https://www.gosh.nhs.uk/wards-and-departments/departments/clinical-specialties/department-child-and-adolescent-mental-health-dcamh/the-tic-service/managing-tics-in-the-classroom/

Managing tics in the classroom

Tourette syndrome (TS) is the diagnosis given when a person has had motor and vocal tics for longer than 12 months. TS begins in childhood and waxes and wanes – tics change in intensity and frequency. For some people, tics may not be noticed, while in others, the tics can be more intense and distracting for the young person and can make certain classroom activities more difficulties. This page describes Tourette Syndrome and how it can impact children at school.

What is a tic?

Tics are quick, repetitive movements (motor) or sounds (vocal) that happen without control and often come in bursts. Tics can be either "simple," involving one muscle or one simple sound, or "complex," involving a coordinated movement of several muscles or the saying of a phrase.

Here are examples of tics:

  • Simple motor tics: eye blinking, head jerks, nose twitching, facial grimacing, shoulder shrugs, etc.
  • Simple vocal tics: grunting, squeaking, coughing, whistling, humming, spitting, etc.
  • Complex motor tics: pulling at clothes, touching people/objects, twirling around, self-injurious behaviour, etc.
  • Complex vocal tics: animal-like sounds, unusual changes in pitch or volume, swearing etc.

Tics may show up suddenly and last for a few weeks, then disappear, only to be replaced by a different tic a few weeks or months later. The location of the tic in the body can change, and so can the frequency and severity of the tics. This change in tics is called the "waxing and waning" of tics. Because tics can vary so much and for brief periods go away altogether, or become very mild, parents and teachers might mistakenly think that tics can be controlled.

Interestingly, tics seem to be ‘suggestible’, meaning that a child can develop a tic after seeing it in another person. This is not ‘copying’, but an involuntary action. A common view of Tourette Syndrome is that people have swearing outbursts, but this only affects about 10-15 per cent of children; which are often first noticed when the child is between five and nine years old.

Managing tics in the classroom

Children and young people with tic disorders, Tourette syndrome, and associated behavioural difficulties and learning challenges can experience challenges in school. These students may need additional support in the classroom to provide them with a safe and nurturing school environment. It is important to be aware of how tics may interfere with the activities of the child (especially reading writing and maths work). In addition, children with TS and co-occurring conditions may experience peer teasing and / or bullying.

Strategies to help in the classroom

The young person’s behaviour and functioning should be a guide to make decisions about what could be a helpful accommodations. Research on children with tics have suggested the following strategies for challenges that may be faced at school, but we realise that not all of them may be possible or achievable.

  • Ignore the tics as much as possible. Avoid commenting or reacting to the tics publicly, as this may worsen the tics. Punishment for tics is not appropriate.
  • Discuss with the student collaboratively, using problem-solving approaches to work out what will be best suited for everyone, teachers and peers included.
  • Ask parents/carers what strategies have worked in the past.
  • Fidget toys and chewing gum, can be useful for tic management in some students.
  • There is evidence to suggest that giving a presentation on tics to the whole class can be beneficial in increasing understanding and changing attitudes to the person with tics.
  • Ensure that all of the student’s teachers know that they have tics and how to respond to them. Information about the student’s tics may need to be updated regularly, as tics change regularly.
  • Speak with the student to see if the classroom seating arrangement is comfortable. Commonly having a student sit at the side of the classroom away from the window is ideal. Seating at the front can attract attention to tics whereas being located at the back of the classroom may result in less engagement in the content of the lesson.
  • Some students may need to exit at planned time; so seating near the door might be helpful.
  • Allow larger ‘personal space’ if the student has a touching tic or has large motor tics, involving limbs.
  • Let the student work in the position that they feel comfortable with.
  • Allow more time to complete tasks and tests. Break projects into shorter manageable tasks with opportunities to deal with tics.
  • For students who are working at a high level and are keen to progress, allow them to work ahead during periods to compensate for the times when tics are most frequent.
  • If written work is difficult due to tics, allow the use of other means of production, e.g., computer programs, keyboarding, oral reports, voice recording and/or longer assignment times; sometimes a scribe may be needed.
  • The student may need to take tests in a separate room.
  • Reading in pairs or ‘read or pass’ can work for some children.
  • Direct contact with the teacher nearby, reducing distractions, and breaking up tasks into small discrete sections could help with attention.
  • Speak with the student about tasks involving reading aloud to the class to understand what they feel comfortable with.
  • Evaluate a child who is struggling for associated learning difficulties (this is most commonly with writing or maths, but may also relate to reading) and provide help for any identified needs.
  • Increase self-esteem, give praise for accomplishments, encourage the student to talk about their feelings, help the student to develop coping strategies, and encourage participation in group activities.
  • Make use of learning mentors if available.
  • Developing circle time in PSHE lessons has also proved useful (after seeking permission from the student and the student’s parents).
  • Detect and deal with teasing, taunting, bullying, or peer rejection.
  • Extra adult supervision may be needed in unstructured or less structured settings, such as during PE or in the playground.
  • Stress may increase tics. Learning coping skills to handle stress is helpful.
  • Involvement in enjoyable activities (for example, music or sports) can decrease tics temporarily and reduce stress.
  • Provide opportunities for physical movement and encourage relaxation and body control techniques.
  • In cases of explosive anger, ensure the students’ and others’ safety.
  • Explain to other colleagues that the student has very limited control over TS and that the tics are associated with involuntary and ever-changing symptoms.
  • Introduce new staff to tic management techniques, ensuring that the Individual Education Plan is up to date – this is vital.
  • Establish a consistent behavioural management plan for both school and home and set reasonable expectations. Homework diaries or home-school books can be a useful way of communicating with parents.
  • Ensure that consequences for inappropriate behaviours are appropriate.
  • Reward schemes have also proved useful.
  • Liaise with the mental health team for further advice. Try not to get involved with a child’s compulsions but understand that anxiety is the driver to complete them.
  • Small group instruction with individualised attention could also be helpful.

Repetitive large muscle tics and attempts to suppress tics cause fatigue, which may need an increase in calorie intake (allow for snacks between meals).

  • Seek information about the medication and any possible side effects.
  • Cognitive dulling, lethargy, seeming lack of interest and decrease in coordination could all be due to medication and/or depression.
  • Allow extra time and attention for testing and tutoring.
  • Give allowance to medication effects while planning the student’s academic sessions.
  • If it worsens or is severe, report to the parents and/or contact mental health professionals or GP.

In short...

Regular communication between parents, professionals, colleagues, and the young person, about what might be helpful can considerably reduce some of the frustrations associated with Tourette syndrome.

Recognition and acknowledgement of the student’s struggle with their condition and encouragement of discussion around the support that is needed will make a world of difference to the student.

Further reading