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Executive Function TS and Comorbidities

School is back in full swing now and as the curriculum progresses and increases in complexity, students have more information and activity to juggle and organize. Students need to manage their schoolwork, establish and follow a routine and schedule, manage time and prioritize tasks, and initiate and finish assignments. These skills are collectively referred to as “executive functioning skills.” In today’s blog, we are discussing how Tourette Syndrome (TS) and its co-morbidities can affect “executive functions.”

According to the Annual Review of Psychology, there are three common core “executive functions” and higher, more advanced skills are built on these basic abilities. First is inhibition, including behavioral inhibition or self-control. The second is working memory, and the third is cognitive flexibility. From these skills are built reasoning, problem solving, and planning – all essential for success in school and life in family and society.

Harvard University’s publication The Developing Child defines “executive functions” as a set of skills that underlie our ability to stay focused and ignore distractions, plan ahead, follow multiple step instructions even if interrupted, and display self-control. Humans are not born with these skills. They develop along the way when we, as young children, use the skills and practice them. Children with disabilities may, like older adults or adults who suffer traumatic brain injury, lack the capacity to be proficient in these skills and consequently these children have difficulty performing in school and in social situations.

Executive Function and Tourette Syndrome

Students with TS frequently require accommodations and substantial support to manage workflow. But do problems with ‘executive function’ and TS go hand-in-hand? Or is difficulty with ‘executive function’ related to TS’s common comorbidities? Tourette Syndrome is a complex condition and is often associated with other neurodevelopmental conditions including attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). Tourette’s, OCD, and ADHD have been shown to share common symptoms and genetic relationships. In a 2016 study, The relationship between tics, OCD, ADHD and autism symptoms: A cross-disorder symptom analysis in Gilles de la Tourette syndrome patients and family-members, researchers found that “TS is a disorder in which obsessive-compulsive (OC), Attention Deficit Hyperactivity Disorder (ADHD) and autism symptoms occur in up to 60% of patients, suggesting shared etiology.”[1]

Given the close relationship between TS and other disorders, it is easy to understand why ‘executive functioning’ difficulties are common among children with TS and may have a significant impact on their progress in school.  The ways to support children who are experiencing trouble with ‘executive functioning’ are varied as are the range of difficulties students display.  Accommodations in school, especially when a diagnosis and establishment of disability status is possible through an IEP or 504 Plan, can be a game-changer.

How can an IEP or 504 accommodate a student with executive functioning difficulties?

An IEP which is also called an individualized education plan, must set out, in detail, the student’s program of special education and related services – in other words, a roadmap specifically for that student to provide education and other services in a way suitable to that student and their disability. An IEP is highly individualized, with personally tailored goals and milestones. It contains a minimum set of components, or parts, that convey key information about your child and details about when and how the plan will be implemented. You can familiarize yourself with the eight key components of an IEP.

A 504 Plan is not based on the special education law but a civil rights law. It required schools and other institutions to remove barriers to access for individuals with disabilities. Examples of accommodations in 504 plans include:

  • Use of speech-to-text technology
  • preferential seating
  • extended time to complete tests and assignments
  • verbal, visual, or technology aids
  • allergy-free environments
  • behavior management support
  • adjusted class schedules or grading
  • excused lateness, absence, or missed classwork
  • pre-approved breaks or nurse’s office visits and accompaniment to visits

The goal of 504 plans is for students to be educated in regular classrooms along with the services, accommodations, or educational aids they might need. To learn more about IEPs and 504s, you may want to watch TOURETTE TALK: Are IEPs and 504s on Your Back to School List?.

TS and common comorbidities affecting ‘executive function’ do not indicate lower intelligence.

As a group, people with TS have levels of intelligence similar to those without TS. However, people with TS might be more likely to have learning differences, a learning disability, or a developmental delay that affects their ability to learn. Open communication and mutual understanding among the student, parents and teachers about a student’s symptoms, triggers, and possible coping skills is critical to managing the effects of decreased ‘executive function’. In addition to the resources mentioned above, NJCTS.org is offering a three part online camp on the topic of ADHD and ‘executive function’ starting September 27.


[1] HM Huisman-van Dijk, R Van de Schoot… – Psychiatry …, 2016 – Elsevier

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