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Keywords:

  • Tourette syndrome;
  • psychoeducation;
  • psychosocial intervention;
  • peer relationships;
  • attitudes

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Background

Tourette syndrome (TS) is a poorly understood condition characterised by motor and vocal tics. It may affect children's social functioning at school. This study examined the impact of a psychoeducational intervention (classroom presentation) from multiple perspectives.

Method

We used a mixed-methods, multiple case-study design with interviews, focus groups and self-report questionnaires. Four children with TS, their parents, teachers and classmates (n = 100) took part.

Results

Questionnaire data showed an increase in classmates' knowledge and positive attitudes about TS postintervention. Qualitative data revealed two overarching themes: the impact on classmates in terms of enabling prosocial behaviours, and the impact on the child in terms of their embracing having TS.

Conclusion

A brief psychoeducational intervention enhances knowledge and attitudes of classmates towards children with TS, and improves how children with TS feel about the condition. Further research is needed to evaluate this approach with larger samples of children and to identify mechanisms of change.

Key Practitioner Message
  • Clinicians routinely recommend psychoeducational approaches for peers of individuals with Tourette Syndrome (TS) to improve knowledge and attitudes; however, there is little research into the effectiveness of this approach
  • This study found that a classroom presentation about TS improved the knowledge and attitudes of the peers of a small number of children with TS
  • The presentation was well received by peers and appeared to improve the self-confidence of the children with TS and help them embrace their condition
  • The findings suggest that clinicians should continue to recommend psychoeducation for peers of individuals with TS
  • Further research is needed to evaluate this approach more systematically in a larger sample of children and to explore mechanisms for any changes found

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Tourette Syndrome (TS) is a condition characterised by multiple, fluctuating tics, which typically start in early childhood. School-aged children with TS have poorer quality of life compared with the general population (Cutler, Murphy, Gilmour & Heyman, 2009); social, emotional and school functioning are particularly vulnerable. Tic severity and common comorbid difficulties such as attention-deficit/hyperactivity disorder (ADHD) and obsessive–compulsive disorder (OCD) are risk factors for poorer quality of life (Eddy et al., 2011; Storch et al., 2007b).

Children and adolescents with TS report ‘teasing’, bullying or victimisation by peers (Jagger et al., 1982; Shady, Fulton & Champion, 1988; Storch et al., 2007a). They struggle to conform to expectations of ‘normal’ behaviour and rate social isolation/embarrassment as disabling as the tics themselves (Cutler et al., 2009; Wand, Matazow, Shady, Furer & Staley, 1993). Young people with tics are rated less favourably and less socially acceptable than those without tics, particularly if they have additional difficulties such as ADHD (Bawden, Stokes, Camfield, Camfield & Salisbury, 1998; Boudjouk, Woods, Miltenberger & Long, 2000; Friedrich, Morgan & Devine, 1996; Stokes, Bawden, Camfield, Backman & Dooley, 1991). Children have more difficulties with relationships within their wider social network (such as with classmates) than in sustaining close friendships (Cutler et al., 2009).

Psychoeducational approaches for the child with TS and important others (i.e. parents, teachers and peers) are a crucial component of any treatment package (Verdellen, Van De Griendt, Hartmann, Murphy & The ESSTS Guidelines group, 2011; Woods, Conelea & Himle, 2010). Given the potential social difficulties, particular emphasis is placed on educating peers, for example, using classroom presentations. However, there is little research into the extent to which presentations have been used or their effectiveness. As TS is estimated to affect around 1% of 5–18-year olds worldwide, a large number of children stand to benefit from further research in this area.

A few studies have examined the use of experimental interventions to change attitudes of peers to TS (Friedrich et al., 1996; Holtz & Tessman, 2007; Marcks, Berlin, Woods & Davies, 2007; Woods, 2002; Woods, Koch & Miltenberger, 2003; Woods & Marcks, 2005). All but one found that provision of information leads to more positive attitudes towards individuals with TS in both adults and children. However, all studies took place in laboratory settings and failed to consider the experiences of individuals with TS, limiting the generalisability of their findings.

The current research therefore examined the impact of a psychoeducational intervention for peers of children with TS (a classroom presentation) in a naturalistic setting. We obtained the perspectives of those involved in planning and giving the presentation [the child, their parent(s) and teacher] and those receiving it (the child's classmates). Because of the paucity of previous research, the study used a mixed-methods, multiple case-study design (with a focus on qualitative data) to understand in detail how the intervention affected the child with TS (index child) and their classmates. It addressed the following research questions:

  1. How do children with TS, their parents, teachers and classmates experience the classroom presentation, particularly in relation to the potential impact on the child's peer relationships?
  2. Do the child's classmates report a change in knowledge about TS and attitudes towards a child with TS following the presentation?

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Overview

The classroom presentation was delivered in four classes of children aged 9–10 years in four schools in England. Interviews with the index child and their parents were conducted prior to, and 2 weeks postintervention. Classmates completed questionnaires immediately prior to, and 2 weeks postintervention, and then took part in focus group discussions. Class teachers were also interviewed 2 weeks postintervention (Figure 1 summarises the procedures). The University Research Ethics Committee granted ethical approval for the study and consent/assent was obtained from all participants.

image

Figure 1. Summary of study procedures

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The intervention

The intervention comprised a presentation produced by ‘Tourettes Action’, a UK charity (freely available from http://www.tourettes-action.org.uk/ts-presentations/). The presentation is a computer-based slideshow aimed at primary school children, containing factual information about TS. For example, it describes what TS is, how common it is and how to act towards children with the disorder. It takes about 15–20 min to present, including time for questions and discussion. In this study, the presentation was given by the teacher and was tailored to the wishes of the child (whether they wanted to disclose that they had TS or not and if/how they wished to contribute). Three of the four children chose to let their classmates know during the presentation that they had TS, and then answered questions in the classroom discussion that followed. To ensure a degree of uniformity in how the presentation was given, guidelines were developed for the teachers. The researcher was present in the classroom during the presentation.

Participants

Participants were recruited through an advertisement on the Tourettes Action website. An initial telephone call established whether the index child met criteria for inclusion (see Table 1). If so, the parent was asked to obtain assent from their child and to seek consent from the class teacher. Consent was also obtained from classmates' parents.

Table 1. Inclusion and exclusion criteria for children with TS
Inclusion criteriaExclusion criteria
Diagnosis of TSNonfluent English speaker
9–11 years oldGeneralised learning difficulties
In mainstream school

Diagnosis of Autistic Spectrum disorder

Behavioural/emotional difficulties that would prevent participation in project

Previous classroom presentation given within the last year

Four children with TS, their parents (n = 5), teachers (n = 5) and classmates (n = 100) took part in the project. Figures 2 and 3 show the recruitment numbers for the children with TS and their classmates respectively. Table 2 shows the characteristics of all the participants. Selection of 9–10-year-old participants was intentional, as this is acknowledged as the time when children with TS experience most frequent tics (Leckman, Zang, Vitale, Lahnin & Lynch, 1998), which peers are likely to notice.

image

Figure 2. Recruitment of children with TS

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image

Figure 3. Recruitment of classmates

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Table 2. Participant characteristics
Participant groupGenderMean age (years:months; range)Year groupEthnicityComorbidity
Children with TSMale (n = 4)9:7 (9:0–10:7)

Year 5 (n = 3)

Year 4 (n = 1)

White British (n = 3)

Mixed (n = 1)

TS plus (traits of) ADHD and OCD (n = 3)

Pure TS (n = 1)

Parents

Mother (n = 4)

Father (n = 1)

White British (n = 3)
Classmates

Girls (n = 58)

Boys (n = 55)

9:2
Teachers (including teaching assistant of child 1)Female (n = 5)White British (n = 5)

Interviews and focus groups

Interviews followed a semistructured format. The objectives of the prepresentation interview were to obtain the views of the child and their parent on the child's peer relationships and their expectations regarding the presentation. The aims of the postpresentation interview were to obtain their views about the process and impact of the presentation. The purpose of the teacher interview, conducted following the presentation, was to gain an understanding of how the presentation went, and the impact on the child's peer relationships from another perspective.

Focus groups were conducted with classmates; each class was divided into 3–4 groups, so that each focus group contained 6–9 children. Using a semistructured format, the focus groups aimed to elicit classmates' reactions to the presentation, and any changes in their knowledge about TS or attitudes towards a child with TS.

Quantitative measures

Two questionnaires measuring classmates' attitudes and knowledge about TS were developed for the study. The questionnaires were administered on two occasions, once immediately prior to the presentation and then again 2 weeks later.

‘Attitudes about TS’ measure

A 12-item measure (‘What I think about people’) was used to assess attitudes. This was a modified form of the CATCH (‘Chedoke-McMaster Attitudes Towards Children with Handicaps’ Questionnaire; Rosenbaum, Armstrong & King, 1986), a 36-item measure used in a previous study on children's attitudes towards TS (Holtz & Tessman, 2007). The current questionnaire examined classmates' attitudes and intended behaviours towards ‘John’, a hypothetical child with unusual habits (tics) described in a written vignette. Classmates were asked to decide whether a given statement (such as ‘I would stick up for John if he was being teased’) was ‘not true’, ‘somewhat true’ or ‘really true’. Four items were selected from each of the three domains of the CATCH (affective, behavioural and cognitive). Items were chosen that showed moderate to high factor loadings in the original study, whilst being different enough from each other to avoid redundancy, and relevant to children in UK primary schools. Items were modified to ensure that the language was age-appropriate and in line with current terminology, and that there was an equal number of positively and negatively worded items, which were ordered randomly.

The full scale showed good reliability overall (Cronbach's α = 0.77 and 0.82, pre and postintervention respectively). The reliability of the individual affective, behavioural and cognitive subscales was poorer (ranging from α = 0.58 to 0.72); therefore, only the full scale was used in the data analysis. Possible scores on the full scale ranged from 0 to 24, with higher scores indicating more positive attitudes.

‘Knowledge about TS’ measure

This nine-item questionnaire (‘What I know about Tourette syndrome’) measured classmates' knowledge about TS using a three-item response choice format. Classmates were asked to respond to a given statement (such as ‘About 1 in 100 school children in England has Tourette Syndrome’) by selecting ‘not true’, ‘true’ or ‘don't know’. The content of the questionnaire was based on the content of the TS presentation (as used by Holtz & Tessman, 2007). Possible scores ranged from 0 to 9 correct items, with higher scores indicating greater knowledge.

Administering the measures

The questionnaires were administered by the teacher to the whole class. The attitude measure was presented before the knowledge measure to reduce the likelihood that the label of TS on the latter measure would influence children's attitudes.

Data analysis

Qualitative

Interviews and focus groups were audiorecorded, transcribed verbatim and analysed using a thematic analysis approach (Braun & Clarke, 2006). In accordance with this method, a series of steps were followed to identify ‘codes’ (key ideas within the transcripts), which were clustered together to form themes, whilst maintaining links to the original text. The approach was tailored to take into account the complex nature of the data set, which involved integrating themes across multiple perspectives and two time points.

In line with good practice guidelines for qualitative research (Barker & Pistrang, 2005), credibility checks were carried out. A second member of the research team reviewed analysis of all transcripts from one participant set. In addition, triangulation was inherent in the study design, which incorporated multiple perspectives, quantitative and qualitative measures (Olsen, 2004).

Quantitative

To answer the second research question of the study (whether there was a change in classmates' knowledge and attitudes following the presentation), paired-sample t-tests, or the nonparametric equivalent, were used to examine change in questionnaire scores following the intervention. Data from 98 children were included in the analysis. Additional exploratory analyses are detailed in the 'Results' section.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The quantitative data are presented first to provide a context for the qualitative data, which are more expansive.

Quantitative change in classmates' knowledge and attitudes

The assumptions of normality necessary for parametric tests were met for both the knowledge and attitude variables across the four schools individually with one exception (the change in attitude score of school 3). The data for all four schools together was negatively skewed for both variables. For nonnormal data, the findings were robust across both parametric tests and their nonparametric equivalents. There were no correlations between knowledge and attitude scores except in school 3, where preintervention knowledge was negatively correlated with preintervention attitude score (r = −0.38, p = .04); that is, greater knowledge was associated with less positive attitudes. There were no differences between the schools in the ratio of boys to girls (determined using Chi-squared tests).

Classmates' knowledge and attitudes about TS improved pre to postintervention across all four schools and in each school individually, except for the classmates in school 3, who showed no change in attitudes (see Table 3).

Table 3. Change in classmates' knowledge and attitude scores pre to postintervention
SchoolMean knowledge scorea (SD)t (df) p Mean attitude scoreb (SD)t (df) p
PrePostPrePost
  1. a

    Possible range 0–9; higher scores indicate greater knowledge.

  2. b

    Possible range 0–24; higher scores indicate more positive attitudes.

13.4 (2.6)8.1 (1.3)9.4 (20)<.00114.8 (3.0)17.3 (3.6)4.1 (20).001
25.6 (1.6)8.1 (1.1)6.9 (21)<.00116.9 (4.8)18.6 (4.5)4.8 (21)<.001
32.2 (2.1)5.6 (2.4)8.6 (30)<.00115.5 (5.0)15.9 (5.4)0.5 (30).627
43.9 (2.3)6.8 (1.9)4.9 (23)<.00116.2 (3.7)19.5 (2.8)7.3 (23)<.001
All schools3.6 (2.5)7.0 (2.1)13.8 (97)<.00115.8 (4.3)17.7 (4.5)5.0 (97)<.001

Themes from the qualitative analysis

The analysis produced two overarching themes relating to perceived outcomes of the presentation, with a number of themes within each of these (see Table 4).

Table 4. Themes from the thematic analysis of the interviews and focus groups
Super-ordinate themeTheme
Impact on classmates: Enabling prosocial behavioursCuriosity about TS
The importance of disclosure
Empathy and tolerance
Impact on child: Embracing having TSFeeling less different
Increased self-confidence

Impact on classmates: enabling prosocial behaviours

Theme 1: curiosity about TS

Most classmates reported that they had previously known little or nothing about TS. Following the presentation, classmates said that they had learnt a lot about TS, which they demonstrated by correctly recalling facts from the presentation and its key message. Classmates said that they enjoyed learning about TS and wanted to know more. Teachers also noted how engaged classmates were during the presentation.

I think the children were, um, quite inquisitive at certain points…. They weren't just watching it, they wanted to know things… (Teacher 3)

In particular, classmates engaged in lively debate during the focus groups to try to recall, understand and explain more complex aspects of TS (such as its causes and developmental course). They were keen to know ‘how does actually Tourette Syndrome happen to children?’ (Boy 1.1, i.e. boy in school 1, focus group 1). They also generated novel questions about TS, which had not been addressed directly in the presentation content.

So has it been happening since the beginning of time or is it something that has evolved with us? (Girl 1.3)

The children were also interested in ‘stories’ of people who have the condition, such as those whose photographs were included in the presentation. This interest was noted by teachers. Classmates reported that the pictures had given them a positive perspective on children with TS.

I liked when they were showing the pictures… they are not embarrassed to have Tourette's. (Girl 3.3)

Theme 2: the importance of disclosure

In general, classmates said that they thought it was helpful to have an explanation for the behaviours of a child with TS, so that they knew how to behave towards children with tics.

When [child's name] kept on doing it, I didn't know he had it so like sometimes I copied…until I found out. So I stopped it cos I knew it was mean. (Boy 3.3)

Children also commented how knowing about TS would enable them to stand up for a child with the condition. Some felt that they had a ‘right’ to know if a child they knew had TS, so they could avoid ‘acting badly’ towards them. Others said that how they would act towards a child with unusual behaviours would depend on whether they knew if the child had TS or not.

If like a new member of the class, came into the class and they saw [child's name] doing his tics, they might think ‘what is he doing?’ and if he starts trying to ask him, or be a little bit horrible, we could stop him and tell him and explain about Tourette's. (Girl 4.2)

It was felt by many of the children with TS, their parents and teachers that disclosure provided an important context for the presentation.

I think in some ways it's quite a lot of information for them to take in, if they are not really sure why they are listening to it. (Teacher 1)

In school 2, the classmates were not told that the child had TS, and this led to confusion where some classmates knew/guessed that the child had TS, whereas others were unaware of the child's diagnosis. This led to instances of some classmates disclosing that the child had TS, whereas others tried to respect the child's choice not to disclose.

B: ‘I know someone in the class who has some… [child with TS's name] G: He doesn't… [child with TS's name] has habits' (2.1)

The teacher also felt that the impact of the presentation might have been limited by the child's decision not to disclose.

Answering the question, ‘have they treated him any differently?’ No, probably not because we haven't said ‘it's [child with TS's name] and this is what we need to do to, er, help him…’ (Teacher 2)

Theme 3: empathy and tolerance

Classmates' accounts suggested an increased capacity to be empathic towards children with TS following the presentation. They expressed concern for how the child might be feeling, tried to understand situations from their perspective and expressed sympathy for children who have TS. As noted in theme 2, classmates appeared keen to use the knowledge they had gained about TS to behave more sensitively or tolerantly towards children with TS. However, a minority reported less empathic ways they would behave, for example, ‘I would tell them to shut up’ (Boy 3.2).

There were also a number of instances where actual changes in classmates' behaviour were reported. In one case, both the child with TS and their teacher reported these changes.

It's mainly been in pupil reactions… I think they've been a lot more understanding, and they might have noticed it more but they haven't given me the look or a glare like they would have before to say ‘well why is he getting away with it?’ (Teacher 4)

No one [is] asking me [about my tics] and stuff… People were a bit bugging me [before] but I think that's got better now, I haven't heard a word about [it] like ‘why do you do that?’ (Child 4)

In another instance, changes were noted by the child and parent that were not observed by the teacher.

But when it was me, cos I did get bullied in the end and he stood up for me. (Child 3)

Everyone's been more supportive now haven't they?… I think they all sort of look out for him… I've seen him sometimes at lunchtime in the hall… and they sit patiently and wait for him now. (Parent 3)

It appeared that in instances where teachers indicated that no noticeable changes in classmates' behaviour had occurred, this was also felt to be positive.

There's been no comeback from it, there's been no, nothing said to [child's name]…not a lot's changed, he's still got friendship groups, he still carries on. (Teaching Assistant of Child 1)

It was noticeable that the other classmates appeared to ‘rally round’ to support the child with TS in the few instances of negative behaviour towards the index child.

[Boy's name] who is a bit, who is maybe not as thoughtful and sensitive as some of the others kept saying ‘oh is this about [child with TS's name]?’ you know, and the others said to him ‘yeah, but you know, shush, cos it's rude to be shouting out like that’. (Teacher 2)

Impact on child: embracing having TS

Theme 4: feeling less different

The three children who disclosed that they had TS felt ‘really happy and almost like really relieved’ (Child 4) that their classmates now knew about their condition. As a result of the positive reactions they received following their disclosure, the children appeared to spend less time thinking about, or monitoring classmates' reactions to their tics.

He doesn't tend to be looking around to see if anyone is watching him anymore, and they don't seem to take as much notice. (Parent 1)

They appeared to feel more accepted or included by other children at school following the presentation. As one parent put it, ‘I think he probably, he feels more gelled in there, you know?’ (Parent 4). There appeared to be positive changes in the children's mood associated with feeling less different, including being ‘a lot happier’ (Father of Child 3) and less anxious. The one child who did not disclose did not appear to benefit in the same way. The accounts of this child and his parent generally lacked comments regarding perceived changes.

Theme 5: increased self-confidence

The three children who disclosed that they had TS reported and/or were noticed by parents and teachers as, being ‘more comfortable’ and ‘relaxed’ following the presentation. This manifested itself in ‘showing the tics a little bit more’ (Teacher 4) and ‘doing better like answering questions, cos I don't feel… ticcy around people that I haven't talked to as much’ (Child 4).

I've heard that children have asked him if something he has done is one of his tics and he's been able to say ‘yes’ whereas in the past he would have probably ignored them completely, or diffused the question so he didn't really need an answer… (Parent 1)

The children seemed more able to ‘be themselves,’ which in turn appeared to enable them to get on with other activities, such as schoolwork. Again, the child who did not disclose did not appear to benefit from any changes in this domain.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

This study used both quantitative and qualitative methods to explore the effectiveness of a psychoeducational intervention (a classroom presentation) for peers of children with TS. Questionnaires were used to establish whether the approach improved knowledge and attitudes of peers towards children with TS. Interviews and focus groups examined the processes by which any changes may have occurred, and the experience of the intervention from the perspective of the child with TS, their parents, teachers and classmates.

Overall, classmates' knowledge of TS and attitudes towards children with the condition improved following the presentation, as indicated by questionnaire scores. In one of the four schools, however, attitudes did not change; the data do not provide sufficient information to explain this negative finding, especially as qualitatively, the child with TS and his parent reported changes in classmates' attitudes and behaviours towards him.

The changes in knowledge and attitudes found quantitatively were reflected in peers' responses in the focus groups and in the comments of the children with TS, their parents and teachers in the interviews. There were indications that the actual behaviour of peers towards the child with the condition may have also changed. As knowledge is proposed to influence attitudes, which to some degree predict behaviour, provision of information may be at least partially responsible for the change in attitudes and behaviours noted (Vignes et al., 2009). It is likely that group processes also influenced change in classmates' individual attitudes following the intervention. Information in the presentation (such as how to treat children with TS) may have influenced classmates' perception of what the majority's view of TS is. If each classmate believes that the majority of children hold a more accepting attitude towards TS, they may also take a more empathic view, and demonstrate prosocial behaviour towards the child (Rivis & Sheeran, 2003). Disclosure about the child's condition during the presentation may have had a positive impact on classmates' attitudes as they could relate the presentation content more easily to their own experiences (Rosenbaum, 2010).

Positive changes in the child with TS were also noted in the interviews with the children, their parents and teachers. Their accounts suggested that the children became more accepting of their condition following the presentation. For example, they appeared to feel less different from their classmates, more confident and relaxed, less focused on suppressing their tics and more involved in other activities. Again, disclosure of the child's condition during the presentation appeared particularly important in the process of bringing about change; the one child who chose not to disclose did not appear to gain the same benefits.

It may have been that a shift in the child's attentional focus was an important mediator of the changes in self-concept. Cognitive biases such as inward focused attention or hypervigilance to threat have been found to be important in psychological difficulties such as anxiety (Clark, 1999). Prior to the presentation, the children with TS appeared focused on monitoring their tics, which may have led them to overestimate others' negative reactions. Following the presentation, their attentional focus may have shifted to other tasks, giving them the impression that they were more accepted by others, further enabling them to ‘forget’ about their TS and ‘get on with’ other activities.

A social-ecological model (Bronfenbrenner, 1979) offers a potentially useful theoretical framework for understanding the relationship between the impact of the presentation on the classmates and the impact on the child with TS. It highlights the importance of intervening within a child's social world to produce positive changes within the child themselves. The current findings suggest that a significant development in the self-concept of the child with TS occurred following a change in their school environment; provision of educational information in the context of disclosure appeared to lead to greater empathy and tolerance from peers, allowing the child to become more accepting of their condition.

Methodological limitations

It remains unclear how far the findings may generalise to other children with TS. The opt-in recruitment design led to a self-selected sample of enthusiastic participants who were keen to go ahead with the presentation. Not all children, families and schools will want to initiate or engage in this process. The inclusion of one child who did not disclose his condition provided a useful comparison, suggesting that the presentation was more successful when disclosure took place. In addition, the children with TS were all 9–10-year-old boys of a largely white British demographic, which limits generalisability. Finally, it remains unclear whether the impact of the presentation varies depending on the severity of the child's TS. The children who disclosed in the study had more severe TS with comorbid ADHD and OCD, whereas the child who chose not to disclose had pure or uncomplicated TS with fewer, milder tics. It was not possible to establish whether the presentation had less impact for this child due to the lack of disclosure, milder tics or other reasons.

The naturalistic study design meant there were uncontrolled differences between schools (such as school ethos/culture or class dynamics). The presence of the researcher in the classroom may also have influenced the outcomes of the presentation and detracted from the naturalistic study design. In addition, we did not examine whether the changes were maintained beyond 2-week follow-up, and there was no control group to provide comparison data.

Several validity issues also need to be considered. The quantitative measures of knowledge and attitudes were developed for this study, so their validity remains unknown. The focus group data may have reflected a social desirability bias; the children in the focus groups were very positive about the presentation and about TS in general, and there may have been some reluctance to express more negative views. However, competing and less positive views were expressed by some children, suggesting that the focus group format did not constrain open discussion; indeed, the advantages of using focus groups with children, for example in facilitating discussion, have been highlighted in the literature (Cutler et al., 2009; Farquar, 1999).

Implications for research and practice

The mixed-methods design of this study, incorporating quantitative and qualitative elements, provided information about the effects of a classroom presentation (on both the child with TS and their classmates) and the processes by which these effects may have come about. Several hypotheses generated by the qualitative data could be tested in larger, quantitative studies, for example: (a) that psychoeducation increases classmates' empathy, which leads to more prosocial behaviours towards the child with TS, and (b) that disclosure is a key component in bringing about change in classmates' attitudes and the impact on the child with TS. Mapping the relationship between knowledge, attitudes and actual behaviour change in a larger number of schools would provide a basis for developing a theoretical model of change.

The consistency of the present findings across four schools is encouraging. It suggests that educational presentations have the potential to improve knowledge and attitudes towards TS, and impact positively on the self-concept of the child with TS. This is likely to be of interest to clinicians as well as children with TS, their families and teachers. A challenge will be to encourage the use of educational presentations across the age range outside of a research context. The effectiveness of this simple, school-based presentation indicates that interventions targeting the child's social environment should be carried out more routinely alongside, or as an alternative to, one-to-one therapeutic interventions. Clinicians could work with families and schools to support this process, using the current research as a model.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Many thanks to: Tourettes Action for use of their presentation and help with recruitment; participants for generously giving up their time. The study received expenses from the subdepartment of Clinical, Educational and Health Psychology at University College London. Based on research conducted by C.N. for a clinical psychology doctoral (DClinPsy) thesis at University College London. The authors have declared that they have no competing or potential conflicts of interest.

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  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
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