Childhood tics are very common and there are many different types which are often misunderstood. Some can be barely noticeable whereas others can be quite distressing and cause social isolation, embarrassment, stigma and low self-esteem (Smith et al, 2015).
Tics are not the fault of students and they are not intentional attempts at gaining attention or to be disruptive. However, they can be unsettling for normal classroom activities and can severely affect a young person’s quality of life.
A tic is an abrupt, uncontrollable movement or sound that deviates from a person’s normal gestures. They are brief, rapid and occur intermittently and the most notable disorder is Tourette syndrome (TS).
Gilles de la Tourette’s syndrome is a chronic, childhood-onset neuropsychiatric disorder characterised by involuntary movements and uncontrollable phonic tics that wax and wane and persist for more than one year. It affects one school child in every 100, is more common among boys, and children have more tics when they are feeling anxious, excited, or tired (Stern et al, 2005; see also Tourettes Action website). TS is on the spectrum of conditions known as tic disorders.
Chronic tic disorder (CT), is similar to TS and defined by the presence of either motor or phonic tics but not both. Phonic tic is preferred to vocal tic, as not all abnormal sounds and noises are made by vocal cords. Transient tic disorder or provisional tic disorder is a condition involving physical and verbal tics (Black et al, 2016).
Isolating what causes a tic disorder is hard because there is a combination of factors at work (again see, Tourettes Action for more details). Some research indicates that tic disorders may be inherited and a genetic mutation can cause TS in rare cases. Abnormalities in the brain may also be responsible for tic disorders.
Most cases of tic disorders are mild and commonly begin between five and seven years of age. They are most severe in early adolescence and tend to decline in the late teen years. Symptoms can fluctuate in severity and change character over an individual’s lifetime and this can contribute to misdiagnosis.
Symptoms usually begin with motor tics with the onset of phonic tics around the age of 11. Children can also demonstrate a variety of movements such as head twitching, eye blinking, nose wrinkling, facial twitching, licking, kicking, lip biting, spitting, jumping, smelling, squatting, abnormalities of gait and forced touching. Common phonic tics include coughing, throat clearing, grunting, sniffing, hissing and barking.
Many of us will automatically associate TS with swearing outbursts but coprolalia (inappropriate involuntary uttering of obscenities) only affects about 10 to 15 per cent. This extreme tic may include yelling inappropriate or culturally taboo remarks or phrases but it is a myth to think of TS as a swearing disease.
TS is a multiple tic disorder and can include copropraxia (involuntary inappropriate obscene gestures), echolalia (imitation of sounds or words of others), echopraxia (imitation of actions of others) and palilalia (repetition of the last word, phrase or last syllable of a word uttered.
The exact number of people with a tic disorder is unknown although studies have demonstrated that TS and CT are more common than previously recognised (Bitsko et al, 2014). They were initially thought to be quite rare and in the region of around five children per 10,000 (Lawden, 1986) but this figure underestimates its prevalence owing to under-reporting and students not seeking help.
The best estimate of prevalence for TS in school-age children is likely to fall between four and eight cases per 1,000 (Scahill et al, 2014) and so “can no longer be considered the rare and bizarre syndrome that it was once thought to be” (Robertson, 2000).
Tics are not things that can just be wiped away, replaced or stopped and there is no one-size-fits-all cure. They often resolve without any treatment.
The main therapies for tics are forms of cognitive behavioural therapy (CBT) called Habit Reversal Therapy (HRT) and Exposure with Response Prevention (ERP). Combining HRT and ERP training has been found to be effective in both groups and as an individual treatment (Nissen et al 2018).
Support strategies for the mainstream classroom
It is essential that children with tic disorders are appropriately supported and get the best support to ensure they can achieve well in school.
Where diversity, inclusion and equality reign supreme in a school environment then differences are celebrated and for students with tic disorders this acceptance and respect is key. In an atmosphere of acceptance then students learn tolerance and compassion for differences and respect that everyone has unique circumstances, attributes and qualities.
The first thing to remember is that tics should not be taken personally. It is easy for teachers to put the focus on themselves but tics are not deliberately pointed in our direction as they are an involuntary symptom of a complex neurological disorder. Punishing is not appropriate.
However, there are a number of tried and tested ideas from the literature and research (see Murdick, 2011) on children with tics.
Normalise
Tics can be upsetting and disruptive when they are given a stress status. When they are explained as not being anyone’s fault but a common medical condition then fellow students can see them from a different perspective, especially when they are frequent and intense. Normalising and reducing anxiety allows everyone opportunities to succeed.
Reshape expectations and share with the class what tic disorders are. Explain that some of their peers across the school may have very limited control over their tics and that these can change frequently.
Challenge misconceptions and myths and explain that students with tics do not need pity. For them it can be difficult and embarrassing. Share real-life stories through BBC programmes such as MisFITS Like US and What Makes Me Tic? (search online for these and see also the Tourettes Action website).
Ignore
Disregard the tics as much as you can and steer away from commenting or reacting publicly. Role model “planned ignoring” in order to reduce bullying and stress.
Problem-solve
Actively seek ways to support a student by discussing with them problem-solving approaches that they can use to be considerate of their classmates. Help them develop coping strategies and encourage participation using learning mentors and establish a consistent behavioural management plan. Be creative with interventions, e.g. permitting students to “fiddle” with specified objects.
Involve parents
Talk to parents about what works and what does not. Discuss any patterns of behaviour, triggers, and strategies and agree on positive and proactive support, accommodations and what modifications. Continually review and update the students’ individual support plan.
Include
Ostracising a student and isolating them from their peers is not desirable because this punishes someone for something they cannot control.
Remember the effort
Students with tics will use a lot of energy holding or suppressing them. This is hard work and requires much concentration, making it very difficult sometimes for them to pay attention to what the teacher is saying. Allow students extra time where needed and repeat instructions and teaching points in combination with chunking work to make things more manageable. Fatigue caused by large muscle tics may require a larger calorie in-take at breaks.
Position
Consider your seating plans very carefully to reflect the needs of students. Some will benefit from a specific place (as well as a back-up) where they may release symptoms. Seating near a door will help those who need to exit frequently. Students with motor tics will also benefit from a position that allows for more personal space. For some situations, such as taking a test, making a separate location available may help a student to excel.
Move it
Provide plenty of opportunities to physically move in a lesson and encourage relaxation, mindfulness and body control techniques. Ensure breaks out of the classroom are provided for everyone.
Handwriting
Tics will affect handwriting production so use technology to assist and use a scribe where appropriate.
‘Lift and shift’
Look for opportunities to boost self-confidence and encourage students to express how they feel on a one-to-one basis to shift their own perceptions.
And finally...
Let us remember that it is not just students who have tic disorders, some staff have these too and we therefore need to think of how we can support everyone in the school community and embrace difference.
- John Dabell is a teacher, teacher trainer and writer. He has been teaching for 25 years and is the author of 10 books. He also trained as an Ofsted inspector. Visit www.johndabell.com and read his previous best practice articles for SecEd via http://bit.ly/2gBiaXv
Further information & research
- An overview of tics, NHS webpage: www.nhs.uk/conditions/tics/
- The lived experiences of individuals with Tourette syndrome or tic disorders, Smith, Fox & Trayner, British Journal of Psychology, February 2015: http://bit.ly/2yJXK7Z
- Gilles de la Tourette’s syndrome and its impact in the UK, Stern, Burza & Robertson, Postgraduate Medical Journal, 2005: http://bit.ly/2M9rPX8
- Symptoms of TS, Tourettes Action webpage: www.tourettes-action.org.uk/19-symptoms-.html
- Provisional Tic Disorder: What to tell parents when their child first starts ticcing, Black, Black, Greene, Schlagger, PMC, April 2016: http://bit.ly/2TigXHi
- Co-occurring features and conditions, Tourettes Action webpage: www.tourettes-action.org.uk/74-managing-ts--associated-conditions.html
- A National Profile of Tourette Syndrome, 2011-2012, Bitsko et al, Journal of Developmental & Behavioral Pediatrics, June 2014 (American study).
- Gilles de la Tourette syndrome: A review, Lawden, Journal of the Royal Society of Medicine May 1986.
- The Prevalence of Tic Disorders and Clinical Characteristics in Children, Scahill, Specht & Page, Journal of Obsessive-Compulsive and Related Disorders, October 2014: http://bit.ly/2OP1OPd
- Tourette syndrome, associated conditions and the complexities of treatment, Robertson, Brain: A Journal of Neurology, March 2000: http://bit.ly/2ZLhYtS
- Combined habit reversal training and exposure response prevention in a group setting compared to individual training, Nissan et al, European Child & Adolescent Psychiatry, June 2018.
- Tourette Syndrome: Classroom Implications, Murdick, 2011: http://bit.ly/2yO5Yfb
- Great Ormond Street Hospital for Children (GOSH) has produced a comprehensive set of documents with information for teachers about managing tics in the classroom: http://bit.ly/2YDAdVC
- You can download a PowerPoint presentation about TS from Tourettes Action: www.tourettes-action.org.uk/86-presentations-for-schools.html
- For a factsheet from Tourettes Action, go to http://bit.ly/31oN8ra
- The Tourettes Action Helpline is available via 0845 458 1252 (Monday to Friday from 9am to 5pm)
- Download An Educator’s Guide to Planning and Support from the Tourette Association of America: https://tourette.org/resource/educators-guide-planning-support-tool-kit/