Tourette Conference April 2000

Accommodation & Accommodation & Implementation:Implementation:

The School ResponseThe School Response

Tourette Syndrome ConferenceTourette Syndrome Conference

April 28, 2000April 28, 2000

Margaret J. Kay, Ed.D., NCSPMargaret J. Kay, Ed.D., NCSPLicensed Psychologist*School PsychologistLicensed Psychologist*School Psychologist

Learning Difficulties in Children with Learning Difficulties in Children with Tourette SyndromeTourette Syndrome

• The effect of tics on school performanceThe effect of tics on school performance

• CONCENTRATIONCONCENTRATION– Mental effort to suppress ticsMental effort to suppress tics– Interference with concentration of Interference with concentration of

othersothers– Teachers may encourage tic suppressionTeachers may encourage tic suppression– Peers encourage tic suppressionPeers encourage tic suppression

The effect of tics on school The effect of tics on school performanceperformance

• MOTOR PERFORMANCESMOTOR PERFORMANCES

– FatigueFatigue– Note-takingNote-taking– Handwriting problemsHandwriting problems– HomeworkHomework– ExamsExams

The effect of tics on school The effect of tics on school performanceperformance

•VocalizationsVocalizations

– Speech hesitationsSpeech hesitations– EmbarrassmentEmbarrassment– Tics are exacerbated by anxiety, Tics are exacerbated by anxiety,

anger & fatigueanger & fatigue– Presence of tics are often emphasized Presence of tics are often emphasized

by peers, teachers and family by peers, teachers and family membersmembers

The effect of tics on school The effect of tics on school performanceperformance

•Social IsolationSocial Isolation

– RejectionRejection– RidiculeRidicule– Barrier to learningBarrier to learning– Case of Robbie: Ate alone in Case of Robbie: Ate alone in

classroom to avoid taunting of classroom to avoid taunting of peerspeers

Obsessive-Compulsive Obsessive-Compulsive BehaviorsBehaviors

• Incidence: Affects 30 to 60% of Incidence: Affects 30 to 60% of children with Tourette Syndromechildren with Tourette Syndrome

– Concentration: Interference of Concentration: Interference of repetitive thoughts & imagesrepetitive thoughts & images

– Fine & Gross motor performances: Fine & Gross motor performances: Interference of repetitive actions (e.g. Interference of repetitive actions (e.g. written work has to be perfect)written work has to be perfect)

Attention DeficitAttention Deficit

• Incidence: Affects 50 to 60% of Incidence: Affects 50 to 60% of children with Tourette Syndromechildren with Tourette Syndrome

– Precedes onset of tics in children with Precedes onset of tics in children with Tourette by 2 to 3 yearsTourette by 2 to 3 years

– Often is the first diagnosisOften is the first diagnosis– Impulsivity, Inattention, HyperactivityImpulsivity, Inattention, Hyperactivity

Executive FunctionExecutive Function

• PlanningPlanning• OrganizationOrganization• AttentionAttention• IntentionIntention• Impulse controlImpulse control• Frontal lobe functionFrontal lobe function

Timed PerformancesTimed Performances

• Almost all children with Tourette Almost all children with Tourette have difficulty completing timed have difficulty completing timed workwork

– The Double Bind:The Double Bind: • Fast & IncorrectFast & Incorrect• Slow & CorrectSlow & Correct

– Lose-Lose situationLose-Lose situation

Written LanguageWritten Language

• Motor strip involvementMotor strip involvement• DysgraphiaDysgraphia• Obsessions & compulsionsObsessions & compulsions• Dyslexia (spelling problems)Dyslexia (spelling problems)• Fine-motor controlFine-motor control• Pencil gripPencil grip

Diagnosis & InterventionDiagnosis & Intervention

• School-Based or Independent School-Based or Independent Educational Evaluation (IEE)Educational Evaluation (IEE)– IntelligenceIntelligence– AchievementAchievement– PerceptionPerception– LanguageLanguage– Social & EmotionalSocial & Emotional– Vocational & Career (14 years+)Vocational & Career (14 years+)

Tourette & Language-Tourette & Language-Based Learning DisorderBased Learning Disorder

•DyslexiaDyslexia

– Average to above average IQAverage to above average IQ– Low reading decoding & spellingLow reading decoding & spelling– High listening comprehensionHigh listening comprehension

Dyslexia & TouretteDyslexia & Tourette

• Associated characteristics:Associated characteristics:

– Poor STMPoor STM– Word finding difficultiesWord finding difficulties– Speech delaysSpeech delays– Articulation deficitsArticulation deficits– Rapid naming problemsRapid naming problems– Poor spelling & written languagePoor spelling & written language

Tourette & Non-Verbal Tourette & Non-Verbal Learning Disorder (NLD)Learning Disorder (NLD)

• Good reading decoding & spellingGood reading decoding & spelling• Poor listening & reading Poor listening & reading

comprehensioncomprehension• Poor understanding of novel Poor understanding of novel

material and complex mathematicsmaterial and complex mathematics

Tourette & Non-Verbal Tourette & Non-Verbal Learning Disorder (NLD)Learning Disorder (NLD)

• Some common problemsSome common problems– Poor social cognitionPoor social cognition– Difficulty interpreting non-verbal, Difficulty interpreting non-verbal,

social cuessocial cues– Trouble with inferential thinkingTrouble with inferential thinking– Problems not apparent until later Problems not apparent until later

gradesgrades– Writing difficulties related to poor Writing difficulties related to poor

comprehensioncomprehension

Tourette & Frontal Region Tourette & Frontal Region ProblemsProblems

• AttentionAttention• Impulse controlImpulse control• Intention & follow throughIntention & follow through• OrganizationOrganization• HyperactivityHyperactivity• HypoactivityHypoactivity

Tourette & Motor Strip Tourette & Motor Strip InvolvementInvolvement

• WritingWriting• Time managementTime management• Listening & note takingListening & note taking• HomeworkHomework• ““Something gets lost on the way to Something gets lost on the way to

the task.”the task.”

Psychoeducational Psychoeducational EvaluationEvaluation

• Request in writingRequest in writing• District has 45 days to completeDistrict has 45 days to complete• Ask for list of tests to be usedAsk for list of tests to be used• Request results in writingRequest results in writing• If you disagree with district results, If you disagree with district results,

you have the right to obtain a you have the right to obtain a publicly funded IEEpublicly funded IEE

Exceptional Children get Exceptional Children get IEP’sIEP’s

• Present levels sectionPresent levels section– Must be described in objective and Must be described in objective and

measurable termsmeasurable terms– Children who are learning disabled Children who are learning disabled

must demonstrate a severe must demonstrate a severe discrepancy between ability & discrepancy between ability & achievement in one or more of the achievement in one or more of the following areas: following areas: Basic Reading Skill, Reading Basic Reading Skill, Reading Comprehension, Math Reasoning, Math Calculation, Comprehension, Math Reasoning, Math Calculation, Written Expression, Listening Comprehension or Written Expression, Listening Comprehension or Spoken LanguageSpoken Language

Goals & Objectives in the Goals & Objectives in the IEPIEP

• GoalsGoals– Mechanism for Mechanism for

determining if determining if outcomes are outcomes are being achievedbeing achieved

– Allow you to keep Allow you to keep track of track of educational educational progress (or lack progress (or lack of it)of it)

• ObjectivesObjectives– MeasurableMeasurable– Intermediate steps Intermediate steps

between presents between presents levels & goalslevels & goals

– Milestones for Milestones for measuring measuring progress (or lack progress (or lack of it)of it)

Specially Designed Specially Designed Instruction in the IEPInstruction in the IEP

• What happens that is special?What happens that is special?– MethodsMethods– ScheduleSchedule– Teacher-to-student ratioTeacher-to-student ratio– Where instruction is to be deliveredWhere instruction is to be delivered– How instruction will be deliveredHow instruction will be delivered– MaterialsMaterials

Objective Measures of Objective Measures of ProgressProgress

• MeasurableMeasurable

• ObjectiveObjective– Test scoresTest scores

• Not subjectiveNot subjective– Teacher judgmentTeacher judgment

• Standard scoresStandard scores

Program & PlacementProgram & Placement

• ProgramProgram

– IEP is based in IEP is based in comprehensive comprehensive educational educational evaluation (CER)evaluation (CER)

– Program is based Program is based upon present upon present educational levelseducational levels

• PlacementPlacement

– Must be Must be determined after determined after IEP is completedIEP is completed

– Must be Must be appropriateappropriate

– Appropriate does Appropriate does not mean “The not mean “The Best”Best”

Problems & RemediesProblems & Remedies

• Failure to base the IEP on a Failure to base the IEP on a comprehensive evaluationcomprehensive evaluation

• Failure to describe SDI’sFailure to describe SDI’s• Failure to specify placementFailure to specify placement• IEP must confer educational IEP must confer educational

benefitbenefit

Due Process SafeguardsDue Process Safeguards

• FAPE (The right to a Free & FAPE (The right to a Free & Appropriate Public Education)Appropriate Public Education)

• The IEP must be reasonably The IEP must be reasonably calculated to confer calculated to confer “educational benefit”“educational benefit”

Section 504 of the Section 504 of the Rehabilitation Act of 1973Rehabilitation Act of 1973

• What accommodations and/or What accommodations and/or services will the student require in services will the student require in school to “level the playing field”?school to “level the playing field”?

• Also applies to extracurricular Also applies to extracurricular activities & non-student situations, activities & non-student situations, such as employmentsuch as employment

Section 504 PlanSection 504 Plan

• AccessAccess– Schools must provide access to Schools must provide access to

equivalent facilities, services & equivalent facilities, services & activities.activities.

• AccommodationsAccommodations– Regardless of the nature or severity of Regardless of the nature or severity of

the handicapthe handicap• EvaluationEvaluation

– Districts must determine who is in Districts must determine who is in need to Section 504 servicesneed to Section 504 services

Section 504 PlanSection 504 Plan

• DisciplineDiscipline

– Removal of a Section 540-eligible Removal of a Section 540-eligible student for 10 or more days student for 10 or more days constitutes a “significant change constitutes a “significant change in placement.” in placement.”

– Triggers a reevaluation & due Triggers a reevaluation & due process requirement.process requirement.