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					  Understanding Tourette
Syndrome, Related Disorders
   Effective Interventions
                  Kathy Giordano,
                  Education Specialist, TSA
         Tourette Syndrome Assoc., Inc.
Education                        Research                           Service
• Briefings                      • Grants                           • Information
• Education                      • Scientific Advisory              • Referrals
• Advocacy                         Board (SAB)                      • Fundraising
• Publications                   • Genetics                         • Local TSA
• DVDs                           • Clinical trials                    Chapters
• Conferences                    • Neuroimaging                     • Newsletters
• Public policy                  • Treatments

                                                                         There’s Room
                                                                           for YOU!

                  Our Mission Is To Identify The Cause Of, Find The Cure
                   For And Control The Effects Of Tourette Syndrome

                                                            Education, Research and Support   2
           A Teacher’s Perspective

I’ve come to the conclusion that I am the decisive
element in the classroom. It’s my personal
approach that creates the climate. It’s my daily
mood that makes the weather.

As a teacher, I possess a tremendous power to
make a child’s life miserable or joyous. I can be a
tool of torture or an instrument of inspiration. I
can humiliate or honor, hurt or heal.

In all situations, it is my response that decides
whether a crisis will be escalated or de-escalated
and a child humanized or de-humanized.

                                    – Haim Ginott

                                   Education, Research and Support   3
        Wise Words

“Don’t ever tell THEM what you
  like, because they will either
  make you earn it or they will
           take it away”

               Teenage Boy

                      Education, Research and Support   4
                “CHILDREN DO WELL
                   IF THEY CAN”

“If a child is NOT doing
  well, there may be a
  Universe of explanations”.

“If they CAN’T, then it is
  the job of the adults to figure
  out why so that they CAN.”
           Dr. Ross Greene “The Explosive Child”
                                           Education, Research and Support   5
           Major Life Lesson
We Cannot FIX! – They are not Broken!

                              BUT we Can &
                              Must Provide
                               Tools to help
                                Their Lives
                                  Education, Research and Support   6
           Educate the World
…… is the key to success for people with
 neurological difficulties. Educate peers and there is
 less teasing; educate teachers, there is more positive
 support, with academic and personal success; educate
 parents, there is understanding, nurturing resulting in
 increased self-esteem; educate the person, there is
 pride in who they are; educate the world and there is
 more acceptance and an increased emphasis on
 strengths, acceptance and similarities rather than
 differences and difficulties .

                                      Education, Research and Support   7
             Tourette Syndrome

• Neuro-biological disorder
• Genetic
• Involuntary
• More common than once thought
• Symptoms involve both motor and
  vocal tics
• Due to the nature of TS, symptoms
  will vary from person to person

                              Education, Research and Support   8
               Motor Tics

 Simple Motor Tics
    Eye blinking, grimacing, nose
     twitching, leg movements, shoulder
     shrugs, arm and head jerks, etc.
 Complex Motor Tics
    Hopping, clapping, throwing,
     touching (self, others, objects)
    Holding funny expressions, sticking
     out the tongue, kissing, pinching,
     tearing paper or books, etc.

                                       Education, Research and Support   9
                        Vocal Tics

Simple Vocal Tics
   Whistling, coughing, sniffling, screeching,
    animal noises, grunting, throat clearing, etc.
Complex Vocal Tics
   Linguistically meaningful utterances
        Coprolalia (racial slurs, inappropriate language),
         repeating words/phrases
Speech Atypicalities
   Unusual rhythms, tone accents, intensity of
    speech, stutter-like, immature voice

               Do Not Need To Swear
                                                  Education, Research and Support   10
       The Nature of Tics

• Naturally wax and wane
• Change in appearance and frequency
• Change in severity and intensity
  – May worsen during adolescence
• Can sometimes be suppressed for
  short periods of time
  – But suppression may cause unanticipated
    and undesirable consequences
• Important:       The Only thing
            consistent about TS is the
                                    Education, Research and Support   11
       Environmental Factors
      May Impact TS Symptoms

• Stress
• Anxiety
• Excitement
• Fatigue
• Holidays
• Illness
• Vacations
• Hunger
• Life & School

                         Education, Research and Support   12
                 General Suggestions for Tics
 Reduce Stress!!!!
     Most important and effective

 Planned Ignorance &
      Acceptance of tics =
        less frequent and with less intensity

 Ask permission to explain to peers
     “I Have TS but TS Doesn’t Have Me” Video
     TS Youth Ambassador

                                                 Education, Research and Support   13
                   Suggestion for Tics

Loud and more obvious (disruptive?) symptoms
   A private place where tics can be expressed
   Individualize approach – talk with student & parent

       Snack?             Water?
       Exercise?          Sleep/rest?
       Helping out?    Enjoyable activity?
       Reduce boredom?     Quiet place to ‘chill’

Try not to take symptoms personally

                                                Education, Research and Support   14





       Elevator story

                        Education, Research and Support   15
    Federal Regulations 300.8(c)(9)
    Comment Section

“We believe that Tourette syndrome is
  commonly misunderstood to be a behavioral
  or emotional condition, rather than a
  neurological condition. Therefore including
  Tourette syndrome in definition of other
  health impairment may help correct the
  misperception of Tourette syndrome as a
  behavioral or conduct disorder and prevent
  the misdiagnosis of their needs.”

                               Education, Research and Support   16
Negative Perspective of Behavior
   (the child IS a problem)

     mean             angry
 disrespectful     threatened

        offer ultimatum
                                            PACER Center, Inc., 1999

                        Education, Research and Support         17
  Positive Perspective of Behavior
     (the child HAS a problem)


             help                        PACER Center, Inc., 1999

                       Education, Research and Support        18
           Educate the World
…….education is the key to success for people with
 neurological difficulties. Educate peers and there is
 less teasing; educate teachers, there is more positive
 support, with academic and personal success; educate
 parents, there is understanding, nurturing resulting in
 increased self-esteem; educate the person, there is
 pride in who they are; educate the world and there is
 more acceptance and an increased emphasis on
 strengths, acceptance and similarities rather than
 differences and difficulties .

                                      Education, Research and Support   19
Positive and Proactive Interventions

   “Information is not Knowledge,
     Knowledge is not Wisdom,
      Wisdom is not Foresight.
        Information is the first
             essential step
            To all of these.”

             Arthur C. Clark
                               Education, Research and Support   20
     “Typical” Strengths

   Sensitive      Music         Creative
  Athletic        Humor         Writing
  Focused                           ART

                                 Education, Research and Support   21
    “Typical” Related Issues

   OCD             Anxiety          Hand-
  Sensory          Social Skills
      LD                            ADHD
   Disinhibition                   Dysfunction.
                     Sleep            Autism
    Gifted                           Spectrum

                                         Education, Research and Support   22
Giftedness disguises disabilities

Disabilities disguise Giftedness


                        Education, Research and Support   23

“A condition in people with primary neurological
  disorders that limit a person’s ability to use his
     inhibitory process and learned inhibitory
    “The individual experiences involuntary
   behaviors that include contextual swearing,
      free-associative comments, emotional
     outbursts, rage, infantile behaviors……...”
                                 Rose Woods
                             “Dysinhibition Syndrome”
                                   Education, Research and Support   24

BEHAVIORS”                   Mental Brakes
                   Education, Research and Support   25


                  Education, Research and Support   26
            Obsessive-Compulsive Disorder
                    (OCD) and TS
•   Obsessions
    – Intrusive and recurring thoughts
      and images or impulses that your
      mind gets stuck on which are
      unpleasant and disrupt functioning
•   Compulsions
    – Behaviors that are used to reduce the
      anxiety accompanying the obsessions
•   OCD and TS share chronic waxing
    and waning
    – Exacerbated by stress, excitement
      and fatigue
•   OCD is often not apparent to the
    teacher or other students
•   OCD makes children feel isolated
                                                         & Anxiety
                                              Education, Research and Support   27
Kids would almost
 always rather be
  bad than to be
            Education, Research and Support   28
            What to do for anxiety &
               OCD symptoms

 Strategize with student
    To-do-later folder
    Copropraxia – poker chips

    Develop Plan with student – Everyone sign
      Number of bathroom passes for the day
      Remove trigger (fire alarm)
      Class Schedule in clear location
      Trusted Adult
      Back-up for trusted adult

       Cognitive Behavior Therapy

    Be aware of whether strategy increasing anxiety

                                                      Education, Research and Support   29


“The minute anxiety
 arises, intelligence
 closes to search for
 anything that
 relieves the anxiety.”
Joseph Chilton Pearson
                             Education, Research and Support   30
      Neurological “Meltdown”
     A cumulative effect – Rick LaVoie

        “Vase” overflows
      and reaction frequently

Question: How do we reduce “vase”
     so less likely to overflow?
                               Education, Research and Support   31
          Dysgraphia - Written Language LD

 Characteristics may include

   Slow and laborious writing
   Hand and finger cramping
   Sloppy handwriting, e.g., uneven
    spacing, irregular margins, and
    inconsistent lettering
   Inability to copy correctly from
    book to paper or board to paper
   Inability to transfer thoughts onto
   Perfection

 Often can be addressed with the use
 of computer technologies
                                          Education, Research and Support   32
      What to do Dysgraphia or Written Language LD

Evaluations for Writing LD, Possible Assistive
 Technology Evaluations
Give extra assistance in class
   Use a scribe, provide class notes, study
    guides, alternatives methods of testing
Be proactive with assistive technology
   Research frequently changing
       assistive computer software (organization)
   Teach keyboarding early
   Use of computer at home and in class

                                         Education, Research and Support   33
      Processing Speed
• Difficulty following directions, whether
  simple or complicated
• Difficulty processing abstract
  information, such as math word
• Difficulty following conversations
• Difficulty with noisy
• Difficult responding quickly
• Difficulty following thru with
  information such as directions, lists
                                  Education, Research and Support   34
           What to Do For
           Processing Difficulties
Provide extra time for response
Develop a plan that allows student to know that they will
 be asked a specific question
Subtly provide extra cueing and prompting
Provide directions both auditory and visually
Keep directions brief
Provide visual, auditory & concrete examples
Allow preferential seating
Encourage student to ask for clarification

                                      Education, Research and Support   35
      Social Skills Deficits
Students with social skills deficits
  will tend to
   Be socially immature
   Interact better with adults than
      with their peers
     Experience some anxiety in social
     Demonstrate lack of judgment
     Experience social rejection
     Miss social cues
     Know what to do, but can’t “in the

                                           Education, Research and Support   36
         Helping Social Skill Develop

Pragmatic language support (speech therapist)
Use of social stories by counselor and the classroom
Participation in a social skills group
Encourage involvement in groups with similar interest
Focus on child’s strength/interest
Carefully place student when doing group work
Establish a safe classroom

                                       Education, Research and Support   37
           Sensory Processing Issues

Can affect any of the senses; cause great anxiety for
 many children with TS
Common indicators are:
   Sensitivity to touch, Noise, smells
   Inability to tolerate the texture of
    certain foods, fabrics, tags
   Sensitivity to bright or fluorescent lights
   Easily Overwhelmed
   Behaviors in unstructured settings

                                           Education, Research and Support   38
           More Sensory Issues

 Need for increased sensory input - Running into
  things purposefully, frequent hugs, painful
 Experiencing “sensory tics” e.g. picking at scabs;
  biting nails, scratching, hurting or hitting self
 Excessive chewing on clothes, or objects
 Difficulty in highly over stimulating
  environments such as the school bus, cafeteria,
  gym, hallways, etc

                                    Education, Research and Support   39
             What Can Be Done for
               Sensory Issues

Evaluation by occupational therapist trained
 in sensory processing issues
Sensory Diet - A plan is developed,
 explained and followed by all adults
   Use a headset to avoid auditory overload and
    distractibility (with or without music)
   Chewing Gum – hard candy           1. OT ‘web video’
   Weighted Jacket                    2. “Out-or-Sync Child” by
                                            Carol Kranowitz
   Exercise Ball/Bean Bag Chair
   Scheduled or as needed drumming, activities, etc.

                                             Education, Research and Support   40
         Possible Modifications

• Leave class 3-4 minutes early or late to
   avoid crowded hallways
• Avoid loud, chaotic environments
• Find alternate place to eat lunch with friends
• Allow Doodling, Movement, Sandpaper/Felt
• Reduced Distractions
• Separate Location for Tests
• Designated Space for ‘quiet’
• Breaks
• Be Creative

                                  Education, Research and Support   41
     Oppositional Defiant Disorder (ODD)

         “Chronically Inflexible”
                 Dr. Ross Greene

Could be: Means of Communication

  We Need to Look for Underlying Reason

                                   Education, Research and Support   42
Old Adage – In order to be
successful, we must work hard!
In order for some
students to work
 hard, they must
 first experience
“   But it’s not Fair……”
     Fair Is Not Equal


       Equal is not
                      Education, Research and Support   44
         Executive Function Deficits (EFD)
Executive Function = mental processes involved in goal-
  directed activity and ability to:
   plan and organize
   remain focused and ignore distractions
   retrieve and recall information
   have the ability to be flexible with changes in routine
    when encountering unexpected situations
   Keep track of Time
   Reflect on Work
   Wait to Speak until Called on

                                          Education, Research and Support   45
       Ex. Func. Problems May Manifest As:

  Difficulty planning and finishing a project

     Locating Salient Information

      Being Overwhelmed - Anxiety

 Beginning; remaining focused; completing assignments

 Struggles telling a story (verbally or in writing) – trouble
  communicating details in organized, sequential manner

 Organizing thoughts, materials, - Learning strategies

                                              Education, Research and Support   46
 Consultant/Resource Teacher/counselor
    Assistance
          Managing Work Load
          Check Homework – end & beginning of day
          Test/quizzes - quiet, read to, ensure understanding
          Trusted Person
          Checking in for progress on long term assignments

          Teach Life-long strategies
             Organization
             Time Management
             Writing Skills
             Changing Strategies midstream
             Editing

                                                 Education, Research and Support   47
            Regular Kids
 All walks of life & all professions
 TS is an Equal Opportunity Disorder
   o New Study – Caucasian boys; under reported
     in various cultures
 Students with TS are kids first
 TS is life long and at this time, there is no
 Symptoms can look controllable
    But they really aren’t
        You can hold your breath, but eventually you will

                                               Education, Research and Support   48
     Something to think about…..
If a child doesn’t know how to read, we teach.

If a child doesn’t know how to swim, we teach.

If a child doesn’t know how to multiply, we teach.

If a child doesn’t know how to drive, we teach.

If a child doesn’t know how to behave, we………

………..teach? ………….punish?
Why can’t we finish the last sentence as    automatically as we
do the others?

                     Tom Hemer (NASDE President) Counterpoint 1998
                                             Education, Research and Support   49
 Symptoms or Behaviors?

   Often complex symptoms are
  misunderstood to be purposeful
      misbehaviors. Instead of
   punishment, symptoms require
 support which allow students to be
successful in spite of this complicated

                         Education, Research and Support   50
•   Threaten consequences of a misbehavior ( stress)
•   Plant the suggestion of misbehavior (dysinhibition –
    inability to inhibit)
•   Restart the confrontation by immediately demanding
    difficult actions
•   Rehash the incident in front of peers
•   Have more than one staff person discipline student at
•   Ignore or interrupt students attempts at communication

                                        Education, Research and Support   51
   Remain Calm physically & verbally

   Provide time to shift gears (transition)

   Avoid debates, sarcasm, Put Down,
     Power Struggle

   Choose your battles carefully!!!!!

   Avoid the word “no”

   Why do Rewards sometimes „work‟ ??

                                         Education, Research and Support   52
 Reduce Stress/Anxiety when possible
 Allow Movement (doodling, gum chewing, etc)
 Promote hands-on activity
 Sensory diet
 Consultant, Resource Teacher
    Study skills
    Organization strategies & support
    End of Day check in
    Begin HW, ensure assignment written down
    Assist in Managing Workload/assignments
    Chunk materials
    Experiment with strategies
    Meet with team to assist with understanding & providing
     supports and strategies

                                            Education, Research and Support   53
      Suggestions, cont’d
Avoid embarrassing
Ask – what would help you (provide ideas)
Let them know you are attempting to understand
Let them know you are on their side; respect
Recognize how difficult and exhausting this must be
Remember the only thing consistent is the
Remind yourself – It Often APPEARS Purposeful

                                    Education, Research and Support   54
         Suggestions, cont’d
Symptoms can be just about anything –
Every person is Different; Resist generalizing
Invisible symptoms can be most disruptive
You WILL make mistakes and ok to discuss with student
Remember – “Explanation for Behavior” & ‘All students
 want to be successful’
Do Not Take Behaviors Personally

                                      Education, Research and Support   55
We expect that consequences, usually negative, will put an
end to behaviors that we believe to be „poor choices‟ and
replace those behaviors with those that we believe to be
„better choices‟.

•Works for 90% of students.

•What to do for the Other 10%

      •Symptoms of complex neurological disorder?

      •Some kids don‟t have ability to process consequences
      in the manner that is “typical/normal”

Natural & Positive Consequence -- (group)
        Individuals with Disabilities
           Education Act (IDEA)

IDEA 2004 requires that an FBA be
conducted and a behavior intervention
plan be developed whenever the
behavior of a student interferes with the
ability of that or other students so that
the behavior is less likely to re-occur.

                            Education, Research and Support   58
       FBA & PBIP
 Functional Behavior Assessment
    Process of determining why an individual engages in
     challenging behavior and how the behavior relates to
     the environment .
 Positive & Proactive Behavior Intervention Plan
    A written plan that provides what supports,
     accommodations and modifications (academic AND
     environmental) will be made by school to assist student
     and reduces likelihood of ‘behavior’ reoccurring.
     Reviewed as needed.

 Workbook for Functional Behavior Assessments and
 Positive Behavior Intervention Plans for students with
 Tourette Syndrome, ADD, OCD, Autism Spectrum
   Looking for Function (avoidance, attention, etc.) ???
   OR a symptom or result of a symptom

 Team Approach (include input from all providers,
 teachers, parents, child)

 Example of a simple FBA & PBIP

                                         Education, Research and Support   60
           FBA & PBIP

  Functional Behavioral Assessment Worksheet
     for a Student with Tourette Syndrome

A) General Information
Student’s Name ____________________________ Grade
__________ Date ____________

Name of Person Completing Worksheet


Position ________________________________________

                                          Education, Research and Support   61
        B) Behaviors Observed

1) The specific behavior(s) impeding learning

__ Off task behavior
__ Out of seat frequently
__ Talking out in class
__ Refusal to work
__ Aggressive behaviors
 __ Disrespect
 __ Dysinhibition
 __ Socially inappropriate behavior with peers
 __ Other

                                     Education, Research and Support   62
Describe precisely what the behavior looks like






_______________________ Use back for more room

                                   Education, Research and Support   63
2) How often does the behavior occur?

3) Where does the behavior occur?
__ In a particular class (Indicate class)
__ Hallway __ Cafeteria __ School bus __ Other

4) Where does the behavior NOT occur?
__ In a particular class (Indicate class)
__ Hallway __ Cafeteria __ School bus __ Other
                                  Education, Research and Support   64
5) When does the behavior most frequently occur?

__ During completion of written work
__ At transition times
__ Testing situations
__ In unstructured environments
__ When tics are exacerbated
__ In noisy environments
__ Interacting with peers
__ Working in groups
__ During a specific task; (Reading, math, writing on board, using a pen or
          pencil, etc.)
__ When directions are being given (__ oral __ written __Simple__Complex)

__ Other

                                                   Education, Research and Support   65
6) From # 2,3,4 & 5 which of the following conclusions might you
draw as to the possible reasons for the behaviors?

__ Attention difficulties __ Interfering tics __ Difficulty transitioning
__ Stress in testing situations __ Anxiety __ Poor social skills
__ Difficulty with written work __ Difficulty processing directions
__ Difficulty remaining seated __ Difficulty working with peers
__ Interfering obsessions __ Sensory overload in noisy environments
__ Sensory overload in unstructured environments
__ Other


** It is always important to consider medication impacts when
evaluating behaviors. Frequent communication with the
school nurse and the parents is crucial.

                                                  Education, Research and Support   66
      Suggestions for Supports

See Catalog of Accommodations for TS, etc.

                                     Education, Research and Support   67
                         Summary of Collected Worksheets
                             by Facilitator
B) Behaviors Observed

1) The specific behaviors impeding learning are: (Target no more than 2
_________________________ _______________________________

2) How often does the behavior occur?
3) Where does the behavior occur?
4) Where does the behavior NOT occur?
5) When does the behavior most frequently occur?
6) When does the behavior NOT occur ______________________
                                                  Education, Research and Support   68
           SUMMARY – from Surveys
6) From # 2,3,4 & 5 which of the following conclusions might
you draw as to the possible reasons for the behaviors?

__ Attentional difficulties __ Interfering tics
__ Difficulty transitioning
__ Stress in testing situations __ Anxiety __ Poor social skills
__ Difficulty with written work __ Difficulty processing directions
__ Difficulty remaining seated __ Difficulty working with peers
__ Interfering obsessions
__ Sensory overload in noisy environments
__ Sensory overload in unstructured environments
__ Other

                                           Education, Research and Support   69
              SUMMARY – from Surveys
C) Strategies / Supports to be Implemented

1) What changes/supports are needed to decrease the likelihood of the
   behavior reoccurring?

__ Writing supports __ Homework reduction __ Organizational supports
__ Testing modifications
__ Assistance with directions
__ Peer education
__ Assistance with transition
__ Social skills education
__ Assistance in reducing anxiety
__ Assistive Technology Evaluation
__ Reduction in amount of time in unstructured situations
__ Occupational Therapy/ Sensory Integration Evaluation & Supports
__ Provide student with specific strategies to assist with impulsivity,
         dysinhibition or other symptoms

                                                   Education, Research and Support   70
        Positive Behavior Intervention Plan

A) General Information
Student Name _____________________Grade _____ Date _______

Name of person completing PBIP ___________ Position _______

B) Behaviors Targeted
1) ____________________________________________________
2) ____________________________________________________

C) Hypothesized Function of the Behaviors (From # 6 of the FBA)


                                                Education, Research and Support   71
D) Behavioral Supports to be Implemented by Staff

1) _______________________4)______________
2) _______________________5)______________
3) _______________________6)_______________

E) Environmental Changes to be Implemented by Staff
2) _______________________4)__________________

F) Positive Rewards (if appropriate) to be Provided to Student for Progress on the

                                                        Education, Research and Support   72
                  Positive Supports

2) What other positive interventions, accommodations,
   modifications, supports, etc. will be implemented by the staff to
   assist the student in maintaining appropriate behavior?

3) How are Student’s strengths used?

(See accompanying possible accommodation sheet)

                                               Education, Research and Support   73
        G) Communication Plan

1) Who will coordinate the PBIP?

2) What is the date of the next PBIP review meeting?

3) Has every teacher/ staff member working with the student received
   and signed the PBIP?__ yes __ no

4) Has the student and parents been informed of strategies?
__ yes __ no

** Be sure to include the list of possible accommodation sheet when
  this is shared with the child’s teachers. **

                                             Education, Research and Support   74
      Critical Questions for FBA & PBIP
• Are there identifiable fast triggers?
• Are there identifiable slow triggers?

• Are there “warning signals” prior to

• Does the time of day play a role?
• Does general “mood” affect likelihood?
•What are the known techniques that reduce
likelihood of occurrence?
                                      Education, Research and Support   75
        Critical questions, cont’d

• How does the environment affect behavior?

• Do certain tasks, surroundings, events play a role?

• Are social, academic and task expectations

• Does the student respond better to a different style of
teaching and/or intervention?

• Are different motivators or incentives needed?

                                      Education, Research and Support   76
    Critical questions, cont’d

• Is it a result of dysinhibition?

• Is it either due to or an unrecognized symptom
  of related disorders? (Dysgraphia; Sensory;
• What are student’s strengths? How can they be
  used in positive fashion?
• Is student underachieving or bored? What
      specific support is required so this
      doesn’t occur?
                                     Education, Research and Support   77
      Critical questions, cont’d

• Does the student know what to do, but is not able
  to use this knowledge “in the moment”?

• Do we need to Un-teach difficult behaviors or
  Teach replacement strategies? (statistics show

• Has the student been taught alternative
  response or skill and HOW are these being
  supported by all team members?

                                   Education, Research and Support   78
     Critical questions, cont’d

•How are social skills? Need support?
• How is the word ‘consequence’ being interpreted
by providers? Does it mean ‘punishment’? Or
does it represent natural consequence of the
•How do learning deficits affect “behavior”
•Do we recognize & understand symptoms?

   Is the behavior worthy of an FBA or is
          planned ignorance best?
                                    Education, Research and Support   79
  James Patterson
    “If you are going
   around in circles,
you are cutting corners.”
                ‘Alex Cross – Nana’

                   Education, Research and Support   80
     Contact TSA for More
     Information and Resources

Tourette Syndrome Association, Inc.
       42-40 Bell Boulevard, Suite 205
       Bayside, New York 11361-2820
       Tel: (718) 224-2999
       Fax: (718) 279-9596

                                         Education, Research and Support   81

              Education, Research and Support   82

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