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Question: My child has Asperger and Tourette syndromes. The school tells me that his work avoidance is not related to his disorders but instead due to his emotional disturbance. They say that he verbally tells the teacher to do things for him (when she asks him to get out his textbook he'll say, "you do it") and they say that they do not see tics, etc. They also say they do not see sensory issues and that his problems with turning in homework is similar to others his age so it is normal behavior and not related to his disorders. Any suggestions?

Answer: Many children with neurological differences such as in Asperger’s and Tourette Syndrome do not produce expected behaviors consistently, particularly when an expected behavior involves following the agenda of others. Doing what is expected by others requires an intact ability to take in available information (e.g., verbal requests, vocal tones, facial expressions), interpret it in a conventional way, think through possible responses and alternatives to predict their outcomes, and then produce the behavior that others expect. Any link in this chain of events can be affected in children with these differences, resulting in an underdeveloped way of responding to environmental demands, e.g., refusal.

Part of the confusion about the relationship between patterns of response to requests or demands and emotional dysregulation in children with this kind of presentation is rooted in the fact that difficulties with managing emotion are not part of the official diagnostic criteria for Asperger’s or Tourette syndromes. As any experienced clinician or parent will tell you, however, challenges in emotional regulation are very often a part of the presentation of these children.

To underscore this point, consider the approaches science has used to attempt to uncover the "cause(s)" of Asperger's and other autism-related challenges. Published researchers widely point to the involvement of certain brain structures known to be involved in emotional processing and output, e.g., the amygdala, in autism spectrum disorders such as Asperger's, and a high percentage of studies have focused on emotional regulation in these children and its relationship to brain development. Obviously, there is some level of emotional dysregulation that goes hand-in-hand with having an autism spectrum disorder in a highly significant percentage of cases. With this in mind, it does not seem prudent to try to account for this emotional dysregulation by presuming the presence of a distinct emotional disturbance, if in fact that emotional disturbance is a very common feature of the primary diagnostic category.

We cannot say, however, that it is not possible for a child to meet criteria for an impulse control disorder or mood disorder in addition to the neurological differences your child faces. A thorough, multi-modal, multi-method evaluation of the whole child as he initiates and responds across settings would shed light on this matter. This kind of evaluation (such as is offered through the Monarch Diagnostic Clinic and other community-based sources) may also help to determine the function of the behaviors you describe. For example, it may be determined through targeted interactions, observations, and fact-gathering that a particular child (not necessarily yours) makes demands of his teachers to avoid doing his work. Neurotypical children may learn quickly that this is a failed strategy if adults respond consistently in ways that help the child engage with the task, but children who experience difficulty with predicting social outcomes, e.g., children with Asperger's, may not do nearly as well in changing this pattern because of challenges in social comprehension and interpersonal coordination.

While children with neurological differences may do some of the same things their peers do, such as not doing their homework, their reasons for doing so may be vastly different. Your child's difficulty with turning in assignments should be considered and evaluated on an individual basis to determine the child- and environment-specific factors that relate to the behavior. While it may be that the factors are similar to those seen in peers, e.g., a seeming lack of appreciation for the purpose of the assignment, there may also be other factors, e.g., difficulty with getting started, at work.

Lastly, the current presence of tics is not necessarily an indicator that a child has Tourette’s. A child may meet criteria for Tourette's if his or her tics occurred at some time in the past. As scientific understanding of children with this presentation and neurology has grown in recent years, the lens through which we view Tourette Syndrome has widened dramatically. Many in the Tourette's community view their inherent neurological differences as contributing to a wide range of functional challenges, including the management of impulses and coordination of interpersonal behaviors.

Bryant Shaw, Ph.D.
Multidisciplinary Psychology Team, Apprentice Program
Clinical Coordinator, Diagnostic Clinic
(713) 479-0800

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