Growing Proficiency in Tic Disorder Care and Skills (GP-TiCS): A Thematic Analysis of Patient and Professional Group Experiences in Primary Care for Primary Tic Disorders

Growing Proficiency in Tic Disorder Care and Skills (GP-TiCS): A Thematic Analysis of Patient and Professional Group Experiences in Primary Care for Primary Tic Disorders | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Growing Proficiency in Tic Disorder Care and Skills (GP-TiCS): A Thematic Analysis of Patient and Professional Group Experiences in Primary Care for Primary Tic Disorders Adam Parker, Blandine French, Madeleine J Groom, Charlotte L Hall This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7328271/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Around 300,000 people in the UK are thought to be living with Tourette syndrome. Many people with tics and their families report negative experiences when approaching their General Practitioner (GP) for advice and support. Limited education during medical training coupled with a lack of National Institute of Health and Social Excellence (NICE) guidelines for tic disorders creates clinical challenges for healthcare professionals (HCPs). Building on the results of an international systematic review of healthcare experiences, the GP-TiCS project explored this further within the UK, conducting a thematic analysis of interviews with adults with tics (n = 5), parents of young people (n = 5) with tics, GPs (= 6), and secondary care HCPs working with people with tics (n = 4). The Factors Impacting GPs’ Knowledge and Education of Tics theme suggested that limited education and guidance made it more difficult for GPs to support people presenting with tics yet also considers how surmounting pressures and expectations on primary care may exceed the responsibility and capabilities of GPs. Inconsistent Availability of Support for Tics Across the Country continues to be an issue for GPs making referrals to services and for people seeking support, while secondary HCPs report receiving unclear referrals with limited information which makes service allocation more difficult. The Experiences of Primary Care for Tics theme explores how the wider impact of living with tics is often left unexplored, including persistent stigma, and poor communication and signposting from GPs. The results suggest accessible and appropriate education opportunities for GPs may improve experience for people presenting with tics by increasing GP knowledge and awareness of tics. This study precedes the development of an online learning resource for GPs. Tic disorders Tourette syndrome experiences healthcare professionals primary care medical education knowledge stigma service provision Background Primary tic disorders (TDs), including Tourette syndrome (TS), chronic tic disorder, and provisional tic disorder, are characterised by the onset of tics, typically emerging around the age of 6 years and before the age of 18 (Robertson, 2008). Tics are repetitive movements or sounds that often present as jerking, grimacing, and coughing, and less frequently, coprolalia (explicit language) or copropraxia (offensive gestures) ( 1 ). A recent National Institute for Health and Social Care Excellence (NICE) survey revealed that people waited between 6 months and 2 years to receive a diagnosis of either TS or chronic tic disorder ( 2 ). For adults with tics, these challenges can be further compounded due to the diagnostic criteria for TS requiring tics to be present before the age of 18 ( 3 ). Therefore, both clinicians and patients must be confident that tics existed in childhood before a diagnosis can be made. In the UK, healthcare support for tics begins with the general practitioner (GP) who, in most cases, will refer children to paediatric services or child and adolescent mental health services (CAMHS), while adults may be referred to neurology. However, many patients report difficulties in getting their GP to initiate a referral, with barriers including the belief that there is no onward care available ( 4 ). Even once referred, patients continue to report long waits to being seen by specialist services ( 5 ). Medical Doctors internationally report receiving very little education on tics during their medical training ( 6 ). First exposure to tics often depends on clinical placements or engaging with continued professional development (CPD) training opportunities. GPs report that they do not often see people with tics in their clinic, however, with an estimated 300,000 people in the UK living with tics ( 7 ), it does raise the question whether a lack of knowledge of tics and TDs ( 4 ) has contributed to an under-recognition of tics amongst medical professionals. Furthermore, there currently are no dedicated NICE guidelines to aid GPs in how to assess tics or provide support for people with tics. Knowledge of tics also includes understanding which local services are available to support people with tics. With limited services and unclear pathways for tics nationally ( 8 ), offering and accessing treatment can be distressing, frustrating, and confusing for all parties ( 9 ). A recent systematic review (Parker, French ( 6 ), highlighted the main issues in healthcare for tics as: lack of confidence in understanding and managing tics; presence of misconceptions and stigmas; inconsistent communication by healthcare professionals (HCP). There is a clear need to improve GPs’ knowledge and awareness of tics to improve recognition/identification of tics, facilitate appropriate referrals, and provide longer term support to people living with tics. However, there is a lack of training currently offered to GPs on this topic. GPs in the UK are expected to complete 50 hours of CPD each year. Previous research in the UK demonstrated that 87% of GPs preferred to use online educational resources for CPD purposes ( 10 ). There is also evidence to show that online learning resources are effective at improving GPs’ knowledge and confidence of neurodevelopmental disorders, such as attention-deficit/hyperactivity disorder (ADHD) ( 11 ). This qualitative study aimed to explore the many aspects involved in primary care for tics, including healthcare support, referrals, and the overall patient experience. It was key to understand experiences to understand experiences from all the key professional groups, GPs and HCP in secondary care, and the people and families accessing primary care for tics, adults with tics and parents. Understanding the needs of professionals and service users will inform the development of a future online intervention aimed at improving GP’s knowledge of tics. Methods Study design Online semi-structured interviews were conducted in late 2024 and early 2025 by the lead researcher (AP). Ethical approval was obtained from the University of Nottingham (UoN) Mental Health and Clinical Neurosciences Ethics Sub-Committee in August 2024. Participants The target sample was 20 participants across four groups: adults with tics; parents of children and young people with tics; GPs; and other HCPs in secondary care. Eligible GPs had previously worked with people presenting with tics. Eligible HCPs had experience working with people with tics, and an understanding of primary care for tics either through working with GPs directly or through patient-reported experiences. For adults living with tics, and parents of young people with tics, it was not necessary for them to have a TD diagnosis, so long as current investigations were indicative of a primary tic disorder, not functional tic disorder. Differences in aetiology, prognosis, and clinical support were the reasons for this distinction between primary and functional tic disorder and were made clear to participants in the expression of interest form and participant information sheet. Two adults with tics and one parent initially submitted interest in the interview but either did not respond to contact attempts or were unavailable to attend interview. Data collection and analysis An advert inviting eligible people was circulated to members of the National Tic Steering Group at the University of Nottingham and posted on the Tourettes Action website. The advert featured a link to an expression of interest form, where people could provide consent for the lead researcher to provide them with additional information about the study. Group-appropriate participant information sheets (PIS) and consent forms were emailed to all who registered interest. Following consent, all participants were sent a group-specific pre-interview questionnaire with clinical and demographic questions. Interview topic guides were also developed specifically for each group (see Appendix 1–4). All interviews were hosted on and audio-recorded using Microsoft Teams and transcribed using Microsoft Teams built-in transcription feature before the lead researcher reviewed for transcription errors and removed identifiable data. The audio recording failed for one participant, and while a transcript was still generated using MS Teams, the data was not included in the analysis as it was felt that without a recording the interview transcript could not be confidently reviewed for errors. Interview duration ranged between 24 minutes and 1 hour 48 minutes. This study aimed to better understand the topic of healthcare for tics in England, not contribute or challenge a proposed theory, and therefore inductive thematic analysis was conducted. Following Braun and Clarke ( 12 ) six stage process, a period of data familiarisation took place during which initial thoughts were noted, before identifying preliminary codes. A portion of the transcripts were reviewed by second coders, CLH and BF, to establish quality and agreement. Codes were then assembled to generate initial themes. Additional familiarisation of data allowed some themes to be combined into broader themes to better encapsulate experiences and perspectives. Themes were reviewed to ensure that subthemes appropriately captured the meaning and relevancy of the data and the main theme. Results Six GPs, four HCPs in secondary care, five parents, and five adults with tics (N = 20) were interviewed on their experiences and perspectives of healthcare for tics in primary care. Participant demographics are illustrated in Table 1 . Table 1 Participant demographic information. Of the patient groups, all adults and YPs (as reported by their parent) had either received a TD diagnosis or were currently under investigation. It was self-reported by adults with tics to have waited between 1 and 10 years for a diagnosis to be confirmed. Parents reported waiting between 5 months and 4 years for their young person’s diagnosis to be confirmed. It is worth noting that one young person diagnosed within 5 months had accessed private healthcare. When tics first emerged, the time taken to seek first-line support was between 4 months and 4 years, when tics first became more frequent, or in adulthood despite having them in childhood. Parents sought support after the first tic emerged, in the first few weeks, or up to a year later. For the clinical groups, GPs had been in practice between 6 and 22 years, with most seeing between 1–3 people with tics annually, and one seeing more than 10. Most GPs report little to no training during their medical education, with just one GP spending a day in a tic clinic as part of their clinical placement. Most GPs developed their knowledge of tics through CPD opportunities. HCPs in secondary care all worked with people up to the age of 18 with most seeing more than 10 people annually with tics and have completed CPD opportunities to develop tic knowledge. Three themes were generated from the data (summary in Table 2 ). Table 2 Summary of themes and sub-themes. Theme Description Subtheme Exemplar Factors Impacting GPs’ Knowledge and Education of Tics This theme explores how GPs have little education on tics, with few guidelines available. This can lead to overcomplicated clinical investigations. GPs often feel under pressure to be more knowledgeable about many disorders, but question whether this is their responsibility. Limited Commissioned Training Opportunities and Guidelines Everything but a Tic Disorder Individualised Barriers and Facilitators of Tic Knowledge Balancing Responsibility and Pressures as a GP “I think the main thing and the pattern all the way through this is that I've been the one who's had to go back with the information, and it's been up to me to research and educate myself about the condition” Inconsistent Availability of Support for Tics Across the Country This theme discusses how access to appropriate support for tics varies nationally and factors which compound referrals include insufficient evidence and only referring once symptoms worsen. Challenges Accessing Support Services Referral Complexities and Challenges “the GPs don't actually know who to refer to because the paediatricians won't see, the neurologist won't see and CAMHS won't see, so they don't actually have anybody to refer to.” Experiences of Primary Care for Tics This theme explores how patient experiences varied in primary care based on factors including: understanding of the impact of tics, the communication between patient and clinicians, and tic-related stigma. Stigma, Dismissal, and Denial of Tics Understanding the Individual Impact of Tics Communication and Educating Patients about Tics "they're OK", and "they're dealing well with their tics". And I often think they just got, they've really not understood, you know, in that 15–20 minute or 10-minute GP appointment. It's not really understood what is going on for a family at all”. Factors Impacting GP Knowledge and Education of Tics Limited Commissioned Training Opportunities and Guidelines All GPs reported receiving very little education on tics disorders in their medical training. Some GPs could recall reading a few lines in a textbook, but nothing formally as part of the curriculum. “It's non-existent. All right, I might have had some tiny, you know, a line of it or something in my years ago medical school. But it's, yeah, definitely not something that has featured in my initial training or many of my updates that I've had over the years. ” – Participant 21, GP. However, beyond taught material, some GPs recall encountering tics during paediatric and mental health placements. One GP recalls learning about the diagnostic criteria for TS on their paediatric placement, but not how they could support families. Others noted that not all GPs complete a placement in paediatrics, therefore limiting their exposure to tics in clinical practice. “I think as a GP in my GP training, I've not received any specific training on tics. It's just purely that I've done a placement in mental health and some GP trainees, I guess most GPs do get mental health as a as a placement block. But not everyone, to be honest. And a lot of their experience is probably going to be in the acute hospitals rather than in the outpatient clinics.” – Participant 20, GP. One GP noted that from their experience, new trainees were not finishing their medical training with the necessary communication skills. “The clinician needs to be confident, competent and comfortable talking about tics and have excellent advanced primary care consultation skills. And I'm sorry to say that a lot of the trainees in my area have a high failure rate and many of them are not leaving the training scheme with such good quality consultation skills as I would like them to have in this context of tics.” – Participant 14, GP. This sentiment was recognised by other groups, who also recall feeling as though GPs lacked knowledge about tics. Additionally, it was common for adults with tics and parents to see locum GPs who were thought to be less familiar with tics than salaried GPs, making continuity of care more challenging. “There's a few very long-established GPs who are very sensible through experience, but the difficulty is that a lot of primary care is now delivered by locum GPs who are not as familiar with any disorders, let alone tics.” – Participant 17, HCP in secondary care. Everything but a Tic Disorder Adults with tics, parents, and secondary HCPs varied in their experience when recalling GP knowledge of tics, but often respondents reported that their GP was unfamiliar with the condition or mischaracterised tics with other conditions, some possibly life-threatening, including epilepsy or brain tumours. “Well before my diagnosis could be fully confirmed, I had to go through a process of elimination of what it is not, “let's rule out it's not this”. Initially the first thing they thought was possibly I had a brain tumour to explain the movements and different things, so it was just a very, very anxious time and uncertain time.” – Participant 6, Adult with Tics. While GPs expressed the importance of ruling out serious health concerns, this further increased patient anxiety and occasionally resulted in inappropriate medications being prescribed, including nasal sprays for allergies. Adults with tics and parents reported that each presentation to the GP was considered in isolation, instead of considering previous contact history to build a greater picture of their experience. “Because the amount of families that have been referred to ophthalmology because of eye tics or they've been referred to allergy clinics because of cough, a consistent cough. Or you know, they've had all their allergy tests done for lactose intolerance and whatever. The assumption is not that it's a tic and 20% of kids have got tics, you know, at some point in their life.” – Participant 12, HCP in secondary care. Individualised Barriers and Facilitators of Tic Knowledge All groups discussed factors they felt made identifying tics and appropriately supporting people easier or more challenging. The most common factors included the number of people encountered with tics, personal experience of tics, self or family member, and general interest in tics and TDs. “Initially, my doctor at the time was very inquisitive. He was curious. He was very pro-wanting to know more and I found that, you know, the treatment has been hit and miss with other GPs basically based on the fact of their interest in it. You know if they're like… if they want to do more about it, they'll educate themselves a lot more about it.” – Participant 6, Adult with Tics. GPs with more experience and interest in tics became more specialist within their practice. However, this may have been at the detriment to colleagues, as they could be less likely to see new tic cases or incentivised to develop their knowledge. “Massively so. So I mean most GP surgeries will have GPs with a special interest if typically you'll have someone who's, you know, really hot on dermatology, and so they'll tend to see the skin lesions and things like that. So and then everyone else, and I've asked them for advice, I guess I'm the equivalent for tics and Tourettes. I'd hope that they're all much better at it now, because I've done quite a few education sessions for them. But the danger of having some in your practice is that everyone else de-skills, but hopefully they're all aware of Tourettes Action and that but they do just now send them to me so.” – Participant 18, GP. Balancing Responsibility and Pressures as a GP GPs acknowledge that they are the gatekeepers for people wanting to access additional support for tics in secondary care. However, GPs also expressed concern as they are expected to know a lot about many conditions, experiencing pressure from various groups and charities to ensure their condition is represented and understood. Regarding tics, GP recognition of these limitations varied with some believing they could be doing more, including diagnosing TDs in primary care and reducing the pressure of waiting lists in secondary care. “I think it's entirely possible for Tourettes to be managed the way we manage many, many, many conditions, as GPs. With common stuff with children, I think asthma is a really good example, is I can see a child. I can diagnose that child. I can treat that child without involving any secondary care conditions.” – Participant 18, GP. As gatekeepers and professionals, adults with tics and parents discussed the trust they placed in GPs to appropriately assess their symptoms and make suitable recommendations, demonstrating the reliance of primary care. However, others felt they had to educate themselves and present this to their GP to progress their care. “I was diagnosed with touretteism which I don't even know as a word. But I think the main thing and the pattern all the way through this is that I've been the one who's had to go back with the information, and it's been up to me to research and educate myself about the condition. Otherwise, I would have been in that vicious circle of just taking antipsychotics just to suppress and hold my tics in.” – Participant 6, Adult with Tics. Inconsistent Availability of Support for Tics Challenges Accessing Support Services GPs and HCPs discussed how acquiring a TD diagnosis was often necessary to access any additional support. However, all groups recalled common challenges in secondary care for tics, including the limited provision of services across the country, with some believing there to be better support in south of the country compared to the north. Even more specifically, it was understood that while some regions offered children services, others only had adult services, both raising doubt around the continuity of care and the ability to support adults undiagnosed as children. “the GPs don't actually know who to refer to because the paediatricians won't see, the neurologist won't see and CAMHS won't see, so they don't actually have anybody to refer to.” – Participant 17, HCP in secondary care. Clinicians in both primary and secondary care felt disillusioned by the lack of support available to those with tics, while adults with tics and parents report the implementation of inappropriate treatment and failure to anticipate future needs of child when moving from primary to secondary school. “I think that that causes a barrier in itself because GPs, like us, are frustrated, they're feeling disillusioned. And so there is a sort of, you know, what's the point in sending off a referral because it's not going to make any difference” – Participant 17, HCP in secondary care. However, it was suggested that a lack of specialists was not exclusive to tics, alluding to wider concerns around the supply and demand of services in the healthcare sector. Of those who accessed private healthcare for tics, adults with tics and parents report shorter waiting times and improved accessibility, but little on the quality of care they received, further implying a need for more specialists and better access to treatment. “But the main problem is actually there's just not enough doctors and specialists out there to cope with the volume of paediatric referrals altogether, let alone absorbing the tics on top of it. So the main thing is actually we just don't have the resources.” – Participant 17, HCP in secondary care. Referral Complexities and Challenges Beside a lack of dedicated services to support tics, a number of factors were identified which made completing a referral more difficult, even in areas that appeared to have specialist services. The most endorsed challenge was the lack of well-defined processes to access referral services. It was also reported by parents that there needed to be a clear mental health component for a referral to be made/accepted. However, while HCPs suggest this was to manage service capacity, it also meant that tic referrals were not appropriately allocated to a service equipped to manage tics. “But neurodevelopmental mental health conditions aren't even owned by mental health services because they see it as kind of like physical that “yeah, that's paediatrics. Then we'll do self-harm and depression and anorexia and stuff like that”. So this kind of middle ground that no one really knows what to do with it.” – Participant 12, HCP in secondary care. Professionals in secondary care reported that occasionally referrals did not contain sufficient information about tics. Interestingly, interviewed GPs recognised the benefit of video evidence and letters from school and the importance of including patients in writing the referral, however, parents and adults with tics report not being asked to provide any such evidence. Since adults with tics and families were not often included in the correspondence between primary and secondary care, it was then the responsibility of the GP to relay the news of rejected referrals to families, further exacerbating their confusion and anxiety and potentially rupturing the therapeutic relationship. “And when referrals are rejected, the patient or carer is not normally copied in this, thus leaving me with the liability… They talk about rejected referrals, which I think is not therapeutic for patients. And I think there's a lot of research to be done about the language we use in our consultations in primary care because the consultation skills, the language, the verbal and nonverbal communication are key to whether our interactions are therapeutic.” – Participant 14, GP. Experiences in Primary Care for Tics Stigma, Dismissal, and Denial of Tics Many interviewees reported that common misconceptions included the belief that tics were voluntary or indicative of attention-seeking behaviour and overestimating the frequency of coprolalia as a presenting symptom. Stigmatising misconceptions about tics were held by adults presented with a TD diagnosis, families, primary and secondary healthcare professionals, and schools. This indicates a broader misunderstanding of tics and TDs which exacerbates misconceptions and harmful beliefs. Despite groups recalling recent positive celebrity awareness campaigns, the over-representation of coprolalia in the media continues to be most noteworthy, instilling stigma and making it more difficult for some to accept a TD diagnosis. “If you say Tourette's syndrome, it is usually the kind of very rare cases which are portrayed in media and sometimes families are quite worried when the diagnosis comes in. And actually it is not the case. It's a very rare situation when there is coprolalia where they see where they say very obscene words and people kind of think that that a Tourettes diagnosis it’s, it's what they saw on the TV. And then we have to kind of dial it back a bit and tell them about what is the criteria and how that is quite rare to have such kind of presentation” – Participant 15, HCP in secondary care. GPs identified that due to service demand, support was often primarily offered to those with more severe tics, causing adults with tics and parents to feel dismissed when their/their child’s symptoms were played down. Consequently, HCPs recognised the belief that symptoms had to get worse before being taken seriously or were deserving of more support. In a desperate attempt to be seen, one interviewee exacerbated their tics and developed an abnormally fixed posture, causing additional physical pain. “the biggest health misconception is that it's severity and I have to wait until it's a severe problem to refer or I can only refer that. I can only refer something that's a problem, you know. It has how you judge impairment and how you judge severity.” – Participant 12, HCP in secondary care. Understanding the Individual Impact of Tics Adults with tics and parents recall the wider impact tics can have when socialising with peers, pain caused by repetitive movements, fatigue levels, and academic engagement. However, while GPs report the importance of understanding impact and building a clinical history, patient groups, HCPs recall a lack of consideration beyond visible symptoms. “I think there is a gap in understanding of how significant tics can be in terms of pain, mental health difficulties and the impact on daily life. I think there's tends to be a “well, there's little movement or a little sound. What's the concern about it?”.” – Participant 17, HCP in secondary care. “A lot of the stuff that's written about meetings is, "oh, they're doing well", "they're fine", "they're OK", and "they're dealing well with their tics". And I often think they just got, they've really not understood, you know, in that 15–20 minute or 10-minute GP appointment. It's not really understood what is going on for a family at all” – Participant 8, Parent. Communication and Educating Patients about Tics Many adults with tics and parents recall being offered little information about tics when approaching their GP, with some only being signposted to charity websites when they were hoping for NHS advice or pain-relieving exercise plans. GPs also recalled offering externally available resources for tics online, including charity leaflets, social media, and support groups. This brings into question whether a lack of signposting is a result of few resources, or a characteristic of inadequate patient communication and consultation style. Most adults with tics and parents reported little reassurance or empathy displayed by their GPs. However, GPs reflected on their approach to patient communication, balancing pragmatism and false hope given the lack of service availability, guidelines, and primary care knowledge. One GP did reflect on the variation in the level of consultation and communication skills amongst GPs, especially in the context of tics. This suggests there may be shortcomings in the communication around tics when responding to patient concern, and the availability and awareness of appropriate signposting information for families. “I think there's a really fine balance between reassuring people and people feeling not heard and dismissed. And I know in the Tourettes community, a lot of what is felt is that they're being dismissed. And I can see there's a big disparity.” – Participant 18, GP. “Of course, for the patient, it should feel holistic and sympathetic, and I'll make sure I say things like “that's very difficult for you”, “That must be very hard for you”, “How does that make you feel?”, “It must be embarrassing for you”. I would be doing all of those things, of course.” – Participant 14, GP Discussion The thematic analysis of primary care experiences across different groups generated numerous, often interwoven, themes covering the identification of tics, inconsistent access to specialist/secondary services, and a range of generalised and individualised factors shaping care experiences. The qualitative methodology encouraged a nuanced exploration of the perspectives of those living with, or involved in the care of, people with tics. Factors Impacting GPs’ Knowledge and Education of Tics included investigating differential diagnoses, few training opportunities, individual clinical interests and presentations, and the balance between GPs’ responsibility and patient expectations. Patient groups and secondary care HCPs felt GPs lacked understanding of tics, meaning various other health conditions were investigated first, including brain tumours and epilepsy, causing additional unnecessary worry for patients. GPs reported limited medical training on tics, with pockets of knowledge originating from personal experience, interest, and the number of presentations in clinic. Ever increasing demands placed upon GPs meant that assigning GP specialists may ease pressure at the expense of deskilling other colleagues about a particular condition, including tics. However, some GPs felt they could be doing more to alleviate demand further along the pathway in secondary care, including diagnosing TDs which one GP was already doing. Previous research has shown that patients’ views on HCPs insufficient knowledge of tics, lead to shallow clinical investigations and limited information or support being offered, even in the context of some knowledge of tics. ( 4 , 6 , 13 , 14 ). Negative experiences may stem from a lack of confidence due to infrequent case presentations and limited training opportunities. Interviews with GPs highlighted time pressure and fear of mistakes as stressors (Riley et al., 2018). In the present study, GPs’ views varied in their sense of responsibility for managing tic cases, with some believing secondary services or the patients themselves should take more responsibility. These findings suggest that improved access to manageable training could enhance GPs' knowledge and confidence in managing tics in primary care. Inconsistent Availability of Support for Tics Across the Country was discussed by all groups, including the geographical sparsity of services. Areas that did not have a dedicated service for children, it was often unclear whether Paediatric Neurology or Child and Adolescent Mental Health Services (CAMHS) was most appropriate. Additionally, CAMHS required a clear mental health component associated with tics before a referral could be accepted, potentially limiting tic-specific support. Rattu, Hall ( 8 ) reported very few service pathways for children and young people with tics in England, with neurodevelopmental services not always accepting cases of tics unless ADHD and ASD were the primary reason for referring. Some GPs were aware of tic specialist services but were unable to refer directly, instead having to refer to Paediatrics before being triaged to the most appropriate service and further delaying access to support. HCPs in secondary care reported that some referrals did not include sufficient information to accurately assess need, resulting in the referral being declined. These inconsistencies may further exacerbate the already lengthy waiting times for secondary care within England (Bhikram et al., 2021; Marino et al., 2023). It can be challenging for GPs to gain all the information relevant to making a referral given the shift to short, often remote appointments in primary care settings. Standardised referral processes may enhance the quality of referral information ( 15 ), coupled with direct liaison with schools, workplaces, and families to gain a fuller picture of the severity and impact of tics. Improving GPs’ tic knowledge and clarifying the most appropriate locally available pathway could facilitate accurate referrals and reduce confusion. While GPs endorsed the usefulness of supporting evidence, including videos, most adults with tics and parents interviewed report not being asked to provide any evidence for their/their child’s tics. Effective non-pharmaceutical treatments including Comprehensive Behavioural Intervention for Tics (CBIT) and habit reversal therapy (HRT) ( 16 , 17 ) exist, yet are often not available due to a lack of expertise and funding ( 4 , 6 , 8 , 18 , 19 ). Systemic improvements in service availability for people with tics could result in better access to treatments that when paired with refined referral processes may greatly improve patient experiences. The theme of Experiences of Primary Care for Tics confirmed that stigma and misconceptions remain an issue for people living with tics. All groups discussed how many people still assume tics are voluntary and that coprolalia is common, and the role media has on experiences. For example, media representations were suggested to occasionally improve public perceptions of TD but the overrepresentation of coprolalia made it more difficult for people who did not experience coprolalia to accept a TD diagnosis. Recent research has found that media portrayal of TS continues to overstate coprolalia as a primary symptom, exacerbating stigmatising beliefs and misconceptions ( 20 ), extending to clinicians in primary care ( 6 , 21 , 22 ). Moreover, since media representations occasionally brought attention to more severe cases of tics, some adults with tics felt their symptoms were not severe enough to warrant support, and parents were encouraged to wait until tics caused pain or distress before the GP would agree to refer their child. This misconception was identified by a HCP working in a tic service, who instead suggested that referrals should consider the many facets of impact in addition to visible symptoms and pain, including mental health and functional ability of living with tics. Appropriate education could dispel problematic beliefs and improve the therapeutic relationship, facilitating earlier intervention. The implications of this study reaffirm that while some GPs actively further their knowledge and understanding of tics, it remains a largely unfamiliar and misunderstood condition that does not feature as part of the core learning curriculum for medical students, or has been picked up by GPs as part of their ongoing CPD. Consequently, the patient experience in primary care continues to be mostly negative. A lack of standardised education does not equip GPs with the clinical and communication skills to appropriately investigate tics. Despite early value assessments (EVA) of digital therapies including the Online Remote Behavioural Intervention for Tics (ORBIT) ( 5 , 18 ) prove promising, a more standardised NICE policy is necessary to streamline investigation and delivery of care for tics. While it is important to rule out other serious conditions, inadequate education engenders anxiety and confusion through delayed diagnosis and inadequate access to support. Improved education may encourage more robust investigation of the impact of tics and the submission of more information-rich referrals, ensuring that people are allocated to the most appropriate service with a clear understanding that tics a primary concern. Resourcing concerns continue within the NHS as service demand grows ( 23 , 24 ), yet it is hoped that ongoing education opportunities and awareness will help bring forth formalised guidelines and the appropriate allocation of resources to implement a dedicated healthcare pathway in England. The findings of this paper will inform the development of a GP-tailored online learning resource that considers the additional needs identified by peoples accessing primary care for tics and secondary care HCPs communicating with primary care. The resource intends to offer information on a range of tic presentations, patient communication and impact awareness (pain, sociability, academia, hidden tics, and mental health), common misconceptions and stigma, and useful signposting information and resources. It is important for the resource to be time-manageable, focusing on content specific to the role of a GP. Future research should continue to raise tic awareness while challenging stigmas and support the need for dedicated services with a clear referral pathway. Some limitations of the study should be considered. Participants were recruited from England, and while geographically diverse, we were unable to recruit any participants from Wales, Scotland, or Northern Island. While there are few tic specialist services within England ( 8 ), none exist in Wales and Scotland, potentially leading to further challenges and uncertainty for patient and families ( 25 ). Additionally, a 2023 study found that a majority of GPs in Wales, Scotland, and England were unsatisfied with their work-life balance ( 26 ). Consequently, this suggests that patient and professional experiences may be similar across the UK, further substantiating the need to better GP support and knowledge of tics within primary care. Professionals were recruited through University of Nottingham TD networks and further snowball sampling. From the interviews, it was apparent that some GPs had more personal interest in tics, which is unlikely to reflect the general population of GPs. Interestingly, many of the needs raised by the adults with tics and parent groups were also highlighted by the GPs who were more knowledgeable about tics. Therefore, while the sample may not be representative of the wider GP population, it does offer some insight into how primary care could benefit from improved knowledge of tics, including the intention to understand the deeper impact of tics. Although the sample of each group was small, this is in line with previous recommendations ( 12 , 27 ), including tic disorder research ( 28 ). Parental viewpoints were relied upon since children and YPs were not interviewed. While parents may often lead discussions in clinical settings, interviews with YP and children may have generated interesting data about self-advocating and the parent-child-professional dynamic when agreeing upon the best course of action. The lead author is a white male who has previous clinical experience working in psychology and occupational therapy teams before transitioning to child and adolescent mental health research. They have frequently collaborated with other researchers and clinicians working in neurodevelopmental, neurological, and child and adolescent mental health research where the challenges of people with living with tics is well understood. It is important to consider that the lead author who conducted the interviews has been researching tics more recently as part of their PhD and acknowledges the expertise of interviewees is far greater than their own. The lead author had been previously trained to conduct interviews, with additional support by supervisors/co-authors with experience in qualitative methods. Conclusion This paper builds upon a limited body of literature in patient and professional experiences of tics in primary care. Some GPs are keen to develop their understanding following the lack of formal education on tics. However, limited availability of resources results in negative patient experiences when considering their GP’s ability to support their care needs. The development of an online learning resource for GPs has potential to improve knowledge of tics and the understanding of impact beyond the immediate symptoms, therefore supporting appropriate, informed and timely referrals to secondary care. Although current support for individuals with tics remains insufficient, ongoing efforts to educate those in professional care positions while developing a dedicated referral pathway integrating evidence-based behavioural therapies will improve clinical competency and patient outcomes. Abbreviations ADHD Attention Deficit/Hyperactivity Disorder ASD Autism Spectrum Disorder BRC Biomedical Research Centre CAMHS Child and Adolescent Mental Health Services CBIT Comprehensive Behavioural Intervention for Tics CPD Continued professional development EVA Early value assessment GP General practitioner HCP Healthcare professional HRT Habit reversal therapy INTEND ImproviNg Tic Services in EnlaND study NHS National Health Service (UK) TS Tourette syndrome NICE National Institute for Health and Social Care Excellence NIHR National Institute for Health and Care Research ORBIT Online Remote Behavioural Treatment for Tics PIS Participant information sheet TD Tic disorder UoN University of Nottingham YP Young person Declarations Ethics Approval and Consent to Participate Ethics approval was granted by the University of Nottingham Mental Health and Clinical Neuroscience Ethics Subcommittee on 21/08/2024 (Ref: 3277). Participants gave their informed consent prior to taking part in the study. Consent for Publication Participants consented to publication as part of the informed consent process. Availability of Data and Materials The data generated during the current study are available from the corresponding author upon request. Competing Interests Dr. BF reports personal fees and nonfinancial support from Takeda and Medice. AP, Dr, CLH, and Dr. MG declare no competing interests. Funding This study was funded by the Joan Brown Legacy Fund, University of Nottingham, with additional support from the NIHR Nottingham Biomedical Research Centre (BRC; Ref: NIHR203310). AP, Dr. CLH, and Dr. BF acknowledge the support of the NIHR Nottingham Biomedical Research Centre. Dr. CLH and Dr. MG acknowledge the support of the NIHR MindTech HealthTech Research Centre (HRC). The support of Dr. CLH is funded by the NIHR Development and Skills Enhancement Award (Ref: NIHR304774). The views expressed are those of the author(s) and not necessarily those of the NIHR, the Department of Health and Social Care, or representatives of the Joan Browne Legacy Fund. The funders had no role in the study design; the collection, analysis, or interpretation of the data; the writing of the manuscript; or the decision to submit the paper for publication. Authors’ Contributions The content of this study is the original work of author AP. Dr. CLH, Dr. BF, and Dr. MG all supported with proof-reading and writing. Dr. CLH and Dr. BF both supported with interview coding. Acknowledgements We would like to extend thanks to Tourettes Action for supporting in the recruitment of participants for this study. We are extremely grateful to everyone who participated in an interview, offering their experiences and contributing to the betterment of tic support in the UK. References Nilles C, Martino D, Fletcher J, Pringsheim T. Have We Forgotten What Tics Are? A Re-Exploration of Tic Phenomenology in Youth with Primary Tics. Movement Disorders Clinical Practice. 2023;10(5):764-73. NICE. Technology for children and young people with chronic tic disorders and Tourette syndrome recommended 2025 [Available from: https://www.nice.org.uk/news/articles/technology-recommended-for-people-with-chronic-tic-disorders-and-tourette-syndrome. Yilmaz AY, Jankovic J. Epidemiology of Tourette Syndrome. Brain Sciences. 2025;15(5):426. Marino C, Khan K, Groom MJ, Hall SS, Anderson S, McNally E, et al. Patients’ experience of accessing support for tics from primary care in the UK: an online mixed-methods survey. BMC Health Services Research. 2023;23(1):788. NICE. Draft guidance, early value assessment: digital therapy for chronic tic disorders and Tourette syndrome 2025 [Available from: https://www.nice.org.uk/guidance/indevelopment/gid-hte10056/documents. Parker A, French B, Groom MJ, Hall CL. Systematic review—understanding the barriers and facilitators experienced by healthcare professionals in providing care for tics: a mixed methods systematic review of clinical knowledge, attitudes, and practices. BMC Medical Education. 2024;24(1):1403. Tourettes Action. What is Tourette Syndrome: Tourettes Action; 2021 [Available from: https://www.tourettes-action.org.uk/67-what-is-ts.html. Rattu NR, Hall SS, Hall CL, Murphy T, Kilgariff J, James N, et al. ImproviNg Tic services in EnglaND: a multi-method study to explore existing healthcare service provision for children and young people with tics and Tourette syndrome. BMJ Mental Health. 2025;28(1):e301599. Malli MA, Forrester-Jones R. Barriers to Care: The Impact of Stigma and Systemic Inequities on Health and Social Care Support for Individuals with Tourette's. In: Malli MA, Forrester-Jones R, editors. Tourette’s Syndrome, Stigma, and Society’s Jests. Cham: Springer Nature Switzerland; 2025. p. 323-55. MacWalter G, McKay J, Bowie P. Utilisation of internet resources for continuing professional development: a cross-sectional survey of general practitioners in Scotland. BMC medical education. 2016;16:1-9. French B, Hall C, Perez Vallejos E, Sayal K, Daley D. Evaluation of a Web-Based ADHD Awareness Training in Primary Care: Pilot Randomized Controlled Trial With Nested Interviews. JMIR Med Educ. 2020;6(2):e19871. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006;3(2):77-101. Cuenca J, Glazebrook C, Kendall T, Hedderly T, Heyman I, Jackson G, et al. Perceptions of treatment for tics among young people with Tourette syndrome and their parents: A mixed methods study. BMC Psychiatry. 2015;15(1):46. Wellen BCM, Bootes KR, Braley EI, Conelea CA, Woods DW, Himle MB. Caregiver Perspectives on the Health Care System for Tic Disorders: Utilization and Barriers. J Dev Behav Pediatr. 2023;44(9):e581-e9. Tobin-Schnittger P, O’Doherty J, O’Connor R, O’Regan A. Improving quality of referral letters from primary to secondary care: a literature review and discussion paper. Primary health care research & development. 2018;19(3):211-22. Dutta N, Cavanna AE. The effectiveness of habit reversal therapy in the treatment of Tourette syndrome and other chronic tic disorders: a systematic review. 2013(0393-5264 (Print)). Hollis C, Hall CL, Jones R, Marston L, Le Novere M, Hunter RM, et al. Therapist-Supported Online Remote Behavioural Intervention for Tics (ORBIT) in Children and Adolescents: A Single-Blind Randomised Controlled Trial. 2021. Hall CL, Le Novere M, Murphy T, McNally E, Hollis C, Hunter R. Healthcare utilisation and costs associated with poor access to diagnosis and treatment for children and young people with tic disorders. BMJ Mental Health. 2024;27(1):e301241. Alalwan AA, Alkhamis MA, Samman AM, Alsharif EHM, Tarabzoni OEM, Khatri IA. The Assessment of Knowledge about Tourette's Syndrome among Medical Students and Primary Physicians in Riyadh, Saudi Arabia: A Cross-Sectional Study. Neurology Research International. 2022;2022((Alalwan, Alkhamis, Samman, Alsharif, Tarabzoni, Khatri) College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia):3018305. Pring K, Malli M, Hardy BW, Rapp SR, Storch EA, Mink JW, et al. Reframing stigma in Tourette syndrome: an updated scoping review. European Child & Adolescent Psychiatry. 2025;34(1):19-39. Rodin A, Fleetwood-Meade K, Gilmour J, Kasujja R, Murphy T. Why don't children in Uganda have tics? A mixed-methods study of beliefs, knowledge, and attitudes of health professionals. Child Adolesc Ment Health. 2021;26(1):47-53. Katona C. Familiarity with and attitudes to Tourette's syndrome in healthcare students: A pilot comparison with epilepsy. European Journal of Psychiatry. 2013;27(2):129-36. Anderson M, McGuire A, Mossialos E. Addressing the fiscal and sustainability challenges for the NHS. The Bulletin of the Royal College of Surgeons of England. 2025;107(2):76-9. Williams B. The British NHS at 75: Past, Contemporary, and Future Challenges. International Journal of Social Determinants of Health and Health Services. 2025;55(1):76-87. Kramer J, Mehta K, Jackson M. Defining and Characterising a Model of Care for the Assessment, Diagnosis and Management of Tic Disorders in Children and Young People: A Delphi Study. 2024. Beech J, Fraser C, Gardner G, Buzelli L, Williamson S, Alderwick H. Stressed and overworked. The Health Foundation. 2023. Ahmed SK. Sample size for saturation in qualitative research: Debates, definitions, and strategies. Journal of Medicine, Surgery, and Public Health. 2025;5:100171. Ludlow AK, Brown R, Schulz J. A qualitative exploration of the daily experiences and challenges faced by parents and caregivers of children with Tourette's syndrome. J Health Psychol. 2018;23(14):1790-9. Additional Declarations Competing interest reported. Dr. BF reports personal fees and nonfinancial support from Takeda and Medice. AP, Dr, CLH, and Dr. MG declare no competing interests. Supplementary Files Appendices.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 11 May, 2026 Reviews received at journal 10 May, 2026 Reviewers agreed at journal 07 May, 2026 Reviews received at journal 19 Sep, 2025 Reviewers agreed at journal 12 Sep, 2025 Reviewers invited by journal 05 Sep, 2025 Editor invited by journal 14 Aug, 2025 Editor assigned by journal 11 Aug, 2025 Submission checks completed at journal 11 Aug, 2025 First submitted to journal 08 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7328271","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":513187914,"identity":"54fb13b1-4cdb-4744-9c54-c08dfb1becad","order_by":0,"name":"Adam Parker","email":"data:image/png;base64,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","orcid":"","institution":"University of Nottingham","correspondingAuthor":true,"prefix":"","firstName":"Adam","middleName":"","lastName":"Parker","suffix":""},{"id":513187915,"identity":"36714fa7-2b8b-44d5-893e-3573a93fe715","order_by":1,"name":"Blandine French","email":"","orcid":"","institution":"University of Nottingham","correspondingAuthor":false,"prefix":"","firstName":"Blandine","middleName":"","lastName":"French","suffix":""},{"id":513187916,"identity":"8ccd70b7-9fa4-442d-92d0-dca0107b5bc1","order_by":2,"name":"Madeleine J Groom","email":"","orcid":"","institution":"University of Nottingham","correspondingAuthor":false,"prefix":"","firstName":"Madeleine","middleName":"J","lastName":"Groom","suffix":""},{"id":513187917,"identity":"56d67a79-f30a-4b65-ace0-1f57207607be","order_by":3,"name":"Charlotte L Hall","email":"","orcid":"","institution":"University of Nottingham","correspondingAuthor":false,"prefix":"","firstName":"Charlotte","middleName":"L","lastName":"Hall","suffix":""}],"badges":[],"createdAt":"2025-08-08 14:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7328271/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7328271/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91092762,"identity":"7a3cfa4e-d5a7-4536-89ff-d5720ee7e5f2","added_by":"auto","created_at":"2025-09-11 13:37:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":458922,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7328271/v1/4c47db17-f744-4223-854b-43f47b2d2450.pdf"},{"id":91092399,"identity":"a8d1f7d3-07ab-43dd-838d-d72f08824b74","added_by":"auto","created_at":"2025-09-11 13:29:03","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":21641,"visible":true,"origin":"","legend":"","description":"","filename":"Appendices.docx","url":"https://assets-eu.researchsquare.com/files/rs-7328271/v1/51e2fa46f17de05156be2733.docx"}],"financialInterests":"Competing interest reported. Dr. BF reports personal fees and nonfinancial support from Takeda and Medice. AP, Dr, CLH, and Dr. MG declare no competing interests.","formattedTitle":"Growing Proficiency in Tic Disorder Care and Skills (GP-TiCS): A Thematic Analysis of Patient and Professional Group Experiences in Primary Care for Primary Tic Disorders","fulltext":[{"header":"Background","content":"\u003cp\u003ePrimary tic disorders (TDs), including Tourette syndrome (TS), chronic tic disorder, and provisional tic disorder, are characterised by the onset of tics, typically emerging around the age of 6 years and before the age of 18 (Robertson, 2008). Tics are repetitive movements or sounds that often present as jerking, grimacing, and coughing, and less frequently, coprolalia (explicit language) or copropraxia (offensive gestures) (\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e1\u003c/span\u003e). A recent National Institute for Health and Social Care Excellence (NICE) survey revealed that people waited between 6 months and 2 years to receive a diagnosis of either TS or chronic tic disorder (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2\u003c/span\u003e). For adults with tics, these challenges can be further compounded due to the diagnostic criteria for TS requiring tics to be present before the age of 18 (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Therefore, both clinicians and patients must be confident that tics existed in childhood before a diagnosis can be made.\u003c/p\u003e\u003cp\u003eIn the UK, healthcare support for tics begins with the general practitioner (GP) who, in most cases, will refer children to paediatric services or child and adolescent mental health services (CAMHS), while adults may be referred to neurology. However, many patients report difficulties in getting their GP to initiate a referral, with barriers including the belief that there is no onward care available (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Even once referred, patients continue to report long waits to being seen by specialist services (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMedical Doctors internationally report receiving very little education on tics during their medical training (\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e6\u003c/span\u003e). First exposure to tics often depends on clinical placements or engaging with continued professional development (CPD) training opportunities. GPs report that they do not often see people with tics in their clinic, however, with an estimated 300,000 people in the UK living with tics (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), it does raise the question whether a lack of knowledge of tics and TDs (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) has contributed to an under-recognition of tics amongst medical professionals. Furthermore, there currently are no dedicated NICE guidelines to aid GPs in how to assess tics or provide support for people with tics. Knowledge of tics also includes understanding which local services are available to support people with tics. With limited services and unclear pathways for tics nationally (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), offering and accessing treatment can be distressing, frustrating, and confusing for all parties (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A recent systematic review (Parker, French (\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e6\u003c/span\u003e), highlighted the main issues in healthcare for tics as: lack of confidence in understanding and managing tics; presence of misconceptions and stigmas; inconsistent communication by healthcare professionals (HCP).\u003c/p\u003e\u003cp\u003eThere is a clear need to improve GPs’ knowledge and awareness of tics to improve recognition/identification of tics, facilitate appropriate referrals, and provide longer term support to people living with tics. However, there is a lack of training currently offered to GPs on this topic. GPs in the UK are expected to complete 50 hours of CPD each year. Previous research in the UK demonstrated that 87% of GPs preferred to use online educational resources for CPD purposes (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). There is also evidence to show that online learning resources are effective at improving GPs’ knowledge and confidence of neurodevelopmental disorders, such as attention-deficit/hyperactivity disorder (ADHD) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis qualitative study aimed to explore the many aspects involved in primary care for tics, including healthcare support, referrals, and the overall patient experience. It was key to understand experiences to understand experiences from all the key professional groups, GPs and HCP in secondary care, and the people and families accessing primary care for tics, adults with tics and parents. Understanding the needs of professionals and service users will inform the development of a future online intervention aimed at improving GP’s knowledge of tics.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design\u003c/p\u003e\u003cp\u003eOnline semi-structured interviews were conducted in late 2024 and early 2025 by the lead researcher (AP). Ethical approval was obtained from the University of Nottingham (UoN) Mental Health and Clinical Neurosciences Ethics Sub-Committee in August 2024.\u003c/p\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003cp\u003eThe target sample was 20 participants across four groups: adults with tics; parents of children and young people with tics; GPs; and other HCPs in secondary care. Eligible GPs had previously worked with people presenting with tics. Eligible HCPs had experience working with people with tics, and an understanding of primary care for tics either through working with GPs directly or through patient-reported experiences. For adults living with tics, and parents of young people with tics, it was not necessary for them to have a TD diagnosis, so long as current investigations were indicative of a primary tic disorder, not functional tic disorder. Differences in aetiology, prognosis, and clinical support were the reasons for this distinction between primary and functional tic disorder and were made clear to participants in the expression of interest form and participant information sheet. Two adults with tics and one parent initially submitted interest in the interview but either did not respond to contact attempts or were unavailable to attend interview.\u003c/p\u003e\u003cp\u003eData collection and analysis\u003c/p\u003e\u003cp\u003eAn advert inviting eligible people was circulated to members of the National Tic Steering Group at the University of Nottingham and posted on the Tourettes Action website. The advert featured a link to an expression of interest form, where people could provide consent for the lead researcher to provide them with additional information about the study. Group-appropriate participant information sheets (PIS) and consent forms were emailed to all who registered interest. Following consent, all participants were sent a group-specific pre-interview questionnaire with clinical and demographic questions. Interview topic guides were also developed specifically for each group (see Appendix 1–4).\u003c/p\u003e\u003cp\u003e All interviews were hosted on and audio-recorded using Microsoft Teams and transcribed using Microsoft Teams built-in transcription feature before the lead researcher reviewed for transcription errors and removed identifiable data. The audio recording failed for one participant, and while a transcript was still generated using MS Teams, the data was not included in the analysis as it was felt that without a recording the interview transcript could not be confidently reviewed for errors. Interview duration ranged between 24 minutes and 1 hour 48 minutes.\u003c/p\u003e\u003cp\u003eThis study aimed to better understand the topic of healthcare for tics in England, not contribute or challenge a proposed theory, and therefore inductive thematic analysis was conducted. Following Braun and Clarke (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) six stage process, a period of data familiarisation took place during which initial thoughts were noted, before identifying preliminary codes. A portion of the transcripts were reviewed by second coders, CLH and BF, to establish quality and agreement. Codes were then assembled to generate initial themes. Additional familiarisation of data allowed some themes to be combined into broader themes to better encapsulate experiences and perspectives. Themes were reviewed to ensure that subthemes appropriately captured the meaning and relevancy of the data and the main theme.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSix GPs, four HCPs in secondary care, five parents, and five adults with tics (N\u0026thinsp;=\u0026thinsp;20) were interviewed on their experiences and perspectives of healthcare for tics in primary care. Participant demographics are illustrated in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003eParticipant demographic information.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cimg 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\"\u003e\u003c/div\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003eOf the patient groups, all adults and YPs (as reported by their parent) had either received a TD diagnosis or were currently under investigation. It was self-reported by adults with tics to have waited between 1 and 10 years for a diagnosis to be confirmed. Parents reported waiting between 5 months and 4 years for their young person\u0026rsquo;s diagnosis to be confirmed. It is worth noting that one young person diagnosed within 5 months had accessed private healthcare. When tics first emerged, the time taken to seek first-line support was between 4 months and 4 years, when tics first became more frequent, or in adulthood despite having them in childhood. Parents sought support after the first tic emerged, in the first few weeks, or up to a year later.\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eFor the clinical groups, GPs had been in practice between 6 and 22 years, with most seeing between 1\u0026ndash;3 people with tics annually, and one seeing more than 10. Most GPs report little to no training during their medical education, with just one GP spending a day in a tic clinic as part of their clinical placement. Most GPs developed their knowledge of tics through CPD opportunities. HCPs in secondary care all worked with people up to the age of 18 with most seeing more than 10 people annually with tics and have completed CPD opportunities to develop tic knowledge. Three themes were generated from the data (summary in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003ctable id=\"Tab2\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSummary of themes and sub-themes.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTheme\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDescription\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSubtheme\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eExemplar\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors Impacting GPs\u0026rsquo; Knowledge and Education of Tics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThis theme explores how GPs have little education on tics, with few guidelines available. This can lead to overcomplicated clinical investigations. GPs often feel under pressure to be more knowledgeable about many disorders, but question whether this is their responsibility.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLimited Commissioned Training Opportunities and Guidelines\u003c/p\u003e\n \u003cp\u003eEverything but a Tic Disorder\u003c/p\u003e\n \u003cp\u003eIndividualised Barriers and Facilitators of Tic Knowledge\u003c/p\u003e\n \u003cp\u003eBalancing Responsibility and Pressures as a GP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;I think the main thing and the pattern all the way through this is that I\u0026apos;ve been the one who\u0026apos;s had to go back with the information, and it\u0026apos;s been up to me to research and educate myself about the condition\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInconsistent Availability of Support for Tics Across the Country\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThis theme discusses how access to appropriate support for tics varies nationally and factors which compound referrals include insufficient evidence and only referring once symptoms worsen.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChallenges Accessing Support Services\u003c/p\u003e\n \u003cp\u003eReferral Complexities and Challenges\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;the GPs don\u0026apos;t actually know who to refer to because the paediatricians won\u0026apos;t see, the neurologist won\u0026apos;t see and CAMHS won\u0026apos;t see, so they don\u0026apos;t actually have anybody to refer to.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExperiences of Primary Care for Tics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThis theme explores how patient experiences varied in primary care based on factors including: understanding of the impact of tics, the communication between patient and clinicians, and tic-related stigma.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStigma, Dismissal, and Denial of Tics\u003c/p\u003e\n \u003cp\u003eUnderstanding the Individual Impact of Tics\u003c/p\u003e\n \u003cp\u003eCommunication and Educating Patients about Tics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026quot;they\u0026apos;re OK\u0026quot;, and \u0026quot;they\u0026apos;re dealing well with their tics\u0026quot;. And I often think they just got, they\u0026apos;ve really not understood, you know, in that 15\u0026ndash;20 minute or 10-minute GP appointment. It\u0026apos;s not really understood what is going on for a family at all\u0026rdquo;.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eFactors Impacting GP Knowledge and Education of Tics\u003c/p\u003e\n\u003cp\u003eLimited Commissioned Training Opportunities and Guidelines\u003c/p\u003e\n\u003cp\u003eAll GPs reported receiving very little education on tics disorders in their medical training. Some GPs could recall reading a few lines in a textbook, but nothing formally as part of the curriculum.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026apos;s non-existent. All right, I might have had some tiny, you know, a line of it or something in my years ago medical school. But it\u0026apos;s, yeah, definitely not something that has featured in my initial training or many of my updates that I\u0026apos;ve had over the years.\u003c/em\u003e\u0026rdquo; \u0026ndash; Participant 21, GP.\u003c/p\u003e\n\u003cp\u003eHowever, beyond taught material, some GPs recall encountering tics during paediatric and mental health placements. One GP recalls learning about the diagnostic criteria for TS on their paediatric placement, but not how they could support families. Others noted that not all GPs complete a placement in paediatrics, therefore limiting their exposure to tics in clinical practice.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think as a GP in my GP training, I\u0026apos;ve not received any specific training on tics. It\u0026apos;s just purely that I\u0026apos;ve done a placement in mental health and some GP trainees, I guess most GPs do get mental health as a as a placement block. But not everyone, to be honest. And a lot of their experience is probably going to be in the acute hospitals rather than in the outpatient clinics.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 20, GP.\u003c/p\u003e\n\u003cp\u003eOne GP noted that from their experience, new trainees were not finishing their medical training with the necessary communication skills.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The clinician needs to be confident, competent and comfortable talking about tics and have excellent advanced primary care consultation skills. And I\u0026apos;m sorry to say that a lot of the trainees in my area have a high failure rate and many of them are not leaving the training scheme with such good quality consultation skills as I would like them to have in this context of tics.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 14, GP.\u003c/p\u003e\n\u003cp\u003eThis sentiment was recognised by other groups, who also recall feeling as though GPs lacked knowledge about tics. Additionally, it was common for adults with tics and parents to see locum GPs who were thought to be less familiar with tics than salaried GPs, making continuity of care more challenging.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There\u0026apos;s a few very long-established GPs who are very sensible through experience, but the difficulty is that a lot of primary care is now delivered by locum GPs who are not as familiar with any disorders, let alone tics.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 17, HCP in secondary care.\u003c/p\u003e\n\u003cp\u003eEverything but a Tic Disorder\u003c/p\u003e\n\u003cp\u003eAdults with tics, parents, and secondary HCPs varied in their experience when recalling GP knowledge of tics, but often respondents reported that their GP was unfamiliar with the condition or mischaracterised tics with other conditions, some possibly life-threatening, including epilepsy or brain tumours.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Well before my diagnosis could be fully confirmed, I had to go through a process of elimination of what it is not, \u0026ldquo;let\u0026apos;s rule out it\u0026apos;s not this\u0026rdquo;. Initially the first thing they thought was possibly I had a brain tumour to explain the movements and different things, so it was just a very, very anxious time and uncertain time.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 6, Adult with Tics.\u003c/p\u003e\n\u003cp\u003eWhile GPs expressed the importance of ruling out serious health concerns, this further increased patient anxiety and occasionally resulted in inappropriate medications being prescribed, including nasal sprays for allergies. Adults with tics and parents reported that each presentation to the GP was considered in isolation, instead of considering previous contact history to build a greater picture of their experience.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Because the amount of families that have been referred to ophthalmology because of eye tics or they\u0026apos;ve been referred to allergy clinics because of cough, a consistent cough. Or you know, they\u0026apos;ve had all their allergy tests done for lactose intolerance and whatever. The assumption is not that it\u0026apos;s a tic and 20% of kids have got tics, you know, at some point in their life.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 12, HCP in secondary care.\u003c/p\u003e\n\u003cp\u003eIndividualised Barriers and Facilitators of Tic Knowledge\u003c/p\u003e\n\u003cp\u003eAll groups discussed factors they felt made identifying tics and appropriately supporting people easier or more challenging. The most common factors included the number of people encountered with tics, personal experience of tics, self or family member, and general interest in tics and TDs.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Initially, my doctor at the time was very inquisitive. He was curious. He was very pro-wanting to know more and I found that, you know, the treatment has been hit and miss with other GPs basically based on the fact of their interest in it. You know if they\u0026apos;re like\u0026hellip; if they want to do more about it, they\u0026apos;ll educate themselves a lot more about it.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 6, Adult with Tics.\u003c/p\u003e\n\u003cp\u003eGPs with more experience and interest in tics became more specialist within their practice. However, this may have been at the detriment to colleagues, as they could be less likely to see new tic cases or incentivised to develop their knowledge.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Massively so. So I mean most GP surgeries will have GPs with a special interest if typically you\u0026apos;ll have someone who\u0026apos;s, you know, really hot on dermatology, and so they\u0026apos;ll tend to see the skin lesions and things like that. So and then everyone else, and I\u0026apos;ve asked them for advice, I guess I\u0026apos;m the equivalent for tics and Tourettes. I\u0026apos;d hope that they\u0026apos;re all much better at it now, because I\u0026apos;ve done quite a few education sessions for them. But the danger of having some in your practice is that everyone else de-skills, but hopefully they\u0026apos;re all aware of Tourettes Action and that but they do just now send them to me so.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 18, GP.\u003c/p\u003e\n\u003cp\u003eBalancing Responsibility and Pressures as a GP\u003c/p\u003e\n\u003cp\u003eGPs acknowledge that they are the gatekeepers for people wanting to access additional support for tics in secondary care. However, GPs also expressed concern as they are expected to know a lot about many conditions, experiencing pressure from various groups and charities to ensure their condition is represented and understood. Regarding tics, GP recognition of these limitations varied with some believing they could be doing more, including diagnosing TDs in primary care and reducing the pressure of waiting lists in secondary care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it\u0026apos;s entirely possible for Tourettes to be managed the way we manage many, many, many conditions, as GPs. With common stuff with children, I think asthma is a really good example, is I can see a child. I can diagnose that child. I can treat that child without involving any secondary care conditions.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 18, GP.\u003c/p\u003e\n\u003cp\u003eAs gatekeepers and professionals, adults with tics and parents discussed the trust they placed in GPs to appropriately assess their symptoms and make suitable recommendations, demonstrating the reliance of primary care. However, others felt they had to educate themselves and present this to their GP to progress their care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I was diagnosed with touretteism which I don\u0026apos;t even know as a word. But I think the main thing and the pattern all the way through this is that I\u0026apos;ve been the one who\u0026apos;s had to go back with the information, and it\u0026apos;s been up to me to research and educate myself about the condition. Otherwise, I would have been in that vicious circle of just taking antipsychotics just to suppress and hold my tics in.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 6, Adult with Tics.\u003c/p\u003e\n\u003cp\u003eInconsistent Availability of Support for Tics\u003c/p\u003e\n\u003cp\u003eChallenges Accessing Support Services\u003c/p\u003e\n\u003cp\u003eGPs and HCPs discussed how acquiring a TD diagnosis was often necessary to access any additional support. However, all groups recalled common challenges in secondary care for tics, including the limited provision of services across the country, with some believing there to be better support in south of the country compared to the north. Even more specifically, it was understood that while some regions offered children services, others only had adult services, both raising doubt around the continuity of care and the ability to support adults undiagnosed as children.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;the GPs don\u0026apos;t actually know who to refer to because the paediatricians won\u0026apos;t see, the neurologist won\u0026apos;t see and CAMHS won\u0026apos;t see, so they don\u0026apos;t actually have anybody to refer to.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 17, HCP in secondary care.\u003c/p\u003e\n\u003cp\u003eClinicians in both primary and secondary care felt disillusioned by the lack of support available to those with tics, while adults with tics and parents report the implementation of inappropriate treatment and failure to anticipate future needs of child when moving from primary to secondary school.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think that that causes a barrier in itself because GPs, like us, are frustrated, they\u0026apos;re feeling disillusioned. And so there is a sort of, you know, what\u0026apos;s the point in sending off a referral because it\u0026apos;s not going to make any difference\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 17, HCP in secondary care.\u003c/p\u003e\n\u003cp\u003eHowever, it was suggested that a lack of specialists was not exclusive to tics, alluding to wider concerns around the supply and demand of services in the healthcare sector. Of those who accessed private healthcare for tics, adults with tics and parents report shorter waiting times and improved accessibility, but little on the quality of care they received, further implying a need for more specialists and better access to treatment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;But the main problem is actually there\u0026apos;s just not enough doctors and specialists out there to cope with the volume of paediatric referrals altogether, let alone absorbing the tics on top of it. So the main thing is actually we just don\u0026apos;t have the resources.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 17, HCP in secondary care.\u003c/p\u003e\n\u003cp\u003eReferral Complexities and Challenges\u003c/p\u003e\n\u003cp\u003eBeside a lack of dedicated services to support tics, a number of factors were identified which made completing a referral more difficult, even in areas that appeared to have specialist services. The most endorsed challenge was the lack of well-defined processes to access referral services. It was also reported by parents that there needed to be a clear mental health component for a referral to be made/accepted. However, while HCPs suggest this was to manage service capacity, it also meant that tic referrals were not appropriately allocated to a service equipped to manage tics.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;But neurodevelopmental mental health conditions aren\u0026apos;t even owned by mental health services because they see it as kind of like physical that \u0026ldquo;yeah, that\u0026apos;s paediatrics. Then we\u0026apos;ll do self-harm and depression and anorexia and stuff like that\u0026rdquo;. So this kind of middle ground that no one really knows what to do with it.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 12, HCP in secondary care.\u003c/p\u003e\n\u003cp\u003eProfessionals in secondary care reported that occasionally referrals did not contain sufficient information about tics. Interestingly, interviewed GPs recognised the benefit of video evidence and letters from school and the importance of including patients in writing the referral, however, parents and adults with tics report not being asked to provide any such evidence. Since adults with tics and families were not often included in the correspondence between primary and secondary care, it was then the responsibility of the GP to relay the news of rejected referrals to families, further exacerbating their confusion and anxiety and potentially rupturing the therapeutic relationship.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;And when referrals are rejected, the patient or carer is not normally copied in this, thus leaving me with the liability\u0026hellip; They talk about rejected referrals, which I think is not therapeutic for patients. And I think there\u0026apos;s a lot of research to be done about the language we use in our consultations in primary care because the consultation skills, the language, the verbal and nonverbal communication are key to whether our interactions are therapeutic.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 14, GP.\u003c/p\u003e\n\u003cp\u003eExperiences in Primary Care for Tics\u003c/p\u003e\n\u003cp\u003eStigma, Dismissal, and Denial of Tics\u003c/p\u003e\n\u003cp\u003eMany interviewees reported that common misconceptions included the belief that tics were voluntary or indicative of attention-seeking behaviour and overestimating the frequency of coprolalia as a presenting symptom. Stigmatising misconceptions about tics were held by adults presented with a TD diagnosis, families, primary and secondary healthcare professionals, and schools. This indicates a broader misunderstanding of tics and TDs which exacerbates misconceptions and harmful beliefs. Despite groups recalling recent positive celebrity awareness campaigns, the over-representation of coprolalia in the media continues to be most noteworthy, instilling stigma and making it more difficult for some to accept a TD diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If you say Tourette\u0026apos;s syndrome, it is usually the kind of very rare cases which are portrayed in media and sometimes families are quite worried when the diagnosis comes in. And actually it is not the case. It\u0026apos;s a very rare situation when there is coprolalia where they see where they say very obscene words and people kind of think that that a Tourettes diagnosis it\u0026rsquo;s, it\u0026apos;s what they saw on the TV. And then we have to kind of dial it back a bit and tell them about what is the criteria and how that is quite rare to have such kind of presentation\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 15, HCP in secondary care.\u003c/p\u003e\n\u003cp\u003eGPs identified that due to service demand, support was often primarily offered to those with more severe tics, causing adults with tics and parents to feel dismissed when their/their child\u0026rsquo;s symptoms were played down. Consequently, HCPs recognised the belief that symptoms had to get worse before being taken seriously or were deserving of more support. In a desperate attempt to be seen, one interviewee exacerbated their tics and developed an abnormally fixed posture, causing additional physical pain.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;the biggest health misconception is that it\u0026apos;s severity and I have to wait until it\u0026apos;s a severe problem to refer or I can only refer that. I can only refer something that\u0026apos;s a problem, you know. It has how you judge impairment and how you judge severity.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 12, HCP in secondary care.\u003c/p\u003e\n\u003cp\u003eUnderstanding the Individual Impact of Tics\u003c/p\u003e\n\u003cp\u003eAdults with tics and parents recall the wider impact tics can have when socialising with peers, pain caused by repetitive movements, fatigue levels, and academic engagement. However, while GPs report the importance of understanding impact and building a clinical history, patient groups, HCPs recall a lack of consideration beyond visible symptoms.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think there is a gap in understanding of how significant tics can be in terms of pain, mental health difficulties and the impact on daily life. I think there\u0026apos;s tends to be a \u0026ldquo;well, there\u0026apos;s little movement or a little sound. What\u0026apos;s the concern about it?\u0026rdquo;.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 17, HCP in secondary care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;A lot of the stuff that\u0026apos;s written about meetings is, \u0026quot;oh, they\u0026apos;re doing well\u0026quot;, \u0026quot;they\u0026apos;re fine\u0026quot;, \u0026quot;they\u0026apos;re OK\u0026quot;, and \u0026quot;they\u0026apos;re dealing well with their tics\u0026quot;. And I often think they just got, they\u0026apos;ve really not understood, you know, in that 15\u0026ndash;20 minute or 10-minute GP appointment. It\u0026apos;s not really understood what is going on for a family at all\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 8, Parent.\u003c/p\u003e\n\u003cp\u003eCommunication and Educating Patients about Tics\u003c/p\u003e\n\u003cp\u003eMany adults with tics and parents recall being offered little information about tics when approaching their GP, with some only being signposted to charity websites when they were hoping for NHS advice or pain-relieving exercise plans. GPs also recalled offering externally available resources for tics online, including charity leaflets, social media, and support groups. This brings into question whether a lack of signposting is a result of few resources, or a characteristic of inadequate patient communication and consultation style. Most adults with tics and parents reported little reassurance or empathy displayed by their GPs. However, GPs reflected on their approach to patient communication, balancing pragmatism and false hope given the lack of service availability, guidelines, and primary care knowledge. One GP did reflect on the variation in the level of consultation and communication skills amongst GPs, especially in the context of tics. This suggests there may be shortcomings in the communication around tics when responding to patient concern, and the availability and awareness of appropriate signposting information for families.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think there\u0026apos;s a really fine balance between reassuring people and people feeling not heard and dismissed. And I know in the Tourettes community, a lot of what is felt is that they\u0026apos;re being dismissed. And I can see there\u0026apos;s a big disparity.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 18, GP.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Of course, for the patient, it should feel holistic and sympathetic, and I\u0026apos;ll make sure I say things like \u0026ldquo;that\u0026apos;s very difficult for you\u0026rdquo;, \u0026ldquo;That must be very hard for you\u0026rdquo;, \u0026ldquo;How does that make you feel?\u0026rdquo;, \u0026ldquo;It must be embarrassing for you\u0026rdquo;. I would be doing all of those things, of course.\u0026rdquo;\u003c/em\u003e \u0026ndash; Participant 14, GP\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe thematic analysis of primary care experiences across different groups generated numerous, often interwoven, themes covering the identification of tics, inconsistent access to specialist/secondary services, and a range of generalised and individualised factors shaping care experiences. The qualitative methodology encouraged a nuanced exploration of the perspectives of those living with, or involved in the care of, people with tics.\u003c/p\u003e\u003cp\u003e\u003cem\u003eFactors Impacting GPs\u0026rsquo; Knowledge and Education of Tics\u003c/em\u003e included investigating differential diagnoses, few training opportunities, individual clinical interests and presentations, and the balance between GPs\u0026rsquo; responsibility and patient expectations. Patient groups and secondary care HCPs felt GPs lacked understanding of tics, meaning various other health conditions were investigated first, including brain tumours and epilepsy, causing additional unnecessary worry for patients. GPs reported limited medical training on tics, with pockets of knowledge originating from personal experience, interest, and the number of presentations in clinic. Ever increasing demands placed upon GPs meant that assigning GP specialists may ease pressure at the expense of deskilling other colleagues about a particular condition, including tics. However, some GPs felt they could be doing more to alleviate demand further along the pathway in secondary care, including diagnosing TDs which one GP was already doing. Previous research has shown that patients\u0026rsquo; views on HCPs insufficient knowledge of tics, lead to shallow clinical investigations and limited information or support being offered, even in the context of some knowledge of tics. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Negative experiences may stem from a lack of confidence due to infrequent case presentations and limited training opportunities. Interviews with GPs highlighted time pressure and fear of mistakes as stressors (Riley et al., 2018). In the present study, GPs\u0026rsquo; views varied in their sense of responsibility for managing tic cases, with some believing secondary services or the patients themselves should take more responsibility. These findings suggest that improved access to manageable training could enhance GPs' knowledge and confidence in managing tics in primary care.\u003c/p\u003e\u003cp\u003e\u003cem\u003eInconsistent Availability of Support for Tics Across the Country\u003c/em\u003e was discussed by all groups, including the geographical sparsity of services. Areas that did not have a dedicated service for children, it was often unclear whether Paediatric Neurology or Child and Adolescent Mental Health Services (CAMHS) was most appropriate. Additionally, CAMHS required a clear mental health component associated with tics before a referral could be accepted, potentially limiting tic-specific support.\u003c/p\u003e\u003cp\u003eRattu, Hall (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) reported very few service pathways for children and young people with tics in England, with neurodevelopmental services not always accepting cases of tics unless ADHD and ASD were the primary reason for referring. Some GPs were aware of tic specialist services but were unable to refer directly, instead having to refer to Paediatrics before being triaged to the most appropriate service and further delaying access to support.\u003c/p\u003e\u003cp\u003eHCPs in secondary care reported that some referrals did not include sufficient information to accurately assess need, resulting in the referral being declined. These inconsistencies may further exacerbate the already lengthy waiting times for secondary care within England (Bhikram et al., 2021; Marino et al., 2023). It can be challenging for GPs to gain all the information relevant to making a referral given the shift to short, often remote appointments in primary care settings. Standardised referral processes may enhance the quality of referral information (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), coupled with direct liaison with schools, workplaces, and families to gain a fuller picture of the severity and impact of tics. Improving GPs\u0026rsquo; tic knowledge and clarifying the most appropriate locally available pathway could facilitate accurate referrals and reduce confusion. While GPs endorsed the usefulness of supporting evidence, including videos, most adults with tics and parents interviewed report not being asked to provide any evidence for their/their child\u0026rsquo;s tics.\u003c/p\u003e\u003cp\u003eEffective non-pharmaceutical treatments including Comprehensive Behavioural Intervention for Tics (CBIT) and habit reversal therapy (HRT) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) exist, yet are often not available due to a lack of expertise and funding (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Systemic improvements in service availability for people with tics could result in better access to treatments that when paired with refined referral processes may greatly improve patient experiences.\u003c/p\u003e\u003cp\u003eThe theme of \u003cem\u003eExperiences of Primary Care for Tics\u003c/em\u003e confirmed that stigma and misconceptions remain an issue for people living with tics. All groups discussed how many people still assume tics are voluntary and that coprolalia is common, and the role media has on experiences. For example, media representations were suggested to occasionally improve public perceptions of TD but the overrepresentation of coprolalia made it more difficult for people who did not experience coprolalia to accept a TD diagnosis. Recent research has found that media portrayal of TS continues to overstate coprolalia as a primary symptom, exacerbating stigmatising beliefs and misconceptions (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), extending to clinicians in primary care (\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMoreover, since media representations occasionally brought attention to more severe cases of tics, some adults with tics felt their symptoms were not severe enough to warrant support, and parents were encouraged to wait until tics caused pain or distress before the GP would agree to refer their child. This misconception was identified by a HCP working in a tic service, who instead suggested that referrals should consider the many facets of impact in addition to visible symptoms and pain, including mental health and functional ability of living with tics. Appropriate education could dispel problematic beliefs and improve the therapeutic relationship, facilitating earlier intervention.\u003c/p\u003e\u003cp\u003eThe implications of this study reaffirm that while some GPs actively further their knowledge and understanding of tics, it remains a largely unfamiliar and misunderstood condition that does not feature as part of the core learning curriculum for medical students, or has been picked up by GPs as part of their ongoing CPD. Consequently, the patient experience in primary care continues to be mostly negative. A lack of standardised education does not equip GPs with the clinical and communication skills to appropriately investigate tics. Despite early value assessments (EVA) of digital therapies including the Online Remote Behavioural Intervention for Tics (ORBIT) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) prove promising, a more standardised NICE policy is necessary to streamline investigation and delivery of care for tics. While it is important to rule out other serious conditions, inadequate education engenders anxiety and confusion through delayed diagnosis and inadequate access to support. Improved education may encourage more robust investigation of the impact of tics and the submission of more information-rich referrals, ensuring that people are allocated to the most appropriate service with a clear understanding that tics a primary concern. Resourcing concerns continue within the NHS as service demand grows (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), yet it is hoped that ongoing education opportunities and awareness will help bring forth formalised guidelines and the appropriate allocation of resources to implement a dedicated healthcare pathway in England.\u003c/p\u003e\u003cp\u003eThe findings of this paper will inform the development of a GP-tailored online learning resource that considers the additional needs identified by peoples accessing primary care for tics and secondary care HCPs communicating with primary care. The resource intends to offer information on a range of tic presentations, patient communication and impact awareness (pain, sociability, academia, hidden tics, and mental health), common misconceptions and stigma, and useful signposting information and resources. It is important for the resource to be time-manageable, focusing on content specific to the role of a GP. Future research should continue to raise tic awareness while challenging stigmas and support the need for dedicated services with a clear referral pathway.\u003c/p\u003e\u003cp\u003eSome limitations of the study should be considered. Participants were recruited from England, and while geographically diverse, we were unable to recruit any participants from Wales, Scotland, or Northern Island. While there are few tic specialist services within England (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), none exist in Wales and Scotland, potentially leading to further challenges and uncertainty for patient and families (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Additionally, a 2023 study found that a majority of GPs in Wales, Scotland, and England were unsatisfied with their work-life balance (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Consequently, this suggests that patient and professional experiences may be similar across the UK, further substantiating the need to better GP support and knowledge of tics within primary care.\u003c/p\u003e\u003cp\u003eProfessionals were recruited through University of Nottingham TD networks and further snowball sampling. From the interviews, it was apparent that some GPs had more personal interest in tics, which is unlikely to reflect the general population of GPs. Interestingly, many of the needs raised by the adults with tics and parent groups were also highlighted by the GPs who were more knowledgeable about tics. Therefore, while the sample may not be representative of the wider GP population, it does offer some insight into how primary care could benefit from improved knowledge of tics, including the intention to understand the deeper impact of tics. Although the sample of each group was small, this is in line with previous recommendations (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), including tic disorder research (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Parental viewpoints were relied upon since children and YPs were not interviewed. While parents may often lead discussions in clinical settings, interviews with YP and children may have generated interesting data about self-advocating and the parent-child-professional dynamic when agreeing upon the best course of action.\u003c/p\u003e\u003cp\u003eThe lead author is a white male who has previous clinical experience working in psychology and occupational therapy teams before transitioning to child and adolescent mental health research. They have frequently collaborated with other researchers and clinicians working in neurodevelopmental, neurological, and child and adolescent mental health research where the challenges of people with living with tics is well understood. It is important to consider that the lead author who conducted the interviews has been researching tics more recently as part of their PhD and acknowledges the expertise of interviewees is far greater than their own. The lead author had been previously trained to conduct interviews, with additional support by supervisors/co-authors with experience in qualitative methods.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis paper builds upon a limited body of literature in patient and professional experiences of tics in primary care. Some GPs are keen to develop their understanding following the lack of formal education on tics. However, limited availability of resources results in negative patient experiences when considering their GP\u0026rsquo;s ability to support their care needs. The development of an online learning resource for GPs has potential to improve knowledge of tics and the understanding of impact beyond the immediate symptoms, therefore supporting appropriate, informed and timely referrals to secondary care. Although current support for individuals with tics remains insufficient, ongoing efforts to educate those in professional care positions while developing a dedicated referral pathway integrating evidence-based behavioural therapies will improve clinical competency and patient outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eADHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eAttention Deficit/Hyperactivity Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eASD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eAutism Spectrum Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eBRC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eBiomedical Research Centre\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eCAMHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eChild and Adolescent Mental Health Services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eCBIT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eComprehensive Behavioural Intervention for Tics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eCPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eContinued professional development\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eEVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eEarly value assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eGP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eGeneral practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eHCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eHealthcare professional\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eHRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eHabit reversal therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eINTEND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eImproviNg Tic Services in EnlaND study\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eNHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eNational Health Service (UK)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eTS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eTourette syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eNICE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eNational Institute for Health and Social Care Excellence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eNIHR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eNational Institute for Health and Care Research\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eORBIT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eOnline Remote Behavioural Treatment for Tics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003ePIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eParticipant information sheet\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eTD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eTic disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eUoN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eUniversity of Nottingham\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eYP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eYoung person\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics Approval and Consent to Participate\u003c/p\u003e\n\u003cp\u003eEthics approval was granted by the University of Nottingham Mental Health and Clinical Neuroscience Ethics Subcommittee on 21/08/2024 (Ref: 3277). Participants gave their informed consent prior to taking part in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for Publication\u003c/p\u003e\n\u003cp\u003eParticipants consented to publication as part of the informed consent process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of Data and Materials\u003c/p\u003e\n\u003cp\u003eThe data generated during the current study are available from the corresponding author upon request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting Interests\u003c/p\u003e\n\u003cp\u003eDr. BF reports personal fees and nonfinancial support from Takeda and Medice. AP, Dr, CLH, and Dr. MG declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Joan Brown Legacy Fund, University of Nottingham, with additional support from the NIHR Nottingham Biomedical Research Centre (BRC; Ref: NIHR203310). AP, Dr. CLH, and Dr. BF acknowledge the support of the NIHR Nottingham Biomedical Research Centre. Dr. CLH and Dr. MG acknowledge the support of the NIHR MindTech HealthTech Research Centre (HRC). The support of Dr. CLH is funded by the NIHR Development and Skills Enhancement Award (Ref: NIHR304774). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe views expressed are those of the author(s) and not necessarily those of the NIHR, the Department of Health and Social Care, or representatives of the Joan Browne Legacy Fund. The funders had no role in the study design; the collection, analysis, or interpretation of the data; the writing of the manuscript; or the decision to submit the paper for publication.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; Contributions\u003c/p\u003e\n\u003cp\u003eThe content of this study is the original work of author AP. Dr. CLH, Dr. BF, and Dr. MG all supported with proof-reading and writing. Dr. CLH and Dr. BF both supported with interview coding.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe would like to extend thanks to Tourettes Action for supporting in the recruitment of participants for this study. We are extremely grateful to everyone who participated in an interview, offering their experiences and contributing to the betterment of tic support in the UK. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNilles C, Martino D, Fletcher J, Pringsheim T. Have We Forgotten What Tics Are? A Re-Exploration of Tic Phenomenology in Youth with Primary Tics. Movement Disorders Clinical Practice. 2023;10(5):764-73.\u003c/li\u003e\n\u003cli\u003eNICE. Technology for children and young people with chronic tic disorders and Tourette syndrome recommended 2025 [Available from: https://www.nice.org.uk/news/articles/technology-recommended-for-people-with-chronic-tic-disorders-and-tourette-syndrome.\u003c/li\u003e\n\u003cli\u003eYilmaz AY, Jankovic J. Epidemiology of Tourette Syndrome. Brain Sciences. 2025;15(5):426.\u003c/li\u003e\n\u003cli\u003eMarino C, Khan K, Groom MJ, Hall SS, Anderson S, McNally E, et al. Patients\u0026rsquo; experience of accessing support for tics from primary care in the UK: an online mixed-methods survey. BMC Health Services Research. 2023;23(1):788.\u003c/li\u003e\n\u003cli\u003eNICE. Draft guidance, early value assessment: digital therapy for chronic tic disorders and Tourette syndrome 2025 [Available from: https://www.nice.org.uk/guidance/indevelopment/gid-hte10056/documents.\u003c/li\u003e\n\u003cli\u003eParker A, French B, Groom MJ, Hall CL. Systematic review\u0026mdash;understanding the barriers and facilitators experienced by healthcare professionals in providing care for tics: a mixed methods systematic review of clinical knowledge, attitudes, and practices. BMC Medical Education. 2024;24(1):1403.\u003c/li\u003e\n\u003cli\u003eTourettes Action. What is Tourette Syndrome: Tourettes Action; 2021 [Available from: https://www.tourettes-action.org.uk/67-what-is-ts.html.\u003c/li\u003e\n\u003cli\u003eRattu NR, Hall SS, Hall CL, Murphy T, Kilgariff J, James N, et al. ImproviNg Tic services in EnglaND: a multi-method study to explore existing healthcare service provision for children and young people with tics and Tourette syndrome. BMJ Mental Health. 2025;28(1):e301599.\u003c/li\u003e\n\u003cli\u003eMalli MA, Forrester-Jones R. Barriers to Care: The Impact of Stigma and Systemic Inequities on Health and Social Care Support for Individuals with Tourette\u0026apos;s. In: Malli MA, Forrester-Jones R, editors. Tourette\u0026rsquo;s Syndrome, Stigma, and Society\u0026rsquo;s Jests. Cham: Springer Nature Switzerland; 2025. p. 323-55.\u003c/li\u003e\n\u003cli\u003eMacWalter G, McKay J, Bowie P. Utilisation of internet resources for continuing professional development: a cross-sectional survey of general practitioners in Scotland. BMC medical education. 2016;16:1-9.\u003c/li\u003e\n\u003cli\u003eFrench B, Hall C, Perez Vallejos E, Sayal K, Daley D. Evaluation of a Web-Based ADHD Awareness Training in Primary Care: Pilot Randomized Controlled Trial With Nested Interviews. JMIR Med Educ. 2020;6(2):e19871.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006;3(2):77-101.\u003c/li\u003e\n\u003cli\u003eCuenca J, Glazebrook C, Kendall T, Hedderly T, Heyman I, Jackson G, et al. Perceptions of treatment for tics among young people with Tourette syndrome and their parents: A mixed methods study. BMC Psychiatry. 2015;15(1):46.\u003c/li\u003e\n\u003cli\u003eWellen BCM, Bootes KR, Braley EI, Conelea CA, Woods DW, Himle MB. Caregiver Perspectives on the Health Care System for Tic Disorders: Utilization and Barriers. J Dev Behav Pediatr. 2023;44(9):e581-e9.\u003c/li\u003e\n\u003cli\u003eTobin-Schnittger P, O\u0026rsquo;Doherty J, O\u0026rsquo;Connor R, O\u0026rsquo;Regan A. Improving quality of referral letters from primary to secondary care: a literature review and discussion paper. Primary health care research \u0026amp; development. 2018;19(3):211-22.\u003c/li\u003e\n\u003cli\u003eDutta N, Cavanna AE. The effectiveness of habit reversal therapy in the treatment of Tourette syndrome and other chronic tic disorders: a systematic review. 2013(0393-5264 (Print)).\u003c/li\u003e\n\u003cli\u003eHollis C, Hall CL, Jones R, Marston L, Le Novere M, Hunter RM, et al. Therapist-Supported Online Remote Behavioural Intervention for Tics (ORBIT) in Children and Adolescents: A Single-Blind Randomised Controlled Trial. 2021.\u003c/li\u003e\n\u003cli\u003eHall CL, Le Novere M, Murphy T, McNally E, Hollis C, Hunter R. Healthcare utilisation and costs associated with poor access to diagnosis and treatment for children and young people with tic disorders. BMJ Mental Health. 2024;27(1):e301241.\u003c/li\u003e\n\u003cli\u003eAlalwan AA, Alkhamis MA, Samman AM, Alsharif EHM, Tarabzoni OEM, Khatri IA. The Assessment of Knowledge about Tourette\u0026apos;s Syndrome among Medical Students and Primary Physicians in Riyadh, Saudi Arabia: A Cross-Sectional Study. Neurology Research International. 2022;2022((Alalwan, Alkhamis, Samman, Alsharif, Tarabzoni, Khatri) College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia):3018305.\u003c/li\u003e\n\u003cli\u003ePring K, Malli M, Hardy BW, Rapp SR, Storch EA, Mink JW, et al. Reframing stigma in Tourette syndrome: an updated scoping review. European Child \u0026amp; Adolescent Psychiatry. 2025;34(1):19-39.\u003c/li\u003e\n\u003cli\u003eRodin A, Fleetwood-Meade K, Gilmour J, Kasujja R, Murphy T. Why don\u0026apos;t children in Uganda have tics? A mixed-methods study of beliefs, knowledge, and attitudes of health professionals. Child Adolesc Ment Health. 2021;26(1):47-53.\u003c/li\u003e\n\u003cli\u003eKatona C. Familiarity with and attitudes to Tourette\u0026apos;s syndrome in healthcare students: A pilot comparison with epilepsy. European Journal of Psychiatry. 2013;27(2):129-36.\u003c/li\u003e\n\u003cli\u003eAnderson M, McGuire A, Mossialos E. Addressing the fiscal and sustainability challenges for the NHS. The Bulletin of the Royal College of Surgeons of England. 2025;107(2):76-9.\u003c/li\u003e\n\u003cli\u003eWilliams B. The British NHS at 75: Past, Contemporary, and Future Challenges. International Journal of Social Determinants of Health and Health Services. 2025;55(1):76-87.\u003c/li\u003e\n\u003cli\u003eKramer J, Mehta K, Jackson M. Defining and Characterising a Model of Care for the Assessment, Diagnosis and Management of Tic Disorders in Children and Young People: A Delphi Study. 2024.\u003c/li\u003e\n\u003cli\u003eBeech J, Fraser C, Gardner G, Buzelli L, Williamson S, Alderwick H. Stressed and overworked. The Health Foundation. 2023.\u003c/li\u003e\n\u003cli\u003eAhmed SK. Sample size for saturation in qualitative research: Debates, definitions, and strategies. Journal of Medicine, Surgery, and Public Health. 2025;5:100171.\u003c/li\u003e\n\u003cli\u003eLudlow AK, Brown R, Schulz J. A qualitative exploration of the daily experiences and challenges faced by parents and caregivers of children with Tourette\u0026apos;s syndrome. J Health Psychol. 2018;23(14):1790-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tic disorders, Tourette syndrome, experiences, healthcare professionals, primary care, medical education, knowledge, stigma, service provision","lastPublishedDoi":"10.21203/rs.3.rs-7328271/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7328271/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAround 300,000 people in the UK are thought to be living with Tourette syndrome. Many people with tics and their families report negative experiences when approaching their General Practitioner (GP) for advice and support. Limited education during medical training coupled with a lack of National Institute of Health and Social Excellence (NICE) guidelines for tic disorders creates clinical challenges for healthcare professionals (HCPs). Building on the results of an international systematic review of healthcare experiences, the GP-TiCS project explored this further within the UK, conducting a thematic analysis of interviews with adults with tics (n\u0026thinsp;=\u0026thinsp;5), parents of young people (n\u0026thinsp;=\u0026thinsp;5) with tics, GPs (=\u0026thinsp;6), and secondary care HCPs working with people with tics (n\u0026thinsp;=\u0026thinsp;4). The \u003cem\u003eFactors Impacting GPs\u0026rsquo; Knowledge and Education of Tics\u003c/em\u003e theme suggested that limited education and guidance made it more difficult for GPs to support people presenting with tics yet also considers how surmounting pressures and expectations on primary care may exceed the responsibility and capabilities of GPs. \u003cem\u003eInconsistent Availability of Support for Tics Across the Country\u003c/em\u003e continues to be an issue for GPs making referrals to services and for people seeking support, while secondary HCPs report receiving unclear referrals with limited information which makes service allocation more difficult. The \u003cem\u003eExperiences of Primary Care for Tics\u003c/em\u003e theme explores how the wider impact of living with tics is often left unexplored, including persistent stigma, and poor communication and signposting from GPs. The results suggest accessible and appropriate education opportunities for GPs may improve experience for people presenting with tics by increasing GP knowledge and awareness of tics. This study precedes the development of an online learning resource for GPs.\u003c/p\u003e","manuscriptTitle":"Growing Proficiency in Tic Disorder Care and Skills (GP-TiCS): A Thematic Analysis of Patient and Professional Group Experiences in Primary Care for Primary Tic Disorders","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 13:28:58","doi":"10.21203/rs.3.rs-7328271/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-11T05:16:44+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-10T21:13:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2026-05-07T08:38:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-20T03:56:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329645457434652743836523802643141769188","date":"2025-09-12T18:08:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-05T10:22:10+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-14T05:07:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-12T01:27:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-12T01:25:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-08-08T14:26:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"85a35d9f-a98e-4a82-b6d9-0ad4f0968d21","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-11T05:16:44+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-10T21:13:40+00:00","index":74,"fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2026-05-07T08:38:41+00:00","index":73,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T15:23:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-11 13:28:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7328271","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7328271","identity":"rs-7328271","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}