Tourette Syndrome

Understanding tics, comorbidities, and how to support students with Tourette syndrome

For paraprofessionals and the teachers who supervise them

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| The frameTourette syndrome (TS) is a neurodevelopmental disorder characterized by multiple motor tics and at least one vocal tic, persisting for more than one year. It is often misunderstood -- by students, by peers, and by adults. Most people associate Tourette syndrome with coprolalia (involuntary swearing), but this symptom occurs in only a minority of people with TS. Understanding what TS actually is, how tics work, and how the common comorbidities affect school performance helps paras provide meaningful support. |

What tics are

Tics are sudden, rapid, recurrent, non-rhythmic motor movements or vocalizations. They are neurological in origin and are not intentional behaviors -- the student cannot simply choose not to tic. However, many people with TS can temporarily suppress tics in certain situations, at the cost of significant internal effort and often a rebound increase in tics when the suppression is released.

Motor tics

Motor tics involve movement. Simple motor tics include eye blinking, shoulder shrugging, head jerking, and facial grimacing. Complex motor tics involve more elaborate movement patterns -- touching objects, hopping, repeating a gesture, or echopraxia (repeating another person's movements).

Vocal tics

Vocal tics involve sounds. Simple vocal tics include throat clearing, sniffing, grunting, or clicking sounds. Complex vocal tics include repeating words or phrases, echolalia (repeating what others say), or palilalia (repeating one's own words). Coprolalia -- involuntary use of obscene words -- is a complex vocal tic that occurs in approximately 10-15% of people with TS, not the majority.

Tic variability

Tics wax and wane -- they increase and decrease in frequency and intensity over time. A student may have significant tics during one period and barely noticeable tics during another. Tics are typically worse when the student is stressed, fatigued, or excited, and may be less noticeable during focused, engaging activities. This variability is often misinterpreted: a student whose tics are visible at some times but not others is not faking the tics -- the neurological variability is real.

Tic suppression and release

Many people with TS experience a premonitory urge before a tic -- a building sensation of tension or discomfort that is relieved by performing the tic. The tic is partially reinforcing because it provides relief. Students can often suppress tics for a period, but this requires significant cognitive effort and typically results in a rebound increase when suppression is released (after school, after a test, in a private space).

Implications for paras:

Do not ask or expect the student to suppress tics during class -- this is exhausting and interferes with learning

If the student suppresses tics during an assessment and then has increased tics afterward, this is expected and appropriate

Private spaces and breaks can be helpful for students who need to release suppressed tics

Never call attention to tics in front of peers -- this increases self-consciousness and can worsen suppression attempts

Common comorbidities

TS rarely occurs in isolation. The majority of people with TS have at least one comorbid condition, and many have several. The comorbidities typically cause more academic and social difficulty than the tics themselves.

ADHD

Approximately 50-80% of people with TS also have ADHD. The combination of TS and ADHD creates particular challenges: difficulty sustaining attention, impulsivity, and the additional cognitive load of managing tics. When a student with TS and ADHD is struggling in class, it may be difficult to determine which difficulties stem from each condition -- in practice, the supports often overlap.

OCD

Approximately 50% of people with TS have obsessive-compulsive symptoms. OCD in the context of TS often presents differently than classic OCD -- it may be characterized by aggressive or sexual obsessions, touching or ordering compulsions, and intrusive thoughts. See Brief 07.16 for more on OCD.

Anxiety and depression

Both anxiety and depression are significantly elevated in people with TS, partly as a consequence of the social and academic challenges TS creates. A student who is chronically self-conscious about their tics, who has experienced peer teasing, or who is exhausted from suppression may develop secondary anxiety or depression. These emotional consequences are not inherent to TS but emerge from the experience of having TS in a social environment.

Learning disabilities

Some students with TS have co-occurring learning disabilities, particularly in written expression. The motor demands of handwriting can be particularly challenging when combined with tics that affect the hand or arm.

CBIT basics

Comprehensive Behavioral Intervention for Tics (CBIT) is the evidence-based behavioral treatment for TS. It includes Habit Reversal Training (HRT), in which the person learns to identify the premonitory urge and substitute a competing response (a behavior that is physically incompatible with the tic). CBIT is delivered by a trained therapist; it is not something paras implement. However, paras may support a student who is doing CBIT:

Be aware the student is working on tic management and may be practicing specific techniques

Do not comment on whether the student's techniques appear to be working

Understand that CBIT requires significant effort and may itself increase fatigue during the school day

Scenario

The peer reaction

A student with TS has a vocal tic that sounds like a bark. In a quiet classroom during independent work, the tic is noticeable and peers react -- some laugh, some stare. The para does not comment on the tic itself, but when a peer whispers to another peer and both look at the student, the para quietly redirects both: eyes on your own work, please. After class, the para speaks with the teacher about whether a brief classroom education session about neurological differences (without naming the student) would be appropriate. This is the right sequence: protect the student in the moment, then address the systemic issue through proper channels.

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| Try this | Watch out for |

| Respond to tics with neutrality -- neither calling attention to them nor expressing concern | Calling attention to a tic in front of peers, which increases self-consciousness and suppression attempts |

| Never ask the student to stop ticcing or suppress during academic work | Interpreting tic suppression as evidence that the student could control tics all along if they wanted to |

| Redirect peer reactions calmly and without drama in the moment | Assuming a student with TS has coprolalia -- the majority do not |

| Understand that variability in tic severity is neurological, not behavioral | Focusing intervention on the tics when the comorbidities (ADHD, OCD, anxiety) are creating more educational impact |

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| Bottom lineTourette syndrome is not what most people think it is, and it is rarely the tics themselves that create the most educational challenge. The comorbidities -- ADHD, OCD, anxiety -- are where most of the support work happens. Know the student's full profile, not just the diagnosis name. |

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