Tics have been defined as sudden, rapid, recurrent movements or sounds which are not rhythmic and are commonly seen in conditions such as Tourette syndrome (1). Tics, and tic-like movements or sounds, can also occur as part of a functional neurological disorder (FND) and these are currently being referred to as functional tic-like behaviours (FTLBs) (2, 3). While there are many similarities between tics and FTLBs, there is emerging evidence of some key differences. These include a sudden onset, more complex movements, less likelihood of experiencing a pre-monitory urge and less reported suppressibility than Tourette-related tics. There are often associations with higher rates of anxiety, self-harm, and copro-phemonema, a higher female predominance and a later age of onset (2). FTLBs are likely to worsen if inadvertently rewarded, for example, by being given too much attention, or if they result in being removed from an activity that is not usually enjoyed (4). Anecdotally, we hear that these symptoms often provoke strong responses from others, which can be reinforcing for the symptoms.

Since the onset of the COVID-19 pandemic, clinicians globally have noticed an increase in tic-like symptoms in young people already diagnosed with tic disorders (5). A significant increase in the sudden onset of FTLBs, has also been observed (3, 6–9). It is hypothesised that the pandemic could have impacted negatively on the mental health of young people through biopsychosocial factors, with pre-existing or otherwise undiagnosed mental health and/or neurodevelopmental difficulties (3, 6). Anecdotally, within our clinic, we have been informed by our patients of the wide ranging impact of these FLTBS on daily life, in particular, higher reported school absence and difficulties engaging in the curriculum.

As FND, including FTLBs, is thought to be triggered by a range of predisposing and precipitating biopsychosocial factors, in our clinic we advise a holistic approach to management, with careful assessment and formulation guiding an individual plan for each young person. Using a five Ps formulation approach is a helpful way to determine any underlying predisposing and precipitating factors for the presenting difficulty, factors which may be perpetuating the difficulty and any protective factors which may support management (10).

With regard to management, studies have highlighted the importance of psychoeducation about FND and a focus on externalised attention training techniques to reduce an exacerbation of symptoms that are caused by suggestibility (11, 12). There is also an emerging evidence base for FND and FTLBs management plans which are built upon Cognitive Behavioural Treatment (CBT) principles to address underlying anxiety, depression, and trauma (13). This approach can also address maladaptive behaviours and challenge unhelpful beliefs related to the movements (14). It is of note that many of the usual recommended interventions for the management of typical tics, such as medication, are not effective for FTLBs (2). Due to the similarity in presentation between FND and FTLBs, we may be able to draw on interventions shown have efficacy in FND populations, such as psychoeducation, externalised attention and CBT, and trial these with those experiencing FTLBs. Anecdotal reports from patients within clinic and one study investigating psychoeducation, CBT and externalised attention in FTLBs (11) lend support to this idea.

Schools may be able to play a vital role in supporting holistic management plans to aid symptom reduction in FTLBs and to minimise the interference of these episodes, therefore promoting participation. Qualitative research has highlighted that teachers feel they lack the professional training needed to understand and support individuals with Tourette syndrome within schools (15) and anecdotal feedback from schools our clinic has consulted with indicates the same with regard to FND and FTLB’s.

Generally, there is a paucity of rigorous evidence supporting school intervention for the management of non-academic conditions, however, some studies do highlight certain interventions, such as extra time in exams, being beneficial for academic attainment in those with ADHD (16). With regard to managing FTLBs in schools, there is no known research investigating available support, however, research investigating therapeutic support for young people with FND highlights the importance of including school management plans as part of the overall treatment package (17). The importance of learning interventions, where necessary, and social reintegration is also highlighted as part of the overall management of FND (14).

The aim of this paper is to share some of our clinical expertise and experience when helping to manage FTLBs within schools. This is presented via case studies and an advice sheet (see Supplementary appendix). Our aim is to promote a wider understanding and to generate multiagency models for optimal ways of supporting young people with FTLBS within schools so that the affected children can increase their access to education. These strategies should be viewed as part of a wider, holistic support package for those presenting with FTLBs episodes, rather than as an isolated intervention.

All young people presented were reviewed in the Tics and Neurodevelopmental Movements Service (TANDeM) at Evelina London Hospital, UK between January 2019 and January 2022 and diagnosed by a multi-disciplinary team as having FTLBs. A total of 10 children have been described here and their clinical characteristics, school intervention and outcomes are presented in Table 1. Six of the young people received additional therapy or medication from their local services as part of their overall care package and three remained on waiting lists to receive therapy. Two young people are presented in further detail for clarity.

There has been a significant increase globally in the presentation of FTLBs over the course of the pandemic, with considerable repercussions on quality of life and access to education. Research has demonstrated the longer-term impact of pandemic-related disruption to education specifically when neurodiversity, anxiety, and unmet needs are present, leading to an increase in school refusal (18). This highlights the pressing need for health and education services to work together and share information regarding how to support young people with these unmet needs. The advice sheet developed by the TANDeM service aims to consolidate the most effective management strategies trialled by schools and to give advice on how to determine which strategies might be most impactful for an individual.

Initial clinical experience of school consultation and particular management strategies suggests a potential positive impact of school input on symptom reduction and access to education. The most common strategies implemented by schools in our case studies were reducing attention around FTLBs, supporting the young person with their own management strategies, access to student support or equivalent and exam modifications. With regard to outcomes, six out of the ten children showed a reduction in symptoms and all of them reported an improvement in the time and quality of access to education. This is an important point as it highlights that, if young people are well-supported, they can manage within school despite FTLBs. These changes in school support often have a positive impact on symptom reduction even in the absence of formal therapy.

The advice sheet has limitations as it has not yet been through a rigorous evaluation process and, therefore, these preliminary, anecdotal findings regarding symptom improvement must be treated with caution. Additionally, we are not able to claim correlation between the use of the advice sheet and any symptom improvement as many of the young people have undergone other interventions as part of their recommended holistic care package. A more rigorous evaluation process is planned as the next step in our process and the publication of this leaflet will enable this process. There is a clear need to gain school and patient feedback to ensure the accessibility, feasibility, and effectiveness of the advice given. There have been no reports of a negative impact from the advice used.

In conclusion, there is an urgent need to provide management advice to schools to support those with FTLBs. There is a need for further investigation into the current proposed advice sheet to determine its usefulness and its wider impact. It is timely, however, to release this advice now to generate awareness of the importance of school management, to further stimulate multi-agency collaborations and to promote the discussions on optimal pathways for care in health, social settings, and in education.

The original contributions presented in this study are included in this article/Supplementary material, further inquiries can be directed to the corresponding author.

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin. Written informed consent was obtained from the individuals and their legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.

TO and TH contributed to the design and conception of the manuscript. TO wrote the first draft of the manuscript. TO, TH, SR, SA, AL, and JS contributed to the written manuscript. TO, TH, CG, AB, and JS designed the advice sheet for schools and were involved in gaining feedback from patients. SS, LT, TO, and TH contributed to the schools survey design and analysis. All authors contributed to manuscript revision and read and approved the submitted version.