An Introduction
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"Barb" ammer...@epix.net
Hi, I'm the kindergarten teacher of a boy who has a string of neurological diagnoses. Most are supposed to be subsimal to Tourette's. He is having a tough time in a cl***room of 15 children, despite many interventions.
Tics are the least of the problems. The most troubling inappropriate behaviors involve oppositional defiance and physical agression, both to cl***mates and to me. I've had some training in supporting children with problem behaviors (and have 24 years experience in kindergarten). I am writing to ask if there are others in the group who have dealt with a child whose main diagnosis is Tourette's, but whose school conduct is the main issue. He has a "wrap around" aide, a behavior plan, mental health agency and physician support and parents who are trying hard. I am implementing the behavior plan, but not feeling very successful. I'll consider any suggestions, and would appreciate any responses.
Thanks, Barb
cyberb ...@aol.comNONITPIC (NONITPIC)
What are the other diagnoses?
Is the wrap around aide with him fulltime?
Has he had a Functional Behavioral ***essment?
Are there deficits that are causing his oppositional behavior (i.e. lack of social skills or understanding the nuances of language)?
cyberb ...@aol.comNONITPIC (NONITPIC)
P.S. Check out this site for comprehensive information on TS and comorbidities: http://www.tourettesyndrome.net/
"Barb" ammer...@epix.net
Thanks for the pointer to a cite. I've book marked it for future reference.
In answer to your questions: The co-morbities are ADHD, OCD, Oppositional/Defiance, and a rather unspecified mood disorder. There may be an additonal one or two that escape me at the moment.
Yes, the wrap around is full time at school (with a shortened school day).
Yes, he has had a functional behavior ***essment by the school's behavior specialist. There is also a behavior specialist ***igned from the mental health agency that supplies the wrap around. With these specialists, there is a behavior plan...It hasn't kept this child from hitting and kicking me during the implementation. There will soon be a meeting to do a manifestation determination.
I'm trying hard to meet this child's needs and continue to teach to 14 other kindergarten children. I've got my hands full.
Barb ...
"Linda G" allstar...@earthlink.net
digging in his heels, being uncooperative, oppositional, obstinate, or perserveratin were symptoms of my sons TS that manifest when he felt threatened by something, especially too much sensory stimuli.
Taking him to task for manifesting such, only escalate the situation, which can easily spiral out of control with someone reacts poorly to a child not in total control of .their vocalizations and movements.
SO...his teachers were all advised, that when he got uncooperative, and oppositional, to realize he was feeling threatened, and see if they could figure out what it was, (a seatmate invading his personal space, too much noise in cl***) and lessen stimuli.
Then, deal with his having become oppositional and uncooperative by saying to him...."That's Ok, but whenever you are ready will you please do such and such", and then turn away, from him, as if totally expecting him to calm down, and do as asked. THe act of turning away, generally dissipated, the hrightened state of feeling threatened, such my child did calm down, and a minute later, did as he was asked to.
The key with my son was to deescalate a situation, lessen stimulation, never increase it, by confronting him while he was already in a heightened state of sensitivity..
"Barb" ammer...@epix.net
Thanks, Linda. Earlier this week, in an attempt to de-escalate a developing situation, I tried walking away from him. Had given him choices and the time to sit to calm down and think. He approached me a few times during that time, wanting to argue. Followed a neuropsychologist's model for eliciting his compliance, followed by a time out---when he promptly kicked me.
Today he acted oppositional and I gave him the choices that had been decided in his behavior plan. He failed to comply, then began to try to break pencils, throw the pencil holder, etc. I used the same neuropsychologist's model, which resulted in a time out. Today he hit me.
He had hit me once before (back in November). This time, I'm afraid that the fact that it's happened a few days apart isn't boding well for the current plan.
Was the lack of interaction the only manner in which your son's teacher lessened the sensory stimualtion? I'm wondering if there is anything more we could try, with sensory stimulation in mind.
I'm really grateful for your contribution. I'm thinking of this little fella in the middle of the night sometimes. Any ideas that come from this group will be thoughtfully considered.
Thanks, Barb ...
greenspa ...@aol.com (Jan)
Hi Barb. Linda's examples were really good ones. It seems that this little guy is not responding to your similar tries though.
I teach in a resource room (even have 2 kindergarten students this year for 1 period per day). I also have a child (now 21) with TS, i.e. my existence on this site.
There are so many behavior management techniques, as you know, out there to try. Problem is he is soooo young. Many of them take an ability to reason with the child for it to work. Faber and Mazlish (like Ginott) have some great I-message things that Kin. can understand. Their books are real hands-on and quick to read.
I think Canter may be "above" that grade level - with the checks and consequences.
May be that this child needs a smaller cl*** size and a self-contained situation to do his best. Keep records of the incidents so that you are able to report accurately at the next meeting about him. If he goes to self-contained, it should only be until he matures. I would think his academics suffer along with these behavior incidents. But, of course, that isn't always the case. Just guessing.
Jan
"Linda G" allstar...@earthlink.net
In my son's case, it always seemed to me it was sensory overload incited his manifesting TS...especially if he was not 100% physically cause he was fighting off a cold.
The thing is, it wasn't only what we usually think of when we think of sensory input, sight, noise, touch...but in my sons case it seemed to me, it was as often SMELL.
s incite him.
Before I was aware my son even had TS..if he was having problems outside our home, the first thing I do is check his immediate surroundings where the problem was occuring, see if there was any known allergin, in immediate vicinity of his seat.
If he was seated by the cl*** pet, (excrement/dander) or supply closet, (chemical fumes) or radiator/sink( mold/mildew) I ask he be moved.
I didnt know if he was allergic, or just sensitive to pungent odors, just knew he couldnt be seated near such for any length of time whichout a change in behavior of the unwelcome kind.
If I saw nothing giving off strong odor to a sensitive nose, I ask about who he was seated with...make sure it was a well behaved child, with a well modulated voice, who repsected another childs personal space...no loud, or touchy feely or fidgety kids as they incite him..
If his seatmates were kewl, then I ask about what was happening..was a party going on, had someone substituted a bit, so the cl*** had been acting up?
When my son't TS was real bad in 6th grade...his teacher call me if she were going to be absent, so I not even bring him to school when a sub was in!
So, yes sensory stimulation played a big role, manifestation of my son's symptoms.
And, once he was overloaded, he wasnt one who could remove himself from the situation, cause he was so defensive, he just dig his heels in, and manifest more and more, especially if demanded not to so long as too much sensory input was incoming..
he was extremely defensive, not aggessive like the child you have. Howeer my sons symptoms included echopraxia, and echolalia, etc ..and if taken to task for tic'ing, he start copycatting the facial expression, the words, and/or the actions of whoever was threatening him, and I can tell you adults take exception to a child scowling at them as they scowl at the child, or a child pointing their finger at them as they point their finger at the child, or a child grabbing their risk as they grabbed the childs wrist, and those that didnt realize he was manifesting echopraxia..and reacted poortly to him copying them, just escalated him to manifest worse and worse.
if the adult whose care he was in, didnt do what could be done to lessen the stimulation, and instead only tried to take my son to task for manifesting..while he was manifesting, it was a disaster, cause you couldnt reason with him while he was in heightened state of sensitivity and feeling threatened.
Had to give him a wide berth...back off, decrease sensory input, deescalate the situation..
then give him a chance to pull together, and be his normal cooperative self.
Time to talk about what happened was later on in the day, or next morning when he was fine aagain.
Accept that as FWIW..since every child's TS manifest differently..
My son, now a sophomore in HS, was able to matriculate through school without any special ed...just accommodations like those I mention above, and no longer even needs accommodations, now a successful sophomore in HS.
( it did seem touch and go there, for a few years.way back when, though)
"Linda G" allstar...@earthlink.net
Where was his time out?
In his seat...where he feels safest?
time outs didnt go over well, if they were outside of my sons "place" as when my son was feeling threatened, my son wanted to dig his heels in, and stay exactly where he was, his "seat" or "place", where he felt safest, and have whoever or whatever was threatening him..move, or moved away from him.
-when he promptly kicked
"ksdpb" ks...@home.ca
Linda G stated in her post.
"The key with my son was to deescalate a situation, lessen stimulation, never increase it, by confronting him while he was already in a heightened state of sensitivity.." As a 41 year old who had similar childhood problems. I would like to agree with Linda's statement and add that as the day progresses the ability to cope with stimulation (stress) lessens. One thing that gets lost when talking about the symptoms of TS and comorbids is that coping with them is tiring. As the day progresses, our strength and ability to cope the world seems to lessen. The world closes in around us and we find ourselves clinging to our personal space as if it were a life raft. If this one last thing is threatened panic and rage are very normal reactions.
We are left the question of how to interact with and mold this child's behaviour. Once the child has regained control and is able to cope treat him like any child with problems in the cl***room. The neuropsychologist's model for eliciting his compliance, followed by a time out may be very effective if it suits his needs or any of the usual cl***room strategies learned through 24 years experience in kindergarten.
On your students behalf I would like to say Thank you for taking the time to seek insight into his needs. He is very lucky to have a concerned teacher like you.
ksdpb ...
"Barb" ammer...@epix.net
Hi Jan, Thanks so much for your reply. I am keeping good behavior reports (including antecedents, behavior and consequences). He is a bright little boy, but I've begun to notice how his mood causes him to lose the ability to focus on the tasks at hand. Redirection, during instruction only works until he goes "over the line". It's like his mind becomes totally absorbed with the behavior, such that he cannot continue to concentrate on the lesson. I think you may be right about a change of cl***room, but we are a very small, rural school district with few options for children with special needs. It helps me just to be able to get my thoughts into print. I've jotted the authors you mention. Again, thank you.
Barb ...
sesgard ...@aol.com (Sesgardner)
I echo this sentiment on behalf of students everywhere. My son is in 6th grade, so perhaps the same methods are not appropriate, but he responds very well to rewards and not well at all to "punishment." The book "The Explosive Child" has helped quite a bit, but I'm not sure if it's appropriate in a cl***room setting.
My heart goes out to you, this boy, his parents and his cl***mates. The world is a better place because YOU care.
Sara
"Barb" ammer...@epix.net
Hi Linda, Thanks for writing. I've especially noted the sense of smell thing you mention. There are no obvious odors in our cl***room, but I do wear perfume. I think I'll try a few days without it.
This child does tic periodically, but I'm fine with ignoring those (as per Mom's and Dr.'s advice). There is some rocking, some head rolling and some vocal tic. He comes up with the finger pointing while he is telling me what he will and will not do. Scowling (actually "snooting" me) when I am absolutely quiet. So, I don't think it's the same as you mention.
I'm glad your son has done so well. It makes me feel better to know that this child doesn't have to go all through school with these sorts of problems.
Thanks again for your response. I've gotten some good ideas from this group.
Barb ...
"Barb" ammer...@epix.net
His time out spot has been both at his own seat and at a second spot a little removed from his cl***mates. Earlier in the school year when I had tried to use his seat as his time out seat, it was close enough to the rest of us for him to begin a series of escalating inappropriate behaviors that actually became dangerous. The second spot was suggested by the behavior specialist so as to remove his "audience". This time he was given a choice.
...
"Barb" ammer...@epix.net
Thanks for your input. I really am trying. This is a beautiful child, who exhibits such sweetness some of the time. And as I've said, he's a bright boy. There is such potential.
The reason his school day is shortened is that I saw that he just couldn't hold it together beyond about 2:00 on most days. We are trying to address how tiring it is for him. The short day has helped, but obviously isn't taking care of the rest of the day.
Thanks again. I'll continue to read and to ask questions.
Barb ...
"Barb" ammer...@epix.net
Thank you, Sara. I really need a little encouragement right now. Your kind words help a lot!!
Barb ...
"Joanne Cohen" joco...@attbi.com
Does this boy have regular breaks throughout the day? That's essential.
Also, have you tried asking *him* what might work for him? His own insight into the problem is important, as well as any sense of control you can give him to aid in rectifying the problem behaviors. Even young children can surprise you when you ask them! Having control, even over a negative behavior, and your response to it, can be very empowering for kids with TS and behavioral problems.
Jo
"Barb" ammer...@epix.net
Hi Jo, The kinds of answers I get when I ask him are things like, "I want to go home and never, ever come back". "I want to play". "I'm not doing this work". His wrap around aide has tried talking through some difficulties. I am engaged with 15 other kindergarten children, in the middle of lessons. I know that giving him respect and responsibility for his own behavior is key. It's how to do it, while minimizing damage to school property, personal attack and while conducting lessons that is the challenge. Thanks, Jo. More food for thought.
Barb P.S. The kindergarteen day has built right in, lots of "breaks". Perhaps he needs more.
...
cyberb ...@aol.comNONITPIC (NONITPIC)
I ***ume this boy is covered under IDEA (has an IEP)? If so, who is providing the specialized instruction that an IEP requires? It also sounds like the wrap around support person might not be adequately trained.
TSNW t...@optonline.net
Hi, Barb~ Welcome to ast, and thanks for caring so much about this child ! It's always encouraging to find a teacher who cares enough to write in and ask for help. I'm mixing up the order of your quotes in order to incorporate your subsequent responses ...
I don't know the word "subsimal," and can't locate it in a dictionary (perhaps Randall can help out), but it seems like you are indicating that you believe or have been told that his "string of diagnoses" are secondary (?) to his Tourette's ? -- due to his Tourette's -- less important than his TS -- or that his TS is the main source of his problems ? ? I'm not sure what you're implying, since I just don't know what subsimal means. At any rate, if you have been led to believe anything like this is the case, it is not correct. You will find the faulty logic of whomever may have told you that his problems were secondary to or due to TS in your own words describing the child ...
The list of diagnoses you indicate almost always take precedence over TS in terms of impairment and need for treatment. The mood disorder would most likely come first in terms of impact upon the child, and ADHD and OCD are also significant features of his neurological makeup. Is the child being treated for a mood disorder? It sounds like he may be on the wrong medications, if his treating professionals are ***uming that TS is his main problem. Do you know what medications he's on?
Stimulants or anti-depressants can *significantly* worsen the situation for a child with undiagnosed bipolar.
Tics, or TS alone, don't typically lead to the type of issues you discuss with this child. Paying attention to his more impairing diagnoses -- mood disorders, ADHD, OCD -- will be much more helpful in terms of figuring out treatment options and how to best help him in the cl***room. As you indicate, the tics are the least of the problem.
You will find the MOST helpful information on the site which has already been referred to you: http://www.tourettesyndrome.net but you will notice throughout Leslie's writing that she does not attribute the types of issues you raise to Tourette's. Perhaps getting the people involved with the child to look beyond the obvious (tics tend to become the focus for less than fully informed professionals and laypersons, as they are more "visible" than mood disorders or ADHD --
the actual tics give professionals something concrete to label, and that can be very misleading). Paying more attention to the more serious issues of mood disorders will be more helpful to the child. Attributing his issues to tics will just simply not result in help in finding the right answers, because the tics are not likely to be the origin of his problems. Helpful books are: The Explosive Child, by Ross Greene and The Bipolar Child, by the Papolos http://www.bipolarchild.com If he has mood disorders, ADHD, and OCD, it is not clear why his treating professionals are considering Tourette's to be his main diagnosis, and it sounds like misdiagnosis or misattribution of behaviors may be where the problem lies. As Leslie covers pretty well in her website, the behavior plans you have in place may not work if you aren't properly addressing mood disorders or other significant underlying issues, or if a mood stabilizer is needed. Often, a child fitting this description may turn out to have undiagnosed bipolar, and addressing that will take precedence over any other diagnoses.
Thanks again for caring ... it sounds like his treating professionals are missing the boat ...
--
Tourette Syndrome - Now What?
http://tourettenowwhat.tripod.com
TSNW t...@optonline.net
I was thinking his treating professionals aren't either ... but maybe I'm missing the boat, since I don't know what the word "subsimal" means. It sounds like they are trying to hang this boy's issues onto TS, when he has much more going on that doesn't appear to have been addressed sufficiently -- if I'm interpreting the word "subsimal" correctly.
--
Tourette Syndrome - Now What?
http://tourettenowwhat.tripod.com
TSNW t...@optonline.net
hmmm ... sorry if this is a double post ... it didn't show up on my reader the first time I posted it ...
Hi, Barb~ Welcome to ast, and thanks for caring so much about this child ! It's always encouraging to find a teacher who cares enough to write in and ask for help. I'm mixing up the order of your quotes in order to incorporate your subsequent responses ...
I don't know the word "subsimal," and can't locate it in a dictionary (perhaps Randall can help out), but it seems like you are indicating that you believe or have been told that his "string of diagnoses" are secondary (?) to his Tourette's ? -- due to his Tourette's -- less important than his TS -- or that his TS is the main source of his problems ? ? I'm not sure what you're implying, since I just don't know what subsimal means. At any rate, if you have been led to believe anything like this is the case, it is not correct. You will find the faulty logic of whomever may have told you that his problems were secondary to or due to TS in your own words describing the child ...
The list of diagnoses you indicate almost always take precedence over TS in terms of impairment and need for treatment. The mood disorder would most likely come first in terms of impact upon the child, and ADHD and OCD are also significant features of his neurological makeup. Is the child being treated for a mood disorder? It sounds like he may be on the wrong medications, if his treating professionals are ***uming that TS is his main problem. Do you know what medications he's on?
Stimulants or anti-depressants can *significantly* worsen the situation for a child with undiagnosed bipolar.
Tics, or TS alone, don't typically lead to the type of issues you discuss with this child. Paying attention to his more impairing diagnoses -- mood disorders, ADHD, OCD -- will be much more helpful in terms of figuring out treatment options and how to best help him in the cl***room. As you indicate, the tics are the least of the problem.
You will find the MOST helpful information on the site which has already been referred to you: http://www.tourettesyndrome.net but you will notice throughout Leslie's writing that she does not attribute the types of issues you raise to Tourette's. Perhaps getting the people involved with the child to look beyond the obvious will help (tics tend to become the focus for less than fully informed professionals and laypersons, as they are more "visible" than mood disorders or ADHD -- the actual tics give professionals something concrete to label, and that can be very misleading). Paying more attention to the more serious issues of mood disorders will be more helpful to the child. Attributing his issues to tics will just simply not result in help in finding the right answers, because the tics are not likely to be the origin of his problems. Helpful books are: The Explosive Child, by Ross Greene and The Bipolar Child, by the Papolos http://www.bipolarchild.com If he has mood disorders, ADHD, and OCD, it is not clear why his treating professionals are considering Tourette's to be his main diagnosis, and it sounds like misdiagnosis or misattribution of behaviors may be where the problem lies. As Leslie covers pretty well in her website, the behavior plans you have in place may not work if you aren't properly addressing mood disorders or other significant underlying issues, or if a mood stabilizer is needed. Often, a child fitting this description may turn out to have undiagnosed bipolar, and addressing that will take precedence over any other diagnoses.
Thanks again for caring ... it sounds like his treating professionals are missing the boat ...
--
Tourette Syndrome - Now What?
http://tourettenowwhat.tripod.com
"Linda G" allstar...@earthlink.net
In kindergarten, my son was made good use of pieces of wood, nails and a hammer. The repetitive motion of hammering some portion of the day seemed an outlet for wayward neurological impulses.
In first through third grades, his erasers served a similiar purpose, in cl***, as an outlet for ridding himself of neurological restlessness. He'd erase away, creating eraser shaving "mounds".
If he was really distressed during those early years, he was giving a small pink rubber ball, and a large concrete wall, to repetitively throw the ball against.
offered some outlet to relieve the neurological impulses plaguing him, before he become so tense, and boil over..
"Pat Wilson" pwil...@neb.rr.com
Barb, I just want to add to the list of helpful books. I just read "Transforming the Difficult Child: The Nurtured Heart Approach" by Howard Gl***er and Jennifer Easley. Prior to purchasing the book I did a web search and found a number of book reviews (which I have posted below.) It's a very easy read, but more importantly it gives a strategy that is very easy to implement and results in a complete transformation in ways adults typically respond to a child that has alot of energy. As the reviews mention, typical strategies used by both parents and educators is to give more huppla to a child when things aren't going so well and a very low keyed response when a child is following rules and behaving properly. We've started using this approach with our son and in just two days are seeing positive results. It's by far the best how-to book I have ever read.
The reviews are as follows: "Transforming the Difficult Child: The Nurtured Heart Approach" is an outstanding book that offers parents new and innovative strategies to parenting children who are challenging. Many of us parents have sought books to help us achieve discipline and balance with our children, only to be disappointed when our children do not respond to the "typical" parenting strategies. The key to parenting difficult children is learning new strategies that will enhance their self-esteem, give them successes, while holding them accountable for their actions. This remarkable book contains the answers that so many of us have been searching for.
Howard Gl***er and Jennifer Easley have authored this book in a no-nonsense style complete with clear explanations and solutions for parents who are at their wit's end.
Howard Gl***er, M. A. is a family therapist and behavioral strategist who has devised new technologies for working with the difficult child in the home and cl***room. He is the founder of the Children's Success Foundation.
Jennifer Easley, M.A. is a child mental health specialist and nationally certified counselor who has worked with difficult children and their families for over fourteen years. She also has worked as a consultant in the school setting.
The goal of this book is to empower families, without placing blame or guilt on the parents. The strategies are clearly defined, easily implemented, and promise to accentuate the positive qualities of your child. Trade Paperback, 250 Pages The Nurtured Heart Approach is an amazing set of strategies developed specifically for children with ADHD and other challenging behaviors to facilitate parenting and cl***room success. These methods have helped thousands of families to transform their child from using their intensity in primarily negative ways to using their intensity in beautifully creative and constructive ways. Most ordinary methods of parenting and teaching inadvertently backfire when applied to ADHD and other challenging children, despite the best of intentions. Most methods accidentally reward children by giving far more energy to children when things are going wrong. The Nurtured Heart Approach is a powerful and quick way to create a new scenario of success. - Patch Adams, MD, renowned physician The Nurtured Heart Approach teaches significant adults how to strongly energize the child's experiences of success while not accidentally energizing his or her experiences of failure. Most approaches, because they were designed for the average child, get stretched beyond their capacity when applied to challenging children. Traditional approaches for parenting and teaching can easily backfire with challenging children: they inadvertently reward children by providing more energy, involvement and animation when things are going wrong. Challenging children wind up being very confused because they perceive a high level of incentive for pushing the limits and for negative behaviors and little incentive to make successful choices. Often, the harder adults try applying these normal methods, the worse the situation becomes, despite the best of intentions.
Pat W
"Barb" ammer...@epix.net
Hello, Yes, the neuropsychologist's report indicated that the Tourette's was the one to watch. But, I can fully "buy" that the behaviors exhibited are NOT tics and Tourette's is probably NOT the disorder that requires the emphasis.
I think his adopted mom has been so ready to attribute his behaviors to Tourette's (calling a lot of things tics) that her belief, in combination with the neuropsychologist's report (subsimal is his word) has had the school (and our various specialists) convinced that his difficulties are mostly Tourette's.
Just today, I was told that the mental health agency professionals (wrap around aide, behavior specialist and supervisor of wrap around aide), as well as our behavior specialist and special education case manager are now believing that quite a lot of the exhibited behaviors are learned.
There is a psychiatrist prescribing for him. This Dr. recently recommended that he be put on a mood stabilizer, but mom wasn't happy about that and the Dr. is trying something else. I don't recall if Mom ever told me the name of the current med. This is in addition to a patch for ADHD. She seems to think that the addition of the new med is making additional irritability.
They have an appointment again on Monday.
So, there are two Drs. here. One is saying Tourette's is the emphasis and the other is trying to treat him for the ADHD and the mood disorder. We are doing a delicate balancing act with a behavior plan that tries to use the neuro psych Dr's. model, while monitoring meds for the psych Dr.
Sure wish we could get a real handle on this child.
Thanks so much for your input. I think you've really hit on something important here, and I'll definitely discuss it in our Monday meeting regarding this little boy.
Barb ...
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