Treating Tics and Tourette’s Disorder in School Settings

Abstract

Children with Tourette’s Disorder (TD) and other forms of tic disorders display a range of academic and psychosocial impairments that place them at risk for experiencing long-term negative life outcomes. Fortunately, effective treatments and interventions such as habit reversal training (HRT) have been developed and implemented in clinical settings to help these children. However, relatively few youth with tics and related sequelae receive effective treatments for their symptoms, often because of various treatment barriers (e.g., travel difficulties, limitations in trained practitioners). To overcome some of these barriers, educators and school-based mental health practitioners can provide a range of academic, social-emotional, and mental health supports to address the needs of youth with tics in school settings. In support of this notion, this article discusses various ways that members of school communities can help support the academic and social-emotional success of students with tics and related impairments.

Keywords

Tourette’s disorder Tourette’s syndrome tics habit reversal training school-based mental health

Tic disorders are characterized by sudden and non-rhythmic motor movements or vocalizations (tics) that usually present in childhood yet can persist across the life span (Bloch & Leckman, 2009). Five nosological categories describe the classification of tics in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013). These include Tourette Disorder (TD), Persistent (Chronic) Motor or Vocal Tic Disorder (PMTD/VTD), Provisional Tic Disorder (PTD), Other Specified Tic Disorder (OSTD), and Unspecified Tic Disorder (UTD). TD is characterized by the presence of multiple motor and one or more vocal tics that can occur at any point during the illness (independently or concurrently). To confer a TD diagnosis, tics must endure for at least 12 months, whereas a PMTD/VTD involves having either single or multiple motor or vocal tics (but not both) over the same time period. PTD is characterized by the presence of short-lived motor or vocal tics that have been present for less than 12 months since initial tic onset. Lastly, although little is known about these disorders, as new diagnoses, OSTD and UTD describe tic presentations that occur outside of the aforementioned diagnostic criteria.

Prevalence Rates

Transient or provisional tics are relatively common in children as almost a quarter (24%) of youth display tics at some point during childhood (Snider et al., 2002). However, TD is far less common in children. A recent meta-analysis aiming to refine the TD population prevalence estimates found that between .3% and .9% of youth have TD (Scharf et al., 2015). However, the authors of this study conclude that sample size limitations as well as the use of outdated DSM criteria likely attenuated prevalence rates of TD. Thus, consistent with previous estimates, approximately 1% to 3% of youth likely will meet diagnostic criteria for TD or PMTD/VTD at some point in childhood (Khalifa & von Knorring, 2003; Scharf et al., 2015).

Comorbidities and Associated Impairments

Tic disorders frequently are comorbid or co-occur with other forms of psychopathology. The most common comorbid psychiatric disorder that co-occurs with tic disorders is attention-deficit/hyperactivity disorder (AD/HD), with comorbidity rates ranging from 50% to 90% (Freeman et al., 2000). Obsessive-compulsive disorder (OCD) also commonly is comorbid with tic disorders; however, comorbidity rates (ranging from 25% to 80%) tend to be more variable (Freeman et al., 2000; Walkup et al., 1999). To a lesser extent than the previous two disorders, mood, anxiety, and disruptive behavior disorders (e.g., oppositional defiant disorder [ODD], conduct disorder) also commonly co-occur with tics (Lewin et al., 2011). Gerard and Peterson (2003) suggest that high comorbidity rates between the aforementioned disorders suggests that dysfunctional activity in nigra–striatal–frontal dopamine pathways may undergird overlapping tic, externalizing behavior disorder, and obsessive-compulsive spectrum disorder symptoms that often present in youth with tics and TDs.

Tic disorders are associated with impairments across multiple domains of functioning (Conelea et al., 2011; Lin et al., 2007; Storch, Lack, et al., 2007a). Tic disorders also are associated with diminished quality of life, whether directly because of the distress that tics cause or indirectly because of the aforementioned impairments (Eddy et al., 2011). Excessive tics can produce physical ailments such as joint pain, inflammation, and contusions (Woods, Friman, & Teng, 2001). Tics also negatively impact academic and psychosocial functioning in students. More specifically, research indicates that students with tics are at-risk for underperforming academically as well as to struggle with developing and maintaining peer and teacher relations (Carter et al., 2000; Packer, 2005). Because of their aberrant and observable motor and vocal tics, students with TD often are and feel ostracized and rejected by their peers and even adults at school (Debes et al., 2010). These students frequently are bullied by their peers and they often are not supported by educators (Storch, Lack, et al., 2007; Zinner, Conelea, Glew, Woods, & Budman, 2012). Regarding the latter, in a seminal study, almost half of children with TD reported having poor relationships with their teachers and one-quarter of these children even stated that they were teased by a teacher because of their tics (Jagger et al., 1982).

In general, students with tic disorders are at-risk for experiencing psychosocial problems and to feel socially alienated. Compared with their non-affected peers, these youth tend to have significantly lower ratings of overall emotional well-being and they often struggle the most when at school (Storch, Merlo, et al., 2007). In a recent study, Hovik et al. (2014) found that children with TD displayed greater problems with emotional control than children with Autism Spectrum Disorders (ASDs) displayed in cognitive flexibility. Furthermore, youth with TD also exhibited more problems with emotional control than were displayed in inhibitory control and planning/organizational deficits by youth with AD/HD diagnosis. Collectively, these findings suggest that students with TD experience marked emotional control problems, problems that may be even more impairing than problematic core symptoms of highly comorbid disorders.

Regarding school functioning, Storch, Merlo, et al. (2007) found that the highest percentage of school-related impairments in students with tic disorders were related to writing in class (25%) followed by doing homework (22%), concentrating on work (22%), being prepared for class (19%), and being teased by peers (18%). In addition to these problems, children with tics also have been found to display elevated rates of deficits in visual–motor integration, fine motor skills, written communication, and speech fluency (Comings & Comings, 1987; De Nil, Sasisekaran, Van Lieshout, & Sandor, 2005; Schultz et al., 1998). Moreover, compared with their non-affected peers, they also are likely to have learning disabilities and to experience academic problems in general (Burd, Freeman, Klug, & Kerbeshian, 2005).

Early Assessment and Intervention

Research indicates that early intervention is needed to help mitigate some of the long-term risks that are associated with severe tics and TD (Piacentini & Chang, 2005). Further supporting this notion, a recent study by Greene et al. (2015) found that children’s ability to resist the urge to perform tics could be enhanced if they were systematically rewarded for doing so within 6 months after the onset of tics. Thus, results of this study suggest that—before tics become chronic—the provision of early behavioral intervention can enhance inhibitory control, which may then improve outcomes for these youth.

However, as a prelude to early intervention, effective assessment and identification practices must be utilized. Although parent-administered clinical and structured interviews often are the norm to assess tic disorders in clinical settings, school-based mental health practitioners who generally have greater access to teachers and caregivers can use a multi-trait, multi-setting, and multi-informant assessment approach to assess tics and related concerns accurately (Saklofske, Joyce, Sulkowski, & Climie, 2013). In this regard, school-based mental health professionals can consult with teachers to identify children who have tics and then follow up with structured behavior observations, teacher and caregiver interviews, and behavior rating scales. More specifically, school-based mental health professionals can interview caregivers and teachers to identify observable tics across a range of settings, especially in those in which they may be pronounced and/or highly impairing. For example, some children with tics are more likely to display them during stressful activities, whereas others display tics when they are fatigued or bored, and still others display them when they are engaged in highly stimulating activities. Thus, it is important to assess the specific antecedent conditions that are associated with tics for each individual student (Corbett, Mendoza, Baym, Bunge, & Levine, 2008).

Following interviews or even a functional behavior assessment, school-based mental health professionals can conduct structured observations to determine the frequency, intensity, and duration of tics or tic episodes over time and across settings. These observations may corroborate information collected from other sources as well as serve as a pre-treatment baseline. Although no “gold standard” has been established for assessing or diagnosing tics and related concerns, the use of multiple data sources and data-triangulation techniques associated with a multi-trait, multi-setting, and multi-informant assessment approach can be useful for establishing sound assessments and potential treatment/intervention recommendations for youth with tics (Woods, Piacentini, & Walkup, 2007). See McGuire et al. (2012) for a comprehensive review of techniques and strategies to assess the presence, severity, and related concerns associated with tics in youth.

Treatment for Tics

Although pharmacological treatment is widely used to treat tics, the efficacy of this approach is limited (Gilbert, 2006). Moreover, people often negatively view the use of this approach with children because of untoward side effects associated with pharmacological interventions (Lazaratou, Anagnostopoulos, Alevizos, Haviara, & Ploumpidis, 2007; Pringsheim & Pearce, 2010). However, in contrast to pharmacological treatment, behavioral treatments for tics such as habit reversal training (HRT) are supported by research, have few side effects, and are comparatively less controversial (Steeves et al., 2012). In addition, behavioral treatment for tics has been found to be effective at not only reducing tics but also at improving overall psychosocial functioning in youth with tics (Piacentini et al., 2010).

Habit Reversal Training

HRT has been established as an effective, efficacious, and highly tolerable treatment for reducing tics in youth, meeting the evidenced-based criteria for a well-established treatment set by the American Psychological Association’s Division 12 Task Force on Promotion and Dissemination of Psychological Procedures (Cook & Blacher, 2007). In the Comprehensive Behavioral Intervention for Tics (CBIT) study, which included HRT as a fundamental treatment component, CBIT treatment was found to be superior to psychoeducation and supportive therapy conditions in its efficacy (Piacentini et al., 2010). Moderate to large reductions (ES = .68) in tic severity were observed in the 126 youth who received active CBIT treatment (aged 9-17), and most of these treatment gains (87%) were durable at a 6-month follow-up. Tic worsening only was reported in a small minority of cases (4%). In addition, a positive response to CBIT therapy was associated with decreased anxiety (d = −.72), disruptive behavior (d = −.30), family strain (d = −.52), and improved social functioning (d = 1.03) in children when they were assessed at a 6-month follow-up (Woods et al., 2011). In light of these findings and others, Steeves et al. (2012) gave HRT a “strong” rating for treating tics because of the “high quality evidence” supporting its efficacy. Thus, HRT is considered to be a first-line treatment for treating tics in youth.

Although treatment duration is variable across studies, HRT usually is delivered over 8 to 10 weekly sessions in clinical trials. However, independent of treatment length, standard HRT treatment components include: awareness training, competing response training, and social support. Awareness training aims to increase an individual’s ability to anticipate premonitory urges (i.e., uncomfortable sensations that precede tics) and/or recognize when tics occur. Once youth have a greater awareness of their tics and they are able to anticipate tics (or their early antecedents), competing/compensatory response training usually is initiated. Competing response training involves teaching individuals to perform behaviors that are incompatible with (or are alternative to) the performance of tics. For example, competing response training for a student with a head-jerking tic may involve encouraging him or her to slowly and deliberately press his or her chin to his chest when s/he feels an urge to perform a tic. Many effective competing responses directly or physically interfere with the performance of tics (e.g., placing one’s arms at one’s side to prevent an arm moving tic (Woods, Piacentini, & Walkup, 2007). However, research indicates that competing responses do not necessarily have to be incompatible with tics as some responses may simply involve performing an alternative behavior when a premonitory urge is experienced (Piacentini & Chang, 2005). To the greatest extent possible, competing responses should be less noticeable than the tics themselves so they do not draw attention from peers and classmates (Storch, Merlo, et al., 2007). Moreover, the application of effective and relatively discreet competing responses can help reduce the amount of negative peer attention students with tics receive (Piacentini & Chang, 2005).

The last HRT component involves providing youth with social support. Consistent with this aim, school-based mental health professionals can help children, caregivers, and educators to provide social support to children with tics. Providing social support involves first identifying key stakeholders who can encourage a child to use competing responses, as well as to help them to manage life stressors and treatment setbacks. Thus, individuals who provide social support should reward children for the successful use of competing responses and adaptive responses to tics (Grapin, Sulkowski, & Lazarus, 2015). Alternatively, if a child does not attempt to use his or her competing responses or uses them ineffectively, the person providing the social support can remind the child to use competing responses and reinforce them for doing so. Because many children have difficulty identifying premonitory urges and recognizing their tics, providing non-demeaning or judgmental reminders can help improve treatment adherence and positive outcomes for students with tics (Banaschewski, Woerner, & Rothenberger, 2003).

Barriers to Behavioral Intervention

Despite the existence of effective treatments for students with tics, there are several barriers to receiving these services (see Woods, Conelea, and Walther [2007] for a detailed discussion). Some of these include the relatively small number of mental health professionals who are trained in delivering HRT, travel burdens associated with finding a knowledgeable treatment provider, limitations in public knowledge about effective treatments for tics, and inadequate or non-existent insurance coverage for treatment in countries such as the United States. Although some of these barriers may be insurmountable for some children and families, modifying existing treatment practices and expanding the use of current practices potentially might help many more students and families who are not being served. For example, even though it is a relatively novel practice, using telehealth modalities to treat children with tics has shown early promise at increasing the dissemination of HRT (Himle et al., 2012). Furthermore, addressing tics and related problems at school—the setting in which tics often are most problematic—may help many affected youth who do not have access to HRT in other settings (Carter et al., 2000; Koutsoklenis & Theodoridou, 2012; Packer, 2005; White et al., 2011).

Overcoming Barriers and Addressing Tics in School Settings

Because tics do not always cause functional impairments, school-based intervention might not always be needed. However, intervention is appropriate (a) when tics impede a child’s academic progress; (b) when tics interfere with learning or participation in classroom activities; (c) when tics causes significant peer-relationship problems (d); and when tics negatively impact a student’s self-esteem (Packer, 2005). Some benefits of providing mental health services to youth with tics in school settings are apparent: Children spend approximately 40 hr in school each week and most school systems employ a range of mental health professionals (e.g., school psychologists, social workers, counselors; Koutsoklenis & Theodoridou, 2012). However, despite the presence of these professionals and the significant number of school-aged children with tics, a survey of caregivers found that few children with TD receive psychoeducational (13%) or helpful psychotherapeutic (9%) interventions at school (Packer, 2005). Furthermore, the majority of respondents in this study, which included parents (75%), reported that no interventions were attempted by school-based personal to modify tics. Thus, similar to other populations that may fly “under the radar” with regard to receiving supportive services in schools, children with tics appear to be underrepresented (Flett & Hewitt, 2013, p. 2). In support of this notion, despite that almost one half of the respondents in the study by Packer (2005) reported to display tic-related peer relational problems, only 13% received peer education programs. In addition, 13% of respondents reported requesting in-school counseling, but were either denied or told that the school did not offer such services. Thus, students with tics constitute a deserving yet relatively under-served population in schools.

Providing Psychoeducation

Few studies have investigated the types of interventions that students with tics receive or the efficacy of these interventions. However, at the most basic level, providing psychoeducation to educators and students appears to benefit students with tics. Functionally impairing tics tend to be easily observable and they often are noticed by teachers, students, and other members of school communities (Friedrich, Morgan, & Devine, 1996). However, these individuals may misunderstand tics and view them as being purposely disruptive (Christie & Jassi, 2002; Chowdhury & Christie, 2003). Therefore, to disabuse misguided notions while simultaneously educating, school-based mental health professionals can provide psychoeducation to members of school communities on tics and tic disorders (Koutsoklenis & Theodoridou, 2012; Sulkowski, Wingfield, Jones, & Coulter, 2011). In support of this intervention, educational workshops provided to teachers have been shown to improve teachers’ knowledge of TD, with the greatest improvements occurring in teachers who had low initial knowledge of the disorder, its characteristics, or its related impairments (White et al., 2011). Workshop trainings on TD may include information about the prevalence of tic disorders, the general course of tic presentation, common co-occurring conditions, educational and psychosocial impacts of tic disorders, and evidence-based treatments for tic disorders (Koutsoklenis & Theodoridou, 2012).

Similar to findings on the effects of providing psychoeducation to educators, one study found that providing psychoeducation about TD to students resulted in more positive attitudes toward individuals with the disorder (Nussey, Pistrang, & Murphy, 2012). Furthermore, in a more recent investigation, Nussey, Pistrang, and Murphy (2013) found that providing psychoeducation on TD increases knowledge, positive attitudes, and behavior toward individuals with TD. However, results of the aforementioned study indicate that the provision of diagnostic information alone is inadequate to achieve a positive outcome. Thus, comprehensive psychoeducation is needed, including information on how tics functionally impact students at school. In addition, it is not known whether improvements in attitudes toward students with tics are maintained over time or generalize to other members of school communities.

Providing Accommodations

A recent study by Wadman, Glazebrook, Parkes, and Jackson (2014) involved asking educators who work with students with disabilities to suggest accommodations or strategies that could be used to help students with TD be successful in school. In addition, participants rated the feasibility of 17 strategies that were grouped into the following categories: promoting knowledge and understanding in school, helping the student to cope with his/her tics, supporting the student’s learning, and providing social and emotional support. Approximately, 80% of educators rated all strategies as being “easy to implement” or “already in place,” and the strategies that were identified as being “least easy to implement” were those requiring extra staff input (e.g., support from teaching assistants, individual/small group working). Thus, in light of these findings, Wadman et al. (2014) conclude that educators are well positioned to support a student with TD by helping them cope with having tics in school and through their ability to provide them with appropriate learning and social-emotional supports.

Although research on the efficacy of providing academic accommodations and behavioral supports to children with tics is limited, one Canadian study asked students with TD and their parents and teachers to rate the usefulness of 84 learning and behavioral strategies (e.g., reduced homework, extra class time, feedback on how to improve work, helping with work initiation; Thomas et al., 2012). Results of this study indicate that 13 strategies were endorsed by greater than 50% of the students, 53 by greater than 50% of parents, and 42 by greater than 50% of teachers. Therefore, students endorsed fewer strategies than their teachers or parents did, and little agreement was found among the most effective strategies between groups of respondents. More specifically, all three groups only listed “using computers for work” and “assigning an appropriate amount of homework” as a top 10 strategy. Thomas et al. (2012) report that study results support the use of assistive technologies to accommodate the academic needs of students with TD as well highlight the importance of teachers taking time at the beginning of the year to ask students how they experience and manage tics at school so they can make appropriate adjustments to instruction. Unfortunately, however, results of the former study do not inform how the aforementioned strategies actually impact the learning or academic success of students with tics. Thus, this topic remains an open area for investigation.

Providing Social-Emotional Support

The provision of social and emotional support has been shown to enhance academic outcomes for all students (see Durlak, Weissberg, Dymnicki, Taylor, and Schellinger [2011] for review). However, this form of support may be particularly needed by students with tics as these youth tend to experience poor peer relationships, negative interactions with teachers, and they also are often bullied (Carter et al., 2000; Packer, 2005; Zinner et al., 2012). In general, students with tics tend to be more successful in classroom settings that are socially and emotionally supportive (Koutsoklenis & Theodoridou, 2012). To help support these students, teachers can ignore tics, immediately address incidents of bullying or peer aggression, provide relevant accommodations, and maintain a positive and supportive environment as stress, criticism, and negative emotions all tend to increase tics and related impairments (Carter et al., 2000; Yoon, Sulkowski, & Bauman, 2014; Zinner et al., 2012). In addition, teachers can allow students with TD to leave the classroom for a short time to either release or better regulate the tics that they have been suppressing (Packer, 2005).

Providing Group Counseling

Schools are unlikely to provide group-based interventions that specifically address tics because of significant heterogeneity in the needs of students with tics and the difficulty of coordinating students’ schedules across various grade and developmental levels (Koutsoklenis & Theodoridou, 2012). However, students with tics may benefit from more general group-based interventions that aim to improve peer relations such as social skills groups and friendship development groups (Schapiro, 2002). In this regard, Lambert and Christie (1998) conducted a social skills group for male youth with TD (N = 8) who reported feeling socially isolated and were already receiving individual therapy. Results of this investigation indicated that the majority of participants (88%) responded favorably to treatment and also displayed increases in their self-esteem and social functioning. Although no group-based treatment studies for tics could be located, regardless of the setting in which they were implemented (e.g., clinic, hospital, school), the use of HRT in group settings has been demonstrated for children with obsessive-compulsive spectrum disorders such as trichotillomania (i.e., a psychiatric disorder involving impulsivity and compulsive hair pulling; Diefenbach, Tolin, Hannan, Maltby, & Crocetto, 2006). Therefore, research is needed on the use of group-based interventions for youth with tics and related conditions. Moreover, as a further step, research is needed on the application of these treatments in school settings.

Providing HRT

Currently, three published case studies have investigated the use of HRT to treat tics in school settings. A study by Pray, Kramer, and Lindskog (1986) involved the use of HRT to treat a 9-year-old female who had a chronic head-shaking tic. Results of this case study indicate that the application of daily HRT over a 2-week period (sessions were conducted daily during school days) resulted in a marked decrease in tics that was maintained at a 1-year follow-up assessment. A second study by Clarke, Bray, Kehle, and Truscott (2001) used a multiple baseline design across individuals to determine the effectiveness of HRT and video self-modeling in reducing tics. Four adolescents with TS were treated in school settings. In this study, 75% of participants were classified as treatment responders and significant overall tic reductions were observed at post-treatment among participants as well as at a 10-week follow-up assessment. Lastly, a case study by Gilman, Connor, and Haney (2005) involved using HRT to treat a 14-year-old male student who had impairing motor tics and limited English proficiency. This student had recently emigrated from Mexico, and an interpreter was used to help implement HRT because of his English language limitations. Results of this case study indicate that HRT was successful at reducing the student’s motor tics at post-treatment as well as at a 3-month follow-up assessment. However, it must be noted that other factors may have caused tic reduction because of this study’s uncontrolled non-reversal design.

Additional considerations for using HRT in schools

Using HRT in schools may involve modifying the treatment approach that usually is delivered in clinical settings to fit an educational setting. For example, sessions may need to be shortened to accommodate students’ schedules and the length of class periods; breaks and school holidays may need to be anticipated so that treatment is not abruptly interrupted or terminated; secure and confidential office space may need to be procured; and several other members of school communities (e.g., teachers, administrators, nurses) may need to be involved in treatment in some capacity. In addition, based on the place in which services will be delivered, laws that govern the provision of special education services and 504 accommodations will need to be considered when providing interventions to treat tics. Because of advancements in the acceptance and application of multi-tiered systems of support (MTSS), which allow for the delivery of intervention services independent of or concomitant with special education services and accommodations, schools may or may not need to appeal to extant educational laws to support the needs of children with tics (Sulkowski, Joyce, & Storch, 2013). However, schools cannot disrupt the provision of special education services if a student already is receiving these services under an individualized education plan (IEP) or individual accommodation plan (IAP; Sulkowski et al., 2011). Therefore, it may be challenging to find time to implement HRT with youth who already are receiving a number of other services that aim to treat extant academic, behavioral, or emotional problems.

Ultimately, the biggest barrier to implementing HRT in school settings is related to the limited number of trained practitioners (Steeves et al., 2012). Although this currently is true and HRT should be administered by a trained practitioner, the HRT skill set is obtainable for many practitioners with a background in behavior modification. In this regard, Packer (2005) encourages for school psychologists to become key stakeholders in efforts to support students with tics, which might involve conducting HRT. In support of this position, results from a recent study suggest that the majority of school psychologists (68%) display knowledge of the use of behavior modification strategies for treating tics as well as the importance broadly supporting TD students’ emotional well-being (Glassman, 2010).

Currently, quality training resources exist that can be utilized by practitioners such as school psychologists to treat tics in students. In this regard, Woods (2006) has published a HRT treatment manual for tic disorders, which is based on Azrin and Nunn’s (1973) original habit reversal procedure. This manual is relatively straightforward in its approach and it can translate to school-based practice. To date, this protocol has also been used in studies on treating transient and chronic motor tics in a variety of settings including schools (Gilman et al., 2005). In addition, Steeves et al. (2012) suggest for clinicians interested in learning more about HRT to consult Leaky Brakes (2010) on the Child and Parent Resource Institute website (http://www.cpri.ca/content/brake-shop-clinic.aspx). Leaky Brakes provides both written information and instructional videos on the application of HRT.

Lastly, for obtaining hands-on training in treating tics, graduate students can take classes or have practicum in departments of clinical psychology, psychiatry, or applied behavior analysis. Similarly, current school-based practitioners can attend conferences and workshops that train practitioners in the use of effective behavioral interventions such as HRT. The Tourette Syndrome Behavior Therapy Institute (TS-BTI), organized by the national Tourette Syndrome Association (TSA), provides a variety of educational programs for mental health professionals including skills development workshops throughout the United States, video webstream trainings, and a range of training webinars/videos that are delivered by expert TD treatment providers. In addition, the TSA provides a range of educational materials and programs on its main website to help students, parents, families, educators, clinicians, and others to understand and manage TD in the school settings.

Conclusion

In conclusion, tic disorders and related sequelae can negatively impact psychosocial and educational outcomes in students, as well as result in poor long-term impairments. Therefore, affected youth should be provided with effective interventions as early as possible to offset these negative outcomes. However, many youth do not receive these interventions in a timely manner in large part because of treatment barriers such as having to travel to a specialty clinic. As one way to reduce barriers to treatment, educators and school-based mental health professionals can address the needs of youth with tics or related concerns in school settings. To help in this regard, Packer (2005) described several ways that these individuals can provide interventions, supports, and accommodations to students with tics. Specific intervention suggestions included providing psychoeducation and staff training, academic accommodations, behavioral and emotional supports, group-based treatment, and HRT. In addition, empirical support for the aforementioned interventions and supports was reviewed. Lastly, the largest treatment barrier—the lack of school-based mental health practitioners who are specifically trained to treat tics—was discussed as well as possible training opportunities for these individuals to increase their competence. This barrier serves as an opportunity for schools to redouble their efforts to support the needs of students with tics and tic-related disorders.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Michael L. Sulkowski, PhD, is an assistant professor in the School Psychology Program and a clinical assistant professor in the Department of Psychiatry at the University of Arizona. He also is the chair of the National Association of School Psychologists (NASP) Early Career Workgroup.

Joseph F. McGuire, PhD, is postdoctoral fellow in the Childhood OCD, Anxiety, and Tic Disorders Program. He received his doctorate in clinical psychology from the University of South Florida.

Andrew Tesoro, MEd, is a school psychology intern in the Lewisville Independent School District. He currently is a doctoral candidate in the School Psychology Program at the University of Arizona.

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