One of the criteria for a diagnosis of Tourette Syndrome is vocal tics. The word vocal is a key word because it indicates that these are tics that one can hear. Vocal tics have always been the most difficult part of life with TS for me and many other persons who have the disorder. Vocal tics can be simple noises that a person makes for example; sniffing, throat clearing, snorting, squeaking, barking, humming, coughing, etc. But vocal tics can also be quite complex. They can include meaningful utterances that a person says that can be totally out of context or that can seem at times very contextual and purposeful. I worked with a young boy who would suddenly yell out “I’ve got a chicken in my pants”. I have heard people with TS who will repeat a phrase over and over or some whose vocal tics are triggered by something in their environment. One young girl had vocal tics which would describe each of her teachers in a not so nice fashion. Her English teacher, who happened to be one of her favorite teachers, became “bubble butt”. Her science teacher was “hairy ears”. She did not want to say these very uncomplimentary things about her teachers but each day as they walked into the classroom, she had to yell out their particular phrase. Immediately she would apologize because she felt so badly even though the tic was completely involuntary. A minority of persons with TS has a vocal tic called coprolalia which takes the form of a curse word or something socially inappropriate. It could be a curse word, a sexual comment, an ethnic slur, a comment on someone’s appearance. Since it often occurs at the most inappropriate time, it is the belief of so many teachers that it is willful behavior which needs to be punished. For example, a young boy developed a vocal tic whereby he would yell out “whore” every time a girl in the class answered a question. I have heard many teachers state that they know it’s voluntary because immediately after saying the word or phrase, the student looks around to see everyone’s reaction. Of course, they look around to see everyone’s reaction because they have uttered something completely inappropriate and are very embarrassed.
So, the big questions that I get asked over and over again from educators is “How do I deal with these disruptions in my classroom?” and “How do I allow one student to use such inappropriate words and phrases and not punish them as I would with any other student who said the same thing?”
Remember the old adage “Beauty is in the eye of the beholder”. My mantra is “Tics are only disruptions in the eyes of the beholder”. It is first and foremost your understanding of and secondly your attitude toward the vocal tics that will make or break your success of having a child in your class with TS. Tics are involuntary. They are in no way willful. All tics both motor and vocal are the result of a chemical imbalance in the brain. Persons with Parkinson’s Disease have slowed down movements because of a similar chemical imbalance. We would never accuse a person with Parkinson’s of being voluntary disruptive and we certainly would not punish them for these uncontrollable movements. Tourette Syndrome is no different. People with TS are sometimes able to suppress some symptoms, but frequently this requires extreme energy and attention and it only can be done for short periods of time. Also, typically when a person is expending so much energy into suppressing, they are unable to concentrate on anything else. Tics when suppressed will almost always worsen in the long run.
With vocal tics, the more a student is told not to do them, the more difficult it is to suppress them. It would be similar to telling you not to blink for the next 2 minutes and reminding you every 20 seconds not to blink. Reminding you would only make this even more difficult to accomplish and require more of your attention and energy. Also, when a person with TS knows that vocal tics are more unacceptable in a certain setting, the more likely it is that they’ll occur in that setting. Tics almost always worsen with stress, anxiety, excitement and fatigue.
So now that we better understand the involuntary nature and the complexity of vocal tics, what do we do in our classrooms?
The most effective plan is simply ignoring the tics which can be role modeled by the teacher. The second most effective strategy is to educate everyone including the other students in the class. TSA has wonderful resources that can be used for this purpose which will be listed at the end of this article. Once classmates understand TS and why the student is doing what he/she is doing, the tics usually calm down naturally because the stress is lessened. Kids can be very understanding when we just tell them the truth. The world is filled with differences and the sooner all students realize this the more tolerant and empathetic they become. They will make fun of and even fear what they don’t understand.
Giving the child frequent breaks out of the classroom to release tics in a more private, less embarrassing environment is also very helpful. I always send kids with these disorders on errands or give them a special pass to leave the room for a short break whenever they need to. I would not recommend suggesting to the child that he needs to leave the room because that in itself can be stressful. Errands are great ways to let kids leave without them feeling like they’re not wanted in the classroom. Providing a safe private place for the child to go when tics are particularly difficult can also help tremendously, e.g. the nurse’s office, the counselor’s office, etc. This does not mean that the child will not tic in class, but the tics will be lessened.
Finally, vocal tics only appear to be disruptive because they are different from what we are used to experiencing in a classroom. I have frequently used a form that I created to perform classroom observations when a teacher appears to be having difficulty dealing with vocal tics in the classroom. In one column I have a list of interruptions that occur in classrooms across the country every day such as coughing, sneezing, blowing one’s nose, sharpening a pencil, intercom announcements, things falling on the floor, etc. In the other column I track the vocal tics of the student with TS. In 100% of the many observations I have done, the normal classroom interruptions far outnumber the vocal tics. So we return to my mantra “Vocal tics are disruptive only in the eyes of the beholder”. Once everyone understands the disorder they will become as accustomed to the vocal tics as any other noises that they are used to hearing in the classroom.
I once conducted an experiment during a presentation on TS that I was giving to the entire staff of a very large public high school. There had been outrage on the part of several teachers because of the vocal tics that a student was exhibiting. Prior to beginning my presentation, I had arranged for the student and his mother to come into the back of the auditorium about 10 minutes after I had begun to talk. Shortly after they entered, we all heard a rather loud vocal tic. The entire audience turned toward the back of the auditorium. I kept talking. About 5 minutes later, we heard another loud vocal tic. This time about half of the audience turned around. The third time about 10 people turned around. After that we heard 8 or 9 more vocal tics before I finished my presentations and absolutely no one turned around. They understood what the noise was and just got used to it. My point was proven.
You as teacher are the role model in your classroom. You can escalate or deescalate a situation simply by your reaction to it. You can allow a child to thrive and be accepted or you can role model for the other students that being different is indeed not to be tolerated. What will you do?
By Susan A. Conners, M.Ed.