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Temper Problems with Tic Disorders
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Families describe that some people with TS Plus have difficulty with poor control of temper,
self regulation of emotions, rage episodes, flashpoint anger, melt downs with minor triggers
or temper tantrums well beyond what is typical of the age.
Which people with TS are more likely to have problems with temper control?
3,500 individuals in 22 countries were surveyed by researchers* to see what sort of problems people with TS have.
They found that:
- 12% who had been diagnosed with TS had no other problems
- 60% had tics plus ADHD
- 59% had tics plus obsessive-compulsive disorder (OCD) or obsessive-compulsive behavior (OCB)
- 26% had tics plus current temper problems
- 37% had tics plus a history of temper problems
There was a low incidence of temper problems with those with only tics but no ADHD or OCD/OCB.
There was a high incidence with those with tics and ADHD or those with tics and OCD/OCB.
There was a very high incidence with those with tics, ADHD, and OCD/OCB.
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In other words, the combination of tics, ADHD and OCD/OCB (called TS Plus) appears to predispose people to the development of problems with control of their temper.
What are the causes of loss of control episodes with TS Plus?
Figuring out what internal and external factors push people with TS Plus into difficulty is the task at hand. What is it about tic disorders, ADHD and OCB/OCD that lead to problems with temper?
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Many of the following suggestions and others are available in the booklet, "It's Not Just the Tics: Learning and Behavioral Issues with Tourette Syndrome". For more information on ordering this booklet, see School Issues on this web site.
These can be factors which the tic disorder can contribute:
A sense of "gotta do" behavior or suggestibility. The word or phrase can get "stuck" in their mind. When a person has suggestibility and hears "Don't slam the door!", they've "gotta" slam the door. When they hear "Shut the door quietly!", they've got the word "quietly" stuck in their head. It is more likely to result in the door being shut carefully. Rather than say "Stop hitting your brother!", word things positively. "Be gentle with your brother. Brothers are for loving and playing." (or something positive like this).
These can be factors which the ADHD may contribute:
- Impulsivity or a tendency to respond first, often in a reckless way and think later.
- Difficulty overcoming distractions so that a chaotic or over stimulating environment will be too much and lead to loss of control episodes.
- A fast and slap-dash approach to solving problems. Struggles to use deliberate problem-solving strategies, instead responding with frustration or impulsively.
- Difficulty tolerating frustration due to impatience and a preference for quick solutions.
- Problems maintaining concentration which is needed to process problem solving in depth
- Difficulty with self-regulation of attention, activity and emotions.
- Continued reliance on adult support and external structure long after the child should be able to self regulate.
- Difficulty overcoming distractions or working in over stimulating environments
These can be factors which OCD or OCB (or anxiety) may contribute:
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Obsessions and compulsions are mental rituals which may look like deliberate behavior. These are involuntary and take a lot of effort, like tics, to suppress. Tension, pressure to perform the ritual, and anxiety build during attempts at suppression until the ritual or habit is performed and it feels "perfect", "just right", "balanced" or "complete". The individual feels as though he/she has "gotta do it". Although OCD and OCB are of neurobiological origins, stress can make them worse. See OCD and TS for more information about OCD/OCB.
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Poor stress tolerance and a tendency to become overwhelmed. This is often expressed as refusals, avoidance, non-compliance, irritability, oppositional behavior, defiance of authority. Things become "too much" to handle and problems in temper control develop. Often they soak up the emotional tone of those around them. They become "emotional barometers" of the family or the classroom/work setting.
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Some people with OCB can have great difficulty shifting gears, adapting to a change, (such as turn off the TV and come to supper). They can make up their mind about something and be totally unable to shift to a different way of thinking. They become "stuck" in their thinking or perseverative. Locking horns in an argument with a person who has become "stuck" is a no-win type of situation. You will lose the argument.
How do I handle loss-of-control episodes at home and at school?
First, try to prevent them and figure out why they are happening. Try to identify the specific triggers. Which of the factors above are contributing? Don't say, "whenever he/she doesn't get his/her way". Think about it more carefully.
Find out what is too much!
This boy who has TS, ADHD, and OCD had a meltdown when he was over stimulated by a youngster who kept pestering him. He couldn't get the younger child to stop. Notice that his shirt is wet because the young child had squirted him with a squirt gun. Things became "too much" for him and he lost control and totally trashed his own room in an explosion of rage. He has given his favorite things to his parents so that he won't damage them because he knows that he tends to react this way if he gets overwhelmed. |
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How can I approach discipline for a child in a way that reduces
the reactivity which results in loss-of-control episodes?
Remember, the goal of discipline is to teach and not to punish. There is an important difference between the two. Discipline works best if it is done in a supportive, mentoring relationship.
- Use a low volume, calm, and non-emotional tone of voice.
- Discipline should be quiet, private, and non-confrontational.
- The focus of disciple should be the teaching of self-control. It should be positive, problem solving and solution seeking. Avoid lecturing, raising your voice, or pleading.
- Don't lock horns and get into an argument. Instead, use diversion, make a joke, or fool around.
- Lighten the mood to reduce the tension of the moment. Helpful phrases to use if you are starting to get engaged in an argument with someone who has difficulty yielding a point are: "Could be", "Possibility", "Uh huh". None of these statements say that you agree but they help you exit the argument.
- Change the subject to something the child is interested in.
- Maintain a sense of humor, fun and playfulness. Keep the environment relaxed.
- Learn to read cues of irritability, impatience, inflexibility, resistiveness, and volatility as signals that something is "too much". Figure out what is too much. Work on changing the environment to reduce the stress that triggers meltdowns.
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How can I teach self control strategies?
The individual who is struggling with self control needs to be helped to understand the triggers and situations where loss-of-control episodes tend to occur and to make a commitment to develop and implement a plan to leave or avoid a situation that is likely to result in a loss of control episode. If their internal engine is starting to race and their tension is building, they need to pull over to a rest area (going into the bathroom, take a walk or exercise, find a quiet spot, or go their own room) rather than end up in the "break-down lane" (being sent to time out, ending up in the principal's office or their supervisor's office).
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How can you create a good environment for someone gaining self control?
Tips for teachers, school staff and parents:
- Provide the child with a quiet "office" area for "time off" (rather than "time out"). It should not be used as a punishment, rather a place to retreat to in order to regain control or work without distracting others. Some children do well in a bean-bag chair with ear phones in a quiet area of the room.
- Keep the classroom and home life structured, quiet, and orderly with predictable routines.
- Provide careful preparation for transitions and changes in schedule.
- Pay careful attention to the selection of friends who visit, class size and composition. Others may feed the loss of control episodes.
- Encourage the child to initiate his/her own exit when he/she feels that a loss of control episode is brewing. Reward him/her for exiting independently. Create a "Graceful Exit" card in the classroom which the child must merely show the teacher prior to the exit.
- Modify the environment. Stressors for children may come as being teased, embarrassed, over stimulated, loud voices, pressure to get work done or "just right", academic work at the frustration level, conflict at home. Do what you can to modify the environment.
- Consider the role of the bus ride and cafeteria, or time in the hall between classes as a set up for over arousal. If going out to play at the playground over stimulates the child, choose a quieter activity. Modify. Modify.
- Identify and anticipate settings in which the child may lose control and restructure the experience.
- View non-compliant behavior not as a challenge to your authority but as an indicator of the child's level of fatigue, anxiety, agitation, distractibility and stress tolerance. Make adjustments in expectations.
- Focus on problem solving and seeking solutions, not on punishment. You are trying to teach, not punish. Avoid lecturing, raising your voice, or pleading. "You're a good boy/girl, and I know what happened upset you. Let's figure out what happened, because I know you don't want it to happen again".
- Don't try to teach in the heat of the moment of the melt down. Nobody's listening and it often just prolongs the tension that is causing the melt down. Wait until the child and adult has regained self control and can listen and dialog without criticism.
- Discuss critical incidents in terms of losing, regaining and maintaining control. It is NOT helpful to label the child as aggressive, destructive, defiant, violent, disrespectful, etc. Personality traits by their nature are difficult to change. It's difficult to escape a label. They add to a child's sense of personal defeat, hopelessness and low self-esteem
- Focus on "next time plans" rather than play "detective" or "true confessions".
- Focus on what preceded the melt down, not the melt down or a punishment/consequence.
Supportive adults need to:
- Understand the contexts in which self-control is possible as well as the triggers for loss of control episodes.
- Communicate this information in a factual manner to the child without anger, annoyance, exasperation or punishment.
- Include the child in developing and amending the behavioral plan.
- Notice escalation in behavior and try to intervene early and directly.
- Use effective interventions such as distraction, redirection, changing the activity, location or players, providing more structure, and/or practicing a calm way to handle the situation.
RESOURCES
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* Freeman, R. et al, An international perspective on Tourette Syndrome: Selected findings from
3500 individuals in 22 countries. Developmental Medicine and Child Neurology, 2000, 42:436-447
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