminding students about their EO and also offering assistive optionssuch as games and role plays in the classroom specifically to addressanxiety (Lerclerc et al 2011).

Theresults of the intervention through pre, during and post interventionshowed a decline in EO frequency. For Kate, there was a stabledecline of 25% in EO during the first and second treatment phaseswith the third phase (follow-up) showing a 50% decline in frequency.For Tim, EO decline was highest during the first and second phaseregistering 66.7% drop in EO frequency. In total, target behavior inKate reduced by 75% while for Tim it reduced by 69%. However, therewas no change EO intensity in both students. Parents and teachers onthe other hand reported that the most common trigger for EO’s wasthe student being told he/she was wrong or feelings of frustrations.Another common EO trigger for Kate was change in plans (Lerclerc etal 2011).

Roleof Social environment

Researchhas associated TS with negative social environments. Several studiesnote that tics place children at the risk of stigmatization,misunderstanding, peer victimization and even bullying (Conville2011 Sentenac et al 2012 Dolowitz 2014: Nussey 2011). One of themost persistent definition views bullying as “A person is bulliedwhen he or she is exposed, repeatedly and over time, to negativeactions on the part of one or more other persons, and he or she hasdifficulty defending him or herself” (Sentenac et al, p. 120,2012). This definition highlights three important elements ofbullying-repetition, harm and imbalance of power. For most childrenperpetrators of bullying, the driving factor to engage in suchbehavior may be linked to poor upbringing or low self esteem amongothers. Victims of bullying on the other hand experience anxiety,injuries in some cases low self esteem, poor academic performance andeven depression. Nussey (2011) also reports that school children withtics were rated lowly in terms of likability and were deemedaggressive or withdrawn.

InSentenac et al’s (2012) systematic review on bullying of childrenwith chronic disorders, results revealed that several studies havepositively related increased cases of peer victimization withincreased phonic tics but not motor tics. Additionally, children withlearning, speech and language disorders registered increased cases ofspecific speech difficulties and increased stammering as a result ofpeer victimization. Children with ADHD also reported higher frequencyof per victimization through cyber bullying via cell phone (32) andphysical, verbal, and relational victimization. Chronic conditionswith higher externalizing disorders received higher frequencies ofpeer victimization. Not all cases of peer victimization were reportedto teachers (Sentenac et al, 2012). In fact, more than twice theproportion of children to teachers in elementary school reportbullying incidences (Hershey et al 2011).

Teachers’role

Teachershave a role to play in the assessment and identification of cases ofTS and other co-morbid disorders. Salmon and Kirby (2009) say thatmanagement and diagnosis of neurodevelopment disorders such as ADHDand TS require multi-disciplinary and a multi-agency input. Thisworking together is based on number of principles noted as earlyidentification, persistent engagement with child and parent, focusedintervention, holistic support, child centered approach anddissemination of effective approaches and techniques. Teachers havean integral role to play in all these. From the previously discussedstudies it is evident teachers play a key role in implementingtherapeutic methods to manage TS and also in diagnosis of thedisorder and recurrent observable tics. Why is the input of teachersnecessary in making diagnosis?

Thereis no single instrument or methodology for assessment and diagnosisof TS. Assessment and diagnosis relies on collection of evidence fromdifferent sources to determine whether these symptoms are pervasiveand consistent with the noted signs and symptoms of TS. Teachersoffer evidence by filing out questionnaires and providing informationpertinent to the assessment process as requested by the child’sclinician, pediatrician or psychiatrist in number of areas.Forexample, the American Academy of Child and Adolescent Psychiatryrecommends that clinicians should contact a child’s school tocomplete standardized behavior questionnaires from teachers for abetter picture of a child’s behavior. This in line with theDiagnosticand Statistical Manual of Mental Disorderswhich requires that a child’s behavior be evident in more than onesetting before making any conclusions(Salmon &amp Kirby 2009).

Trainingteachers

Askey players in the diagnosis and treatment of TS, teachers should bewell versed and trained on TS and associated comorbidities such asADHD and autism. Noting down of symptoms early enough by teacher canaid in early intervention and addressing of symptoms and signs tomake the learning process and life generally easier for the studentsand the affected parties. Soroa Gorostiaga and Balluerka (2013) notethat some governments such as the US federal governments haveprovided guidelines to train teacher on the basics of suchnuero-developmental disorders such as TS and ADHD. In their paper,the authors note that such direct intervention targeting training ofteachers in awareness of such chronic conditions affecting childrenimpact directly and positively in the affected children.

Therealso several anti-bullying programs being employed by individualinstitutions or even countries. Hershey (2011) and colleagues reporton an anti-bullying program utilizing cooperative teaching and peersupport in the US. Other anti bullying programs that have beendeveloped include the Olwus Bullying Prevention Program andPeaceBuilders. Teachers and adult individuals in elementary schoolcommunities have an integral role to play in activating theseprograms. In the program assessed for its effectiveness by Hershey,the model program was applied in a second grade classroom in a publicschool with over 500 pupils. The school reported cases of bullying,taunting and teasing generally which was recorded in the target classbefore the intervention during and after. The model used a bottoms–upapproach by starting with a single classroom which sought to createheterogeneous social groups in the class to foster social interactionand cooperation. Ideally, creating the groups sought to minimizesocial distance between the students by minimizing physical distance.The groups were rearranged severally to promote cohesiveness. Thesubject if bullying was taught to the whole class. During and afterthe semester long implementation period, there was marked reductionin bullying reported with only two bullies who registered persistentbullying tendencies. This means that if teachers are less informedabout bullying than students, then TS learners are at a higher riskof bullying and teachers should offer protection to them.

Teachersgeneral knowledge of TS and comorbids

Teachers’knowledge about TS and other co-morbid disorders is paramount to thetreatment and management of these disorders and the education of theaffected students. A number of tools have been developed throughresearch to assess teachers’ knowledge in TS and otherneuro-developmental disorders. The knowledge of these disorders notonly affects diagnosis and early treatment but also influence severalother factors. The assessment tools also allow for better planning ofteacher training on TS and other disorders to equip the teachers withthe needed skills. Majority of the tools identified by Nussey (2011)used to assess teachers’ knowledge of TS were originally used forADHD but can be adapted to assess TS knowledge given that disordersare comorbid in 90% of all TS cases.

Thefirst tool, ADHD Knowledge Scale was developed by American andCanadian researchers for elementary school teachers. This toolcomprises of two parts with the first part comprising of 20socio-demographic items a multiple choice format. The second partcomprises another 20 items in true/false format. Each question isassigned one point meaning that the range of scoring is 0-20.Although the tool is widely used due to its simplicity, its lack ofpsychometric properties and inability to provide detailed informationabout the teachers’ knowledge of ADHD makes it weak. Other commonlyused tools include Riley’s Knowledge of Attention Deficit DisorderQuestionnaire, ADHD Knowledge Questionnaire, The Knowledge ofAttention Deficit Disorders Scale (KADDS), Attention DeficitHyperactivity Disorder (ADHD) Questionnaire, and Attention-DeficitHyperactivity Disorder Knowledge and Opinion Survey (AKOSIV) –Knowledge Scale (Nussey 2011). All these enable policy makers tomeasure teachers’ knowledge of TS and ADHD to examine their abilityto handle TS learners. Most knowledgeable teachers on TS and ADHD arebest suited to handle TS learners.

Targetingnegative attitudes towards TS and ADHD

Teachershave a role in minimizing discrimination misunderstanding and stigmaassociated with certain disorders and conditions. In this case,teachers’ knowledge and awareness about TS can play a great role inmaking life easier for affected children by sharing that informationwith their teachers and fellow students to foster understanding andfight stigma (Nussey 2011). This kind of approach has also beenapplied successfully in dealing with other conditions and diseasessuch as HIV, physical disability, diabetes and cystic fibrosis(Berlin, Sass, Davies, Jandrisevits &amp Hains, 2005).

Theresearch by Dolowitz (2014) revealed that lack of understanding abouttics and their involuntary nature was the most pressing issue amongTS learners. They longed that their peers would understand them andaccommodate them the way they were. Teachers knowledgeable about ticscan create awareness among peers by sensitizing them about TS andenabling the peers to create a suitable environment by for instanceavoiding anxiety causing situations for the TS learners. It is alsoindicated that any factor whether physical, sensory or psychologicalthat makes one unique affects their functional diversity implyingthey might have trouble relating with people without such factors orthose that do not understand them well (Novo-Corti 2010).

Listeningto the voices of TS learners

Dolowitz(2014) carried out a study among TS learners in South Africa tounderstand their plight and the challenges they face through theirlearning. In her literature review, she notes that there is minimalresearch in the field of education psychology that seeks to explorethe voice of TS learners which led her to hypothesize that currenteducation systems may be unfair and unjust to students with TS whereno active measures have been taken by teachers or schools to includethem. The participants in the study were eight learners (seven boysone girl) aged between 11 and 22 years exhibiting different types oftics. The researcher used interviews to understand how TS learnersexperience school, their feelings, actions and understandings.

Theresults indicated two categories of experiences- interpersonal andintrapersonal. The intrapersonal experiences comprise of threecategories namely physical characteristics, psychologicalcharacteristics and internalized behavioral factors. Under physicalcharacteristics, participants reported being unable to interactnormally with peers as a result of the tics. Under psychologicalcharacteristics, participants felt incapacitated to engage normallywith others emotionally, socially and scholastically. Underinternalized behavioral factors, participants reported overreactinginappropriately in given situations. For interpersonal experiences,the issues indicated were physical, psychological, and temperamentissues.

Itis also notable that the researchers expressed common views inregards to tics. All the students expressed being embarrassed overtheir tics and taking active measure to musk their tics at school.Most of the students reported this as being very exhausting with onestudent reporting that suppressing tics during school hours meantthat they tics increased and were out of control after school hours.Another student indicated that he relied on sports after school tosuppress tics while another one indicated that physical exhaustionfrom sports engagement worsened the tics. All in all, it was evidentthat the students suffered under the hands of tics especially due tostigmatization and misunderstanding. One student summed this to say

Ifind it very difficult and very frustrating to accept and come toterms with my Tourettes, especially when no one understands … youfeel all alone as you do not really know what is happening. No oneknows what it involves … I suffer every day and it is so hard…”(Dolowitz, p. 61, 2011).

Similarclaims of misunderstanding and feeling misplaced were made by thestudents who attended regular schools given that some parents foundit necessary to enroll their children in special schools.

Thisresearch provides a very deep insight into what TS learners feel.Such information is useful to teachers and policy makers. Theresearch design that relied on interviews enabled the research toobtain such subjective data that help point out the actual feelingsof TS learners. An alternative quantitative approach would have justproduced statistics with little ability to appeal to human emotionsand empathy.

Discussion

Itis clear that TS and tics present unending challenges to studentsafflicted with TS. The classroom environment is not conducive in mostcases and student suffering tics face numerous challenges. Forteachers to work effectively with such students in the classroom,they have to involve other parties. The discussion has revealed theinvolvement of pharmacotherapy and behavioral therapy in easing thetics that makes life easy for the affected students (Sentenac et al,2012). The involvement of teachers and educators at large alsoinvolves therapy and psychological support to the students other thanpure education.

Itis also clear that teachers have an active role to play inmaintaining a suitable and supportive inclusive environment in schoolby engaging other students in TS education. This is however onlypossible if the teachers themselves are well educated about TS andunderstand that tics are involuntary and not a case of indisciplineas it can be misunderstood (Novo-Corti 2010). Such knowledge can thusbe shred and imparted to other students and other teachers to offersupport, and understanding to the affected students. For teachers,there is also a need for closer cooperation with a child’s familyand even therapist or even school psychiatrists/psychologists wherethey exist in not only making diagnoses but also in supporting thebehavioral intervention approaches prescribed .

Thisdiscussion has revealed lack of clear research studies seeking tounderstand the place and role of teachers in TS management and howtheir involvement can improve and support treatment and academic lifeof affected students. This is a rich ground for future researchwhich should explore and develop clear benchmarks as to what level ofknowledge regarding TS is deemed sufficient for a teacher to workeffectively with TS learners. This way teachers can have target goalsin terms of TS knowledge and the same can be implemented in futureteacher training courses.

Conclusion

Educatorshave a central role to play in promoting safe and supportiveeducation to TS learners. The best way to promote effectiveness inworking with such students in the classroom and alongside otherstudents in socially inclusive environment is to understand TS andtics better. A teacher understanding of tics, their involuntarynature and the social implications of this condition on the afflictedlearners should direct them in devising new supportive approach andalso imparting the same knowledge to peers. This will address peervictimization offer a supportive environment to TS learners.Additionally, teachers’ new knowledge in TS will assist in makingdiagnosis and also in implementing behavioral management methodsbeing applied by therapists and even develop some supportive therapythemselves. Teacher training should be directed to increasedcompetence in handling TS learners in future.

References

Conville,K. (2011). Tourette Syndrome: Social Implications and TreatmentStrategy Review.

Theschool psychologist65(1): 11-21.

Dolowitz,M. (2014). Listening to the voices of learners with Tourette’ssyndrome. Master of

EducationThesis. Wits School of Education, Faculty of Humanities andUniversity of the Witwatersrand.

Frank,M. &amp Cavanna, E. (2013). Behavioural treatments for Tourettesyndrome: An evidence-

basedreview. BehaviouralNeurology27 (1) 105–117

Hwang,G., Tillberg, C. &amp Scahill L. (2012). Habit Reversal Training forChildren With Tourette

Syndrome:Update and Review. Journalof Child and Adolescent Psychiatric Nursing25 (1): 178–183

Hershey,S., Paquin, G. &amp Banlgan, M (2011). Classroom-Based TieredAnti-bullying Program

UtilizingGroup Cooperative Teaching and Peer support: A Pilot Study. SchoolPsychologist.29-32.

Koutsoklenis,A. &amp Theodoridou, Z. (2012). Tourette syndrome: school-basedinterventions for

ticsand associated conditions. InternationalJournal of Special Education27(3): 213-223

Leclerc,J. O’Connor, K., Forget, J. &amp Lavoie, M. (2011). BehavioralProgram for Managing

ExplosiveOutbursts in Children with Tourette Syndrome. Journalof Developmental Physical Disabilities23(1): 33–47.

Misch,D. (2000). “Basic Strategies of Dynamic Supportive Therapy. JPsychotherapy Practice

Research9(4): 173–189.

Nussey,N. (2011). An evaluation of a classroom presentation about TouretteSyndrome.

Doctorateof Clinical. Psychology thesis (volume 1), 2011 University CollegeLondon.

Novo-Corti,M. (2010). Attitudes Toward Disability and Social Inclusion: An

ExploratoryAnalysis. EuropeanResearch Studies 8(3):83-107.

Piancentini,J., Woods, D., Scahill, L., Wilheim, S., Peterson, A., Chnag,S…..Wlkup, J. (2010).

BehaviorTherapy for Children with Tourette Disorder: A Randomized ControlledTrial.

Journalof the American Medical Association303(19): 1929–1937.

Robertson,M. (2011). Gilles de la Tourette syndrome: the complexities ofphenotype and

treatment.BritishJournal of Hospital Medicine72(2):100-107.

Salmon&amp G. &amp Kirby, A. (2009). The role of teachers in theassessment of children suspected of having AD/HD. BritishJournal of Special Education36(3): 147-154.

Sentenac,M., Arnaud, C., Gavin, A., Molcho, M., Gabhainn, S., Godeau, E.(2012). Peer

VictimizationAmong School-aged Children With Chronic Conditions. EpidemiologicReviews34 ():120–128.

Soroa,M., Gorostiaga, A. &amp Balluerka, N. (2013). Review of Tools Usedfor Assessing

Teachers’Level of Knowledge with Regards Attention Deficit HyperactivityDisorder (ADHD).

Wetterneck,C. &amp Woods, D. (2006). An evaluation of the effectiveness ofexposure and

responseprevention on repetitive behaviors associated with Tourette’ssyndrome. Journal

ofapplied behavior analysis39 (4), 441–444.