Human subtlety will never devise an invention more beautiful ....Da Vinci

'Human subtlety will never devise an invention more beautiful, more simple or more direct than does Nature, because in her inventions, nothing is lacking and nothing is superfluous.' 


Leonardo da Vinci

NLD: Non-verbal Learning Difficulties

NLD (non-verbal learning difficulties) may occur with a number of neuro-developmental disorders, most commonly with Asperger's Syndrome. People with Tourette Syndrome may exhibit some of the symptoms of NLD to a greater or lesser extent. Children and adults in education may experience difficulties which can affect reading/writing and hence academic progress but unlike dyslexia these don't usually delay reading development. Individuals with NLDs / TS are often comparatively early readers and quickly develop an extensive vocabulary.


Symptoms and characteristics of NLD:

• Difficulty with recognition of emotions in other people & in expressing one's own emotions
• Difficulty with the appropriate use of touching others. When to do and when not.
• Misunderstanding or inability to respond appropriately to non-verbal communications.
• Maintaining attention in noisy/visually complex environments.
• Difficulty with remembering/recognising names, faces & locational navigation
• Difficulties with reading & writing quickly despite often having excellent language abilities & early reading abilities
• Often compensate for non-verbal difficulties with highly developed verbal abilities. Often rapid speech & too many words!
• Perception of the environment as chaotic & may attempt to take on too many simultaneous activities.
• Anxious about failure. Often over-compensate by doing too much too quickly and hence become confused with the complexity and magnitude of the tasks they are faced with

.... don't judge or assess unfairly

‎"I you judge a fish by its ability to climb a tree, it will live its whole life believing that it is stupid" 


Albert Einstein

Student with Asperger's takes own life

cambridge-news.co.uk

Article published: 08/12/2010 16:30 - Updated: 08/12/2010 16:53 (article/s now been removed from internet)

Medical student took his own life 

by Julian Makey

"A medical student at Cambridge University killed himself after his bid to take 

a crucial exam for the third time was rejected, bringing his career to an end. 

Ronjoy Sanyal, 26, wrote a long report before his death in which he said he 

had not been best served by the university, an inquest was told. 

Mr Sanyal, of Roseford Road, Cambridge, injected himself with a lethal 

dose of nicotine and was found dead at his home after his parents raised 

the alarm with a neighbour. 

The Gonville and Caius student, who had Asperger’s Syndrome, which can 

cause communications problems, killed himself in July after being told that 

his application to take a paediatrics exam for an unprecedented third time 

had been unsuccessful. 

Mr Sanyal was said to have previously considered taking his own life in 

2006 after running into earlier problems in his medical training. 

Coroner David Morris recorded a verdict that Mr Sanyal took his own life 

after being told that he could not qualify as a doctor. 

He said: “It is a great tragedy and lessons need to be learned. I am sure 

lessons have been learned and will be learned.” 

Dr Diana Wood, director of medical education at the university, said Mr 

Sanyal had been given extra support, but concerns remained over him, 

particularly because of his problems in communication. 

She said changes had since been introduced so that students’ progress 

could be monitored more closely and more personal support was available." 

what will make a difference?

I think although TS itself may cause considerable problems, for most the overwhelming issue is discrimination and bullying, not tics or other symptoms. As bad as they can be they just don't compare with the desolation so many feel because of the way they are treated by others. That's the bit that truly sucks and for me the thing that needs to be changed more than anything! 

I'm not convinced that millions of dollars for research, looking for a 'cure' and trying to educate inadequate doctors is going to make the biggest difference at this stage. It's the lives of kids growing up with TS now that matters (and adults too) and things will only improve with awareness and legal protection neither of which really exists in any substantial form.

To make a difference, I wanted to become the doctor I never had

Knowing what growing up with Tourette Syndrome was like and remembering the difficulties I had with understanding the problems I experienced as a child and what caused them, lead me to finding ways in which I could help children with TS and other 'special' needs caused by neuro-developmental disorders. There was almost no useful advice or support available and I don't believe things have moved on much now that I am an adult.

I wanted to find a way in which I could make a difference and be able to improve awareness, influence professional attitudes, improve diagnosis and subsequent provision and treatment. I determined that the best way to do this was to become a doctor myself and specialise in developmental paediatrics or neurology. I could not only become directly involved in the diagnosis and treatment of TS but also become involved in clinical research. Having TS myself would, I hoped, give me a unique insight and would also ensure I had some idea of the issues that children with TS and their parents face. I hoped my own 'disability' would allow me to better connect with and relate to others who are similarly affected. I wanted to become the doctor I never had.

After gaining my first degree in biological sciences, I taught for several years in a 'special school' as a teaching assistant but eventually found this frustrating as although I was helping with educational aspects I became very aware of the profound lack of understanding about Tourette Syndrome, autism and other disorders, among both health and educational professionals. The misconceptions of the medical profession and very poor advice given to parents and their children was something I found truly astounding and worrying.

I was also aware that I had little opportunity to progress and qualify as a teacher. I had applied for post-grad teacher training during my time as a special-needs teaching assistant but, as I expected, I was not even given an interview. 

I did eventually get a place at medical school but encountered much unexpected discrimination, most of which took place at the very end of four years of extremely hard work which included facing the challenges that studying medicine with a disorder like TS presented. The manner in which I was treated by staff of the medical school came as a big shock and I was ill-equipped to deal with it. I was subjected to what seemed like a concerted effort by my medical school to deter me from completing my training by using every means possible to question my abilities, undermine my self-belief and to even suggest I would pose a risk to my patients should I practice. Instead of supporting me as I had imagined they would, my university made my life impossible. I made the painful decision not to return to complete my degree.

My experiences with medical training and the prejudice I encountered, is a complex story that I hope to tell fully one day and it will help explain how, despite all signs being to the contrary throughout my training, I had to ultimately resign myself to hanging up my stethoscope for the last time and abandon a large collection of costly medical textbooks over which I had pored for unimaginable hours along with the hopes that had driven me forward. I also have a large debt and student loan to repay. 

I at least have the satisfaction that I was able complete all my clinical training rotations successfully and received good commendations, assessments and much encouragement from the consultants under whom I trained in several hospitals. I had put in long hours on the wards, in theatre and clinics. I found clinical practice immensely rewarding and found I was actually good at it. I found patients related to me very well despite my obvious 'differences'. I knew I had to work a lot harder and spend much more time than most students to get through all the reading and written assessments. The time limitation on written exams and having to take them in a crowded examination hall was an enormous challenge. In one major examination I was told to keep quiet at the beginning of a 3 hour written paper in a large hall with several hundred other candidates. A member of staff, a qualified doctor who was well-aware of my TS, even 'shooshed' me because I was making too much noise! I spent most of that particular exam in a state of much higher stress than usual and in concentrating on hiding/suppressing my tics, hoping not to disturb other students. As expected I did not have time to complete all the questions (I got almost 70% but they still failed me on that paper). 


Giving presentations was one of my biggest fear as I would have to become the focus of attention in a room full of smart and articulate people but I managed to overcome this and achieved a passable performance although the stress was often overwhelming. For a while I really thought I would achieve my goal and would be able to transcend the difficulties of my condition.


During my course I was subject to numerous highly discriminatory and unfounded comments by several members of staff of my university who tried to convince me that my disability would mean that I would not be able to carry out my clinical duties adequately despite having successfully passed all my training assessments of clinical competence. This I am certain was a consequence of a profound lack of understanding of what TS entails. They also ensured that I would not be permitted any accommodations or reasonable adjustments during my training and academic assessments. I was informed that the university did not have money or resources to help students with such disabilities. Instead I had various restrictions and additional requirements imposed on me that were not imposed on other students, including what were subsequently determined to be unneccessary successive compulsory medical assessments.

I often feel very disappointed and immeasurably sad that I was prevented from graduating alongside my other classmates with whom I had shared many years of training and share in the mutual sense of achievement. This is often the true reality of Tourette Syndrome. You know you can do something but always have to struggle with others not taking you seriously. Sometimes you just resign yourself to believing that however hard you try to prove yourself, it will never be enough. You get used to seeing your friends and classmates progressing through life and effortlessly overcoming obstacles that may stop you in your tracks. However despite this I still try to keep some belief in myself and never feel willing to give up. A problem with Tourette Syndrome, is that individuals are often painfully aware of how others see them but feel they can do little to change those perceptions. 

I had spent four years with my fellow medical students going from our first clinical experiences to greater challenges with excitement and hope for the future. We went through incredible experiences together and gradually developed confidence in ourselves and our clinical abilities and the potential value of our skills to others. I do however feel a great sense of satisfaction in that my clinical partner, throughout my years of hospital training, managed to graduate successfully despite having many setbacks and struggling on many occasions. In the end she finally made it and I'm sure she will be a competent and dedicated doctor.


I can't emphasise more strongly, the urgent need for better legal protection for students with disabilities and legislation that ensures they are supported appropriately and treated equally with other students.

In a nutshell .... a negative day

I always try to be positive and tell myself never to let TS stop me from doing anything in life or believing I can achieve things. Today however I feel overwhelmed by all the things I know that TS HAS stopped me from doing and all the problems it has and will cause me and my family.


Sometimes I trully hate Tourette Syndrome and wonder if I really should be here at all


The way you are treated by others can be intolerable
There is so little understanding and awareness
Medical provision for TS is so inadequate
There is almost no provision or support for people with TS in the UK
Because of the prejudice of others it is very difficult to earn a living or have a career
There is little protection against discrimination and harrassment 


Most people have little ability to see the person beyond the disorder and so almost never take you seriously however hard you try or however articulate and qualified you are


People seem only to 'define' you by your TS


This IS how I and others with TS often feel when things are getting too much. I can't say whether I would wish to have been born without it. I would have been a different person - it is so much a part of who I am .... for better or worse and there is little I can do about it


The one big dream I have always harboured is the possibility that one day I might be able to live in America where they have legislation to ensure disadvantage is reduced and I believe a better awareness about Tourette syndrome beyond the negative and stereotypical perspective that prevails in the UK.

What Tourette Syndrome is: The Facts

Tourette Syndrome (TS) is a neurological developmental disorder (as is autism and cerebral palsy)

Children and adults with Tourette Syndrome are not disturbed, mentally ill or mad and do not require psychiatric treatment

Tourette Syndrome is known as a 'spectrum' disorder (like autism) in which different individuals will have differing combinations and severities of symptoms that reflect the specific neurological 'impairment' to the affected areas of the brain

Tourette Syndrome has a strong genetic component (autosomal dominant) and so is inherited through one or both parents

People with TS are usually within the normal range of intelligence (IQ) with a considerable number falling into the upper end of the range

The most noticeable symptoms (and well known) are vocal and motor (movement) tics - tics are involuntary behaviours (although they can often be suppressed)

Some individuals are aware of an 'urge' to tic but may find it very difficult to prevent them from occurring

Motor tics may include blinking, nose-scrunching, pouting and other facial tics, eye-rolling and looking in unusual directions, head nodding, neck-twisting, shoulder-shrugging, limb movements, walking-strangely, muscle tightening relaxing (e.g. abdominal and limb muscles, flexing fingers, diaphragmatic movements, tongue movements) and many more. Diaphragmatic movements (tics) may affect breathing efficiency and throat, tongue and soft palate movements (pharyngeal/laryngeal/oesophageal) may affect eating, drinking and swallowing activity and can result in choking.

Vocal tics may include grunting, throat-clearing, squeaking/squeeling, tongue-clicking, blowing raspberries, exhaling rapidly or forcibly, blowing sounds, sniffing, blowing air through nose, calling out words or phrases, repeating other words/phrases or sounds (echolalia), repeating one's own words (palilalia) and making almost any other sound possible

Although highly publicised in the popular media, the symptom of copralalia in which curse words or obscene words are spoken is a rare condition in TS and affects only 10% or less of individuals. This figure is probably much lower in reality as improved diagnostic expertise has revealed TS to be more widespread with the vast majority of cases not involving copralalia. Some individuals also have copropraxia in which gestures are performed that are considered 'socially unacceptable' or rude.

Many people with TS tend to speak impulsively and will often say things spontaneously without being able to filter them out whereas other people might have such fleeting thoughts which go no further. This may include inappropriate words that may nevertheless be very true and relevant to the situation but are perhaps not generally socially acceptable.

Tourette Syndrome, in most cases, becomes apparent during early childhood and a child will usually experience symptoms before the age of 10 years and usually by 18 years. Although often becoming noticeable between the ages of 4 to 7 years it is usual for parents to be able to remember signs of it retrospectively at an earlier age.

There are some incidences of late onset in adulthood however these are sometimes seen as an increase in severity in people who have have had a milder form during earlier life.

Currently TS is diagnosed when both vocal and motor (movement) tics have been present most of the time for at least one year.

There are however many other symptoms and vocal and motor tics are really just the 'tip of the iceberg' but usually the part that gains the most attention.

The following are often a part of Tourette Syndrome:

- Obssessive and compulsive behaviours (OCB). These are neurological in origin (e.g. developmental) and a part of the TS spectrum. They usually differ substantially from the pattern seen in the psychiatric disorder, obssessive compulsive disorder (OCD) and tend to be realtively unresponsive to the drugs commonly used for treating OCD.

- Complex tics: may include: touching and tactile contact with objects and other people, twirling around, touching the ground, jumping and sequential or ritualistic behaviours. These are closely associated with compulsions and it may be impossible to distinguish them from each other. Many tics both simple and complex have a strong compulsive element.

- Impulsiveness

- Sensory hypersensitivity and difficulties with processing sensory input

- Attention deficit and poor concentration

- Sleep difficulties

- Hyperactivity

- Unwanted, 'swirling' and intrusive thoughts (these are rarely talked about but may be very unsettling and distracting to the individual and in some cases become a great difficulty)

- May talk rapidly or excessively. There may be a tendency to perseverate over a topic until it is exhausted due to a need to 'get to the bottom of things')

- Increased urine flow (polyuria) due to abnormalities in the production of neuro-hormones that control water reabsorption in the kidneys (deficit of anti-diuretic control)

- Stress may cause an increase in TS symptoms

- Emotional volatility (some people with TS find it difficult to control impulses and emotional responses  and may experience 'rage' epsiodes

- Stuttering and other speech difficulties

- Impaired ability to 'read' other people's intentions e.g. may not realise they are being deceived or mocked

- Strong need to socialise (although this is often offset by the difficulties that are sometimes experienced due to others reactions and attitudes towards 'Tourettic' behaviours and also to simple prejudice)

- Many of the symptoms and difficulties of Tourette Syndrome are a consequence of reduced filtering by the brain of impulses (motor, thoughts, emotion, vocalisation etc.) and sensory input. Many individuals experience 'low latent inhibition' in which they are aware of an overwhelming amount of detail in their environment which must be consciously and selectively filtered

It is not uncommon that in adulthood there may be an apparent lessening of motor tics. Many people are better able to manage or suppress tics with age although much of the 'hidden' part of TS will often remain. Some people are able to divert motor tic activity and make their tics less noticeable. Many tics may occur in muscles that are less noticeable such as the diapragm, the abdominal or gluteal muscles or involve tightening and relaxing. in some individuals the obssessive and compulsive symptoms may increase with age or there may be an increase in motor or vocal tics later in life. The pattern is highly unpredictable. Most adults report that overall their TS remains with them throughout their lives.

- In children there may be many issues that affect learning: these include slow reading and writing speed (although often very early and proficient readers and excellent at spelling and vocabulary), poor attention and concentration due to sensory processing difficulties and tics and distracting thoughts (thought tics). They may also experience difficulties socially due to other children's perceptions and reactions. One of the greatest difficulties a child with TS may have is having difficulty with following the many 'rules' and restrictions  imposed on them at school. Impulsiveness, involuntary tics and other behaviourisms do not fit well with the constraints of the classroom and the need for order and discipline. Teachers may have to develop an appropriate level of tolerance while still imposing 'normal' restrictions for other pupils. The key to this is usually 'talking about TS and education about the condition among pupils and staff.

Diagnosis can be elusive for many .... is this ineptitude?

In the majority of cases, late diagnosis is usually a consequence of inadequate knowledge and poor diagnostic skills on the part of doctors. TS is not a rare condition and has a complex but comparatively unambiguous clinical presentation. Doctors like to cite an assumed rarity as a reason for not having sufficient knowledge. The reason they have not supposedly encountered it (it's the same with teachers who say they have never seen a child with it) is because they are often unable to recognise it and often have an erroneous perception of the symptomatology.

Misdiagnoses abound and include depression (most common), psychosis (schizophrenia), bipolar affective disorder, ADHD, autism and personality disorders. TS is actually a relatively easy disorder to diagnose and few other conditions are closely similar in terms of the combination and expression of symptoms. Compare for instance with Asperger's or high-functioning autism which has a broadly similar incidence but is extremely hard to determine in some individuals.

There are few excuses for a lack of knowledge in medicine. Doctors are professionally bound to be competent and to ensure their knowledge and ability to manage the conditions they encounter is not wanting. They should be honest if they do not understand something outside their competencies. In that circumstance they must refer to an appropriate specialist. It is unprofessional to falsely claim an ability to diagnose or treat a condition. There have been a number of court cases resulting from missed or misdiagnosis of TS where negligence or incompetence has been claimed. The defence is usually that it is a consequence of 'ignorance' rather than 'negligence' and that TS is a 'rare' condition.


Why are so many doctors unable to correctly recognise disorders such as TS that have very overt symptom patterns and are in hindsight unmistakable? I personally know of doctors who have failed to detect serious life-threatening conditions that had very clear presentation (symptoms and signs) that would not be missed by any medical student, who would have been 'failed' had they done so. As patients we must demand higher standards and ensure we are better educated ourselves about TS and it's pharmacology than many of the physicians who claim expertise. In many cases this is not too difficult! There are many good doctors but still too many who get things wrong without reason. Although with some the reason is one of personal opinions and stereotypical thinking and not based on evidence or good awareness of the medical literature. 


I feel a need to rant a little on this issue. My own parents were told by doctors 'it is just a habit he will grow out of' and that it was nothing to worry about and then later, when TS was eventually established as the diagnosis, I was informed 'it will get better as you get older and disappear' well I didn't and it hasn't. I now know many children and adults with TS and they offer collectively a very different perspective of the disorder, one brought about by first-hand experience and knowing existentially what it is like. It is not just about what others see (including physicians) e.g. some of the more noticeable 'tics' - there is so much more and that is the part that is usually 'for life' and that gives the greatest difficulties. Often it is that very aspect of TS (and it's associated symptoms/conditions) that physicians will deny exists - a source of much annoyance and exasperation to those afflicted.

your child has TS but you do not ....

I think if you have a child with TS but don't have it yourself it is always good to speak to adults or older kids who do as they can give some insight into what it is like (and have lived with it for some time). However all cases vary and there is no one defining normal presentation. Individuals manifest different aspects or combinations of the spectrum of symptoms and behaviours. Parents of TS children often confer mostly with each other and can end up going round and round in circles trying to pin things down, working out parenting approaches and making sense of the collection of 'so called' comorbidities and the confusing and often contradictory literature on TS and it's treatment/provision. I think TS, although a complex disorder involving central processing, needs to viewed holistically, as an integrated whole and not as a bewildering collection of separate disorders. Always beware of over-medicalising developmental disorders like TS and ASD etc. and getting too much into an 'illness' perspective.

People with Tourette Syndrome are not mad

TS is no more a psychiatric illness than autism or cerebral palsy. TS does not mean someone is odd or a social misfit or indeed 'mad'. Most are of normal to above average intelligence and are able to function within a normal environment. Dr Shapiro, a pioneer of the modern functional approach to TS, (a psychiatrist but an enlightened one who helped debunk the Freudian nonsense that once prevailed) once said that it was amazing that with all the difficulties people with TS experience, it is surprising that so few develop mental illness or psychoses. Tourette Syndrome is a neurodevelopmental disorder. Far from being diminished by their Tourette's, it seems that many with the condition are able to outperform others in many areas of endeavour when given the chance. This includes enhanced cognitive skills, rapid thinking with lower rigidity of thought patterns, great imagination, creativity, empathy, honesty (reduced deceptiveness), obssessive commitment and drive and when it comes to motor skills these have been shown in cases to be well above average: speed of movement, reaction times and accuracy. Perhaps being less deceptive comes from the difficulties many with TS themselves experience with reading other's 'intentions' and especially in detecting deception. These attributes are often expressed in musicianship, art, academic ability, science and sports and even comedy. Indeed humour seems to be very important to many with TS and they are often quick to point out the funny side of things or make a joke. There are even excellent Tourettic doctors and surgeons (in the US/Canada) including a family practitioner who has received an award for his work. Sometimes I think other people might be envious of those attributes rather than be bullying and prejudical.

"ADHD, 'comorbid disorders' and the Tourettic Mind

Response to a recent question: Are "ADHD and other 'disorders' comorbid with TS?"


It is unlikely that someone with Tourette Syndrome would not have some degree of attention deficit or hyperactivity - that is the nature of TS. I personally don't believe children or adults with TS always require an additional diagnosis of ADD or ADHD. It is a part of the psychiatric approach to split spectrum disorders into separate 'so-called' comorbidities. The clinical evidence to support this trend is flimsy and often anecdotal and I think in time it will be looked upon as merely collecting or fencing-off symptoms into 'theoretical' disorders (I'm only talking about spectrum disorders here e.g. Autistic Spectrum Disorder, TS etc.). 


There appears to be a distinct difference in the way those without TS 'understand' and describe the disorder compared to those who actually have it. Many people (including health professionals) think of uncomplicated TS as being the cause of movement and vocal tics only because that is what they may see or hear. The reality is rather different. The brain does not consist of two disparate disconnected components, the 'mind' part and the part that controls the 'physical' body. The areas that appear to be implicated in TS are central and involved in filtering and selectively responding to and processing incoming neural transmission whether originating from the motor cortex (afferent signals), sensory input (efferent signals) and the intellectual/emotional/memory areas that are involved in thought and cognition. Vocal tics for instance are not just 'mindless' commands to the vocal apparatus to produce noises - they are often cognitively-based and involve both a compulsive urge and a degree of context or thought-derived influences. Many tics are wholly purposeful and involve a high level of awareness, others may occur with little conscious 'thought' involvement. Mind and body are integrated neurologically and externally noticeable tics (not all are easily observed) are just one aspect, and not always the most important, of the high level of 'brain' activity that may be almost continuous. This unseen but nevertheless intrusive activity, is often referred to as 'tics of the mind' although the true meaning of the word tic does not lend itself well to representing these phenomena. Tics of the mind may or may not give rise to behaviour that has a physical expression. What others observe as TS (tic behaviours) is often merely the 'tip of the iceberg'. There is something of an arrogance among others, without TS, in assessing the severity and consequent impact of TS on the individual purely by means of what 'they' can see. They have little or no inkling of what takes place in the mind of someone with TS, and they themselves, in turn, cannot imagine what it might be like 'existentially' not to have a Tourettic mind. There is however often an affinity between people with TS and those who have high-functioning autism, SPD or ADD and an authentic mutual understanding may occur. This is particularly the case with respect to the difficulties shared between the autistic and Tourette spectrums in relation to understanding intentionality, deception and conversational reciprocity (turn-taking) and the initiation, wrapping-up and general protocol of sustainable social interactions. Both are prone to obsessions, perseverating excessively on a favoured topic and not knowing how and when to stop talking. They similarly often fall prey to social 'faux pas' or inadvertently saying the wrong thing.

 Much of psychiatry (but less so in neurology) is about theoretical disorders. Psychiatrists do not 'prove' most exist, nor cite any evidence-based mechanisms or investigations and more importantly few will claim to ever having 'cured' a patient of a psychiatric disorder. At a recent meeting of the American Association of Psychiatrists, all who were asked if they could recall ever having cured a patient of a psychiatric illness, responded with the admission that they could not.

 It is true that people with ADHD and those with TS share symptoms just as those with ASD and those with TS also share symptoms but symptoms do not make a 'disorder' they are indicative of any underlying pathophysiology, which in most 'psychiatric' disorders is entirely lacking. Both TS and ASD (neurodevelopmental disorders) have strong neuroanatomical and neurophysiological correlates that can often be found on clinical investigation. Evidence suggests people with TS have high brain dopamine activity, especially in the basal ganglia  of the brain which plays a role in filtering/inhibiting nerve impulses flowing between the higher cortex of the brain and the body. In TS it appears this function is impaired. TS appears to be a disorder of 'neuro-inhibitory dyregulation' or dysinhibition. People with TS (like those with ASD) may be subject to excessively detailed or hyper-sensitive sensory input which they are unable to filter without conscious intervention or compensatory strategies. Similarly they  experience reduced control of impulses and compulsions (e.g. motor, speech, thoughts etc.). There is little requirement for the additional labels of ADHD/ADD. In TS, brain serotonin levels appear to be low and may, in part, be responsible for an increase in obssessive and compulsive behaviours (OCB). Low brain serotonin and nor-adrenaline activity may also, in part, explain a succeptibility to low mood. Here again the additional acronymic label of OCD and also major depression may be applied as if they are discrete but co-occurring disorders rather than symptoms shared by both TS and those disorders.

How many are aware of an individual with TS who does not experience a degree of attention deficit and impaired concentration or who is not somewhat driven, restless and obssessive (hyperactive)? It often goes with the territory.

big pharma and medication

At my med school (in UK) there was one consultant psychiatrist in particular who made a point of encouraging us to avoid all contact with the pharmaceutical companies and not to accept all the freebies they offered us (free lunches, equipment, pens, medical conference fees etc) nor to accept appointments with their sales people as he said it makes you less objective about prescribing drugs. Prescribing should only be done on good clinical grounds and only when in the best interests of the patient. I remember after his talk, which boldly was at a pharm company sponsored meeting to discuss clinical psychiatry, I went to the cafeteria for lunch and he and I were the only ones there buying our own lunch all the other docs and med students were having the free food provided by the pharm company.

There is quite a strong relationship between psychiatry and the big pharmas. A lot of clinical research funding come from them inevitably, however they are in the business of selling drugs and that also involves getting docs to prescribe them. Increasingly psychiatrists are not providing non-drug therapies such as psychotherapy and long consultations etc and are becoming locked into an alphabet-soup diagnostic trend and in precribing multiple medications for those supposed conditions (comorbidities). Worringly children are being diagnosed at an earlier age with psychiatric illness and prescribed drugs that potentially may have and have had in some notable recent cases, serious side-effects.

bit of a rant about awareness

While the United States is having a Tourette's Awareness Month (May 15 - June 15), the UK is in the throes of a Tourette's Ignorance Month. Understanding and awareness in the UK seem to be at an all time low. I've heard of so many friends being abused and mocked in public. Are we living in medieval Britain or is this the 21st Century in one of the world's 'apparantly' advanced and educated societies? 


There is currently a 'disability bashing' trend in this country which many feel has been encouraged by the retrogressive attitudes proliferated by David Cameron's government. People with disabilities are having benefits and support withdrawn when at the same time there is no legal protection against disability discrimination by employers. Those with 'disabilities' who are willing and able to work are usually not allowed to and so are trapped in a 'nowhere zone'. People with TS need to have the same right to employment that others enjoy, not made to feel like outcasts not worthy of consideration. Sorry .... bit of a rant .... but feel so passionate about all this!

Tourette Syndrome in the classroom ... for teachers too!

Teachers frequently have difficulties understanding the needs of children with Tourette Syndrome. Despite the free availability of detailed information and advice in the literature and in the the form of printed educational material, videos and presentations by the Tourette Syndrome Association (TSA, Tourette's Action) there still remains much uncertainty among teaching staff about the disorder and the accommodations and provisions that should be considered.


I suggest that the following issues should be a principle concern for teaching staff who have a child with TS in the class:


Always remember that children with TS are often very bright and quick-thinking  but their abilities may be overlooked and less obvious due to the difficulties they may experience. Most fall within the normal IQ range but many are towards the upper end.


Reading speed may be slow despite the fact that children with TS are very often 'early readers' and are very quick at picking up a large vocabulary and are frequently good at spelling. Also be aware that some children with TS may also have dyslexia. A large part of TS involves problems with central processing which may cause a child to have sensory processing difficulties and a poor ability to understand information and concentrate in a busy or noisy classroom. An important aspect of TS is reduced inhibition which may have the consequence of apparantly poor impulse control and may also affect sensory input resulting in hypersensitivity to sound and visual stimuli or other 'disturbances'. They may also have difficulties with using keyboards and in interacting with screen-based text and information.


Written asignments and homework may take the TS child much longer to do than for other children.


In written tests / examinations, additional time or untimed assessments should be considered if there is any indication that they are unable to keep up with the performance speed of other children.


If necessary provide separate accomodation for the child when taking written or other tests / examinations as they may otherwise focus most of their concentration and attention on suppressing their tics and trying to still quietly and trying to remain still for an extended time rather than focusing on the task at hand


Children with TS may suffer from polyuria (frequent need to pass urine) due to neurohormonal imbalances which affect the production of urine in the kidney and reducing water resorption. They should be permitted to leave the classroom to visit the bathroom/toilet whenever they need to and NOT have to ask. Many children are painfully embarrassed by having to constantly ask the teacher in class. The same goes for long examinations and is an additional reason for exams being untimed.


Importantly, if a child, as part of their Tourette Syndrome, calls out or makes inappropriate comments or in rare cases, may curse or make 'socially unacceptable' gestures, do not constantly admonish them. These behaviours are tics and are mostly involuntary. Some children are able to intercept them or suppress them but many cannot and have little control over them. The worst response is to tell them off each time and especially to embarrass them or ridicule them in front of their classmates. Children with TS are often less able to respond to tics and have a low awareness of them. Although they may have little ability to suppress or hide them, doing so increases the stress that 'builds up' inside and can exacerbate their difficulties. Don't fall into the trap of assuming that children with TS will be shouting obscenities and expletives, this does occur but is a rare aspect of TS and ridiculously over-emphasised by an ill-informed media. 


If children with 'special needs' are to be integrated into mainstream classes then teaching staff must excercise an appropriate level of tolerance for children with TS. It is unacceptable, and akin to institutional bullying, to tell a child to 'stop doing that' every time they exhibit symptoms of their disorder. Would you tell a child with cerebral palsy to stop talking in an manner or walking strangely, or a child with autism to stop 'obssessing' or 'look into my eyes when I'm speaking to you' or a child with epilepsy to stop having seizures. Chidren with TS have so much to contend with and are often painfully self-conscious about their disorder. They have few enough opportunities to form close friendships at school and therefore need empathy and compassion not condemnation and negativity which other pupils pick up on and which further isolate the child and further enhance their reputation of 'being different'.


Most adults with TS report that although other children did bully them at school and elsewhere, it was the 'bullying' by teachers and authority figures that was the most traumatic and the hardest to forgive in hindsight (and to most incomprehensible). Rest-assured this does happen frequently and research shows that children with TS are often treated in a very different way to children with other disabilities. The way in which many were treated by teachers is seen as unprofessional and a breach of the trust that society places in such professionals and is not behaviour that suggests as acceptable level of integrity. I have heard first hand accounts of the most appalling actions or verbal abuse by teachers (and latterly by college and university lecturers and more worryingly doctors). Some teachers have even encouraged mocking of a Tourette's child by other pupils during class and have joined in.


It is also absolutely vital that as a teacher, you talk to pupils in an informed way (assuming the child and it's parents have given permission) and let them know what to expect, what TS is and how they can help their fellow pupil negotiate their difficulties at school. Above all teach acceptance and tolerance but also set a good example for your pupils to follow.

for appearances sake only ....

An example of the atitudes towards disability in professional training: When discussing support and accommodations with the senior tutor (also doubles as pastoral care co-ordinator) of my medical school in relation to my 'disability', I was informed that all medical schools have an obligation to follow the General Medical Council's strict guidance on equality for medical students with disabilities. However the same individual then went on to tell me that "we can give students with disabilities all the support we can offer but they are rarely successful".  Is it not then surprising that such students should feel that they have the odds are stacked against them and that they are struggling constantly against negative and stereotypical views.


This typifies the perspective that is prevalent that people with disabilities should be 'patronised' and 'allowed' to join in with what other 'normal' students do, just to give the appearance of acceptance and suggest no discrimination exists, but at the end of the day they are still not really considered to be of the same value as others and are merely taking up valuable university places. In a nutshell they are not taken seriously!


I'm absolutely convinced that when it comes to the professions such as medicine, teaching, law etc. there is a sense of effrontery that their 'exulted' profession could possibly be carried out effectively and with a high level of competence by someone who is in essence seen as 'less' than them. They undoubtedly feel it somehow diminishes their own status, and that of their profession when a person with an 'impairment' can do the same job as they do; heaven forbid that they might even do it better. This kind of prejudice is so deeply ingrained that no limits are to be found to the 'clever' intellectual arguments that are dragged out with regularity in order to make what is a, purely, discriminatory stance in most cases appear acceptable: 
"Would you want someone like that teaching your children?"
"They wouldn't have the necessary cognitive skills"
"They don't understand other people" 
"Patients could be put at risk" 
etc. 


Of course 'normal' teachers or doctors would never represent a source of similar concern. Before people judge they should at least educate themselves about disorders such as Tourette Syndrome, so they can argue their points from an informed perspective rather than one of ignorance. I have experienced this on many occasions and more often would describe it as 'willful ignorance'.


As it turned out almost no support was provided by my university. In fact the more I told my department about my 'disability', the harder thay made life for me. I was not permitted any accommodations and 'reasonable adjustments' at all in regard to teaching and assessments. I was instead put through a gruelling nightmare of committee meetings, required visits to hospital consultants, additional course requirements not imposed on other students and in addition was subjected to discriminatory and offensive comments by members of the medical school staff. Essentially they were more concerned with finding ways to lessen my chance of qualifying than in giving me the encouragement and support I needed (and was entitled to by law). My 'disability' was also used as an effective means to ensure maximum difficulty for me by placing me under as much stress and uncertainty as possible by dragging out their offical assessment of me for as long as possible (I did not even know if I would be allowed to practice medicine after more than a year of being considered at the time of my final exams which had had to be postponed for one year already due to this process). As my condition is 'life-long' this would be a permanent outcome and I would have wasted 5 years of my life working so hard and getting into enormous debt as a student. The medical school staff were fully aware that Tourette Syndrome is exacerbated by undue stress and took every opportunity to pile as much stress onto me as can be imagined. My fellow students (excepting some with disabilities) were not subjected to this treatment and hence were permitted to enjoy their final year and the excitement of qualifying and starting their first hospital jobs - I instead was put through hell and it became the most miserable period in my life which even several years later I find difficult to even think or write about.

not the individual who decides they are not fit to work it is employers

If there wasn't so much prejudice and discrimination in the UK, toward people with neuro-developmental disorders such as autism and Tourette Syndrome, many would not have to claim Disability Living Allowance or ESA or be assessed by organisations such as ATOS with doubtful medical expertise. Many with TS know they are able to do so much in life and have valuable abilities -all they requie is the opportunity. They do not need to be assessed regularly to determine their 'fitness to work'. Their 'disability' is life-long and neuro-developmental, it will not miraculously disappear or be 'cured' between successive assessments. It is employers who ultimately decide they are not 'fit to work' when they choose to disregard an application or make you redundant. Naturally no discrimination is admitted. There are always other 'plausible' but nevertheless transparent excuses made. What the UK needs is a REAL Disability Discrimination Act that is rigorously applied, to prevent people with 'disabilties' being trapped (often in near poverty) because they are denied similar opportunities to others. The UK allows shocking levels of discrimination towards people with disabilities (even when they might not regard themselves as disabled) and any official or legal complaint tends to be disregarded. It starts at school where teachers are often the principle source of bullying and continues through to adult life. Discrimination in the UK is frequently institutionalised and is seen even in government (e.g. House of Commons) and the BBC where few employees have disabilities!


A dramatic cut in the availability of benefits to those with disabilities could mean many will not  have sufficient income to live on if they are not able to secure employment due to discrimination. The UK has no advocacy to help such people negotiate with potential employers nor can most afford legal representation to tackle discrimination.

tics are not the issue .... other people are!

I think something that is rarely addressed on support pages, or in groups, in relation to the probems of TS, is the issue of income and how to make a living. Tics, obssessions, compulsions etc can be lived with and are just a part of life with TS and are not always the biggest challenge in life.


Many people just get on with their lives and make the most of it. The symptoms of TS may or may not be amenable to successful treatment with medications or other therapies but I feel the single most important difficulty is in earning a living. I don't think people realise just how much having TS can affect career opportunities and access to higher education and training. These are only an issue because of others' intolerance and unwillingness to give someone with TS a chance and see through the 'disability'. It is not a problem that lays with the individual with Tourette's or their capabilities and abilities, many know they can do things as well as others and really do believe in themselves, it is just other peoples prejudices that are the problem. People with TS need only to be 'treated like everyone else' and allowed the same opportunities. The medical aspects of TS tend to be, I feel, always over discussed. What we need above all is AWARENESS & OPPORTUNITY! I get so angry sometimes with having to work so much harder than everyone else to get the same opportunities or be denied them just for being 'different'.

When you have kids of your own, it really hits hard because you want to be able to give them the best life you can but when you can't earn enough money that is not easy!

who should support whom .... everyone needs consideration

I know having TS makes you realise how little most people without it actally understand about what it 'feels like' or exactly what difficulties you experience (I include many doctors/professionals in this too). However when you live with someone (e.g. your child/parent/partner etc) who has TS, I think it is possible to gain a very good insight and know almost as much as a TSer. The frustrating thing for parents, if they don't have TS and so have by definition usually little experience if thier child is young, is that it is all so bewildering and they need to understand quickly and get necessary support. If you are a parent with TS (I am) then you will be already well-equipped to raise your child if they have TS and give them the help they may need.

I am very aware that non-TS parents are very much present on FB groups etc, but I can also understand why and it is up to those of us who can offer advice and support to offer it when we can. There are, sometimes, complaints that non-TS parents completely take over support groups. The TS parents probably don't need to discuss personal issues quite so much online. It is also acceptable to discuss personal experiences (although not voluminously!) in such groups when it adds to the general understanding about TS, helps others and especially if it is in response to a request for advice from a parent. Don't forget there are many young people on support pages too who have TS and are able to offer a lot of advice. Many are amazingly knowledgable, very articulate and care about others who are having difficulties. 

There is also the issue of tolerance. TS can make people express themselves in a certain way that doesn't always accord with others. They can also be less inhibited and provocative. Everyone needs to show tolerance and to give others a bit of lee-way however having TS is not an excuse for being rude or discriminatory intentionally. Blogs are a great idea for posting personal stories and should be used more (ideally links can be posted on FB/Twitter so others can follow).

be careful with labels ....

Labelling a child with autism or TS etc without careful and well-informed consideration or objective appraisal, is risky especially when it is done by people who think they have a special understanding of such things but have only picked up a few concepts. Symptoms may or may not belong to one disorder or another. It is the holistic picture that counts with diagnosis. There are many shared symptoms and 'difficulties' that can occur in several 'disorders' but it is the grouping of those symptoms that matters together with collateral evidence from family members etc. People with an interest in psychology or even qualified graduates of psychology frequently have a distorted and non-organic perspective of autism, TS, ADD etc that lacks the biological/medical grounding needed to properly understand the basis of those conditions. The most dangerous are the Freudian's who interpret things wholly in terms of life experiences and early childhood disturbances.


Most responsible paediatricians and neurologists will hesitate to label a developmental disorder initially but will advocate a period of watchful waiting in order to develop a better picture of a child's development, behaviours and symptoms. The best approach is to merely describe what is seen and record the facts and allow time for a clearer picture to emerge before attempting (or announcing) a synthesis and diagnosis. Diagnosis needs a tentative approach.

I worked with and still know many people with autism and have been amazed at what I learn from them (from their perspective) and how wrong some of the explanations and misconceptions about ASD are, as well as the formal teaching I received about this disorder. This is a good reason for those who have TS, or live close to those who do, to 'take control' and become the rational voice of TS. It is also important that a more accurate, inclusive and consistent definition of what TS is, and the spectrum of difficulties that it may involve, is presented by the TS community. Part of the problem is the splitting approach (alphabet soup) favoured by many which makes TS very difficult to explain in a cohesive way and can make the person sound like a living psychiatric diagnostic manual.

Where and who are the experts?

People with TS need to take possession of the 'disorder' in terms of raising awareness and respresenting their rights. It is time to demand a certain standard of provision in terms of medical care, education and human-rights and to require adequate explanations for why they are often treated less favourably than those with other more 'mainstream' conditions such as dyslexia, ASD or cerebral palsy. The medical profession in particular must be 'educated' in a more consistent way and misconceptions addressed. Experts (without TS) who have a true understanding are woefully uncommon. If you have TS you know what it 'feels like' and what information is intuitively 'logical' or illogical regarding TS.

The UK's paediatric 'bible', for example, a substantial textbook which is the standard reference for paediatric practice, contains only a few paragraphs on TS, in fact less than most factsheets, which is both disappointing and of little value for such a complex and prevalent disorder. I have dealt personally and trained with doctors who are professors in paediatrics, neurology and also psychiatry (and also neuropsychologists) and have been astonished at the extraordinary lack of understanding they have about Tourette Syndrome and it's clinical presentation, diagnosis and management. The only solution is for the 'TS community' to take charge of things to a greater extent and to push forward the improvements that are sorely needed.

Education through media portrayal - "Front of the Class"

Perhaps the best example of a movie that helps educate without being comedic or derogatory in any way is 'Front of the Class' about the life of Brad Cohen who, though determined not to let his dream of being a teacher go, came up against prejudice, ignorance and overt discrimination. He was denied 'reasonable adjustments' for professional examinations and encountered rejection and ill-disguised derision. The film portrays the challenges of living with Tourette Syndrome, how it is and is positive and life affirming. It's message really is just about Brad wanting to be treated the same way as everybody else and to be given a chance to prove what he could do when given the opportunity. A well made and sensitive film which would be my first choice for educating people about TS without showing them a documentary. 

Advocacy, rights and rational medicine

The question of rights and advocacy for individuals with Tourette Syndrome and other developmental disorders, is not really just a matter of pleading for special treatment that others don't enjoy. I see the frequent denial of opportunities and non-recognition of their abilities, that people with TS often experience as a form of passive bullying. They are frequently disregarded as suitable candidates for many professional roles. Their lives would be so much easier to negotiate if they were treated and accepted like other people and not always seen as different or a special case and subsequently side-lined. 


It is interesting that the autism 'community' have achieved much greater acceptance and awareness. This is, I feel, due partly to acknowledgment by medical professionals and neuro-scientists of autism (a relatively 'new' disorder) as an interesting or 'cool' field to pursue and specialise in. Few doctors, have an acceptable or credible understanding of TS. Little interest is shown, despite it being a well-described disorder with a greater body of information regarding it's possible neuro-physiology and many well-documented patient symptom profiles. Perhaps it's also due to TS being a bit of a tricky disorder when it comes to  classical  psychoanalytic approaches. I've met psychiatrists and psychologists who have a very confused and inaccurate picture of TS and are very resistant to adopting a neurological perspective of developmental disorders. Despite published evidence and a wealth of patient medical histories, profound misconceptions are prevalent and erroneous diagnoses are frequently made. It was originally determined to be a psychological disorder that arose as a consequence of severely 'repressed anger' which leads to a psychopathology that manifests itself in the symptoms of TS. Considerable risks lie in this tendency for psychiatric diagnoses or diagnosing a plethora of subjectively-derived psychiatric 'comorbidites'.


Acceptance of an assumed psychological aetiology was, and still is, resisted by people with autism and their advocates, who have had to dispel the psychoanalytical legacy of Dr Bettelheim (and others of the Freudian school), whose assertion it was that autism was a disorder caused by inadequate nurturing by cold, unloving parents (the refrigerator mother concept) and that it was an expression of the deepest childhood 'psychic trauma'. Autism like Tourette Syndrome is a neuro-developmental disorder. Some of the psychiatric mythology of TS was dismantled and dispelled by a psychiatrist (Dr Shapiro) who helped establish it's neurological pathophysiology initially by showing that dopamine-antagonists such as Haloperidol could help reduce the severity of tics and other symptoms.

comedic myth .... mocking does damage

Discrimination and the 'mocking' media depictions of Tourette Syndrome (the "comedic myth") are not a laughing matter - true you do have have a sense of humour and laugh sometimes at some of the stuff you find happening to yourself and others as a result of TS. The problem is that this is not just about being irritated by media stereotypes. These misconceptions have very real and damaging affects through disability discrimination and bullying against adults (& kids) with TS. 

It is about time that individuals with TS are permitted access to employment opportunities and professions that are commensurate with their abilities and educational status. For many with TS, gaining academic qualifications necessarily requires a level of commitment and determination that many people without TS could never imagine. Certainly many people with TS have to work significantly harder to study and pass examinations, especially when they are often not entitled to the educational support and accomodations that students with other developmental disorders may enjoy (e.g. those with autism, dyslexia, physical disability etc.). It is even more disheartening (and confidence-undermining) that, despite having good qualifications, you have to frequently settle for poorly paid or demeaning jobs where you are often working for or with other people who may have lesser academic or work-related skills.


Many of us have been denied employment and also academic training due to having TS, as a consequence of misconceptions or just pure prejudice - this is both highly illegal and disheartening for the individual and also financially damaging particularly when you have a family to support. Parents with TS would like to be able to help put their children through university also but are often unable to earn a decent salary and the effects of being seen as having a disabilty have thus a 'knock-on' and multi-generational consequence. I have lost opportunities on many occasions despite the fact that I have good qualifications and graduated top of my class at univ. I have seen so many other people who do not have the same academic qualifications get jobs and progress where I feel I've had to fight to get anything at all. This is a vicious circle as if you don't have money you cannot afford to hire a law firm to fight for your rights under discrimination law. I always try and stay positive but we really shouldn't have to fight continuously for the right to a live a normal life, have an education, a job and buy a home and so provide a good life for our kids.


The issue of advocacy and legal representation for people with TS who have difficulties with getting employment or education/training is something about which greater public awareness is needed (although such resources should ideally be available to all who are placed at an unfair disadvantage due to disability).

a matter of inhibition

A reduced or severely compromised ability to inhibit sub-conscious and conscious impulses is one of the greatest difficulties to negotiate for many people with Tourette Syndrome and one that leads to prejudicial attitudes in others and is often a key aspect in bullying of children with TS. Dysinhibition is absolutely intrinsic to Tourette Syndrome - the fallacy that TS consists of just vocal and motor tics is hopelessly outmoded. A central problem with TS is impulse control which appears to involve regions of the basal ganglia of the brain, in which one of the key neurotransmitters involved is dopamine. TS is a spectrum disorder and the concept of it being a collection of psychiatric co-morbidities with vocal and motor tics representing the TS component really has little clinical or scientific basis. Dysinhibiton is usually regarded as a psychological behaviourism and something that can be ameliorated by therapising or using medication to improve executive control. A similar situation is seen in 'Attention Deficit' disorders (ADD/ADHD) where poor impulse control affects the ability to focus thoughts, concentrate on one task at a time, filter sensory stimuli and not act impulsively or reactively. The reduced control of impulses in TS affects motor, vocal and thought processes as well as incoming sensory signals such as auditory, visual (e.g. reading), tactile, proprioception etc. The basal ganglia appears to have a significant role in filtering of 'information' and, when compromised, leads to greater expression of impulses and also inhibition of incoming stimuli. People with TS often have to 'consciously' perform these filtering functions which in other people are performed with ease and mostly without conscious awareness. The need to label the derivative or consequential aspects of TS separately, and align them with current psychiatric 'disorderism' is unecessary. 

Can anyone who has first hand experience of TS imagine a person (and especially a child) with TS not experiencing difficulties with attention deficit, impulsiveness, poor inhibition (dysinhibition), hyperactivity, uninhibited vocal expression and movements? Any reduction of the ability to filter incoming sensory input leads to problems with 'making sense' of the environment and opens the possibility for misinterpretation or over-reactiveness to sensory input. Many individuals with TS suffer with 'low latent inhibition'. They may 'see' the world around them in extraordinary detail (vision, hearing, tactile etc.) and so find it difficult to focus on the essential information that is only relevant to their interaction with it and other people. A child may seem to be daydreaming, indecisive or in a 'fog' when they are in reality experiencing racing and complex thoughts or may be overloaded with stimuli. Some parallels may be drawn with the sensory 'hypersensitivity' that is seen in autistic spectrum disorder (autism, Asperger's) which is thought to lie at the heart of the disorder. Individuals may shy away from sensory bombardment (sound, visual stimulation, tactile contact, taste, social interaction and sources of strong emotional stimuli (e.g. eye contact, questioning, physical contact) in order not to overwhelmed. This has been described with great eloquence by many with high-functioning autism including Dr Temple Grandin. People with autism will often find solace in and feel they gain some control over the environment, which 'impinges' upon them, by using ritualised comfort behaviours. These may include 'stimming', rocking, physical confinement, focusing on patterned and predictable structure etc. Some of these behaviourisms are interpreted by others as being obssessive and anti-social and that appropriate therapy is needed to get the person to take on the reality of the world. Strangely many people with autism, far from 'hating' physical contact at any cost, may sometimes crave physical contact and would love to be hugged or comforted but wish for this on their own terms, when and how they need it, but not always when others impose on them in an overly presumptive and unexpected way.