Pediatric PANS/PANDAS

Pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) are diagnoses that often include the sudden onset of obsession, compulsions, tics or eating restrictions as well as symptoms from at least two of seven categories. PANS/PANDAS are associated with infections and are diagnoses of exclusion so it is important to rule out other possible medical and psychiatric diagnoses.

The most common symptoms include:

• Significant obsession, compulsions or tics
• Eating restrictions
• Anxiety (separation anxiety in particular)
• Emotional lability and/or depression
• Irritability, aggression and/or severely oppositional behaviors
• Behavioral (developmental) regression
• Deterioration in school performance (related to attention-deficit hyperactivity disorder-like behaviors, memory deficits and cognitive changes)
• Sensory or motor abnormalities
• Somatic signs and symptoms, including sleep disturbances, enuresis or urinary frequency

At Children’s National, child psychologists, psychiatrists and neurologists may all interview the child and parents/guardians. The team may recommend further evaluations by other medical teams, including Infectious Diseases. We may have the child and their family fill out questionnaires about different aspects of the child’s or adolescent’s life, including physical health concerns, difficulties at school or behavior with friends and family. The medical team will rule out other medical diagnoses. Additional investigations may include bloodwork, lumbar punctures, electroencephalography or MRI scans.

Following a full assessment, the members of the Children’s National care team will discuss treatment options with the child and their family. Common pathways are detailed below:

• Therapy follow is often advised. Cognitive behavioral therapy (CBT) includes working with a therapist to help the child or adolescent (and their family) learn how to cope with feelings of anxiety and how to handle behavioral change and emotional lability. During treatment, children learn to gradually face their worries and learn how to manage their anxiety, both during and between flares, using exposure response prevention (ERP).
• Medications, such as selective serotonin reuptake inhibitors (SSRIs), may be recommended. These medicines affect neurotransmitters (nerve cells in the brain that carry signals) linked to anxiety.
• If there are concerns for immunodeficiency, families may be referred to immunology.
• If there are concerns for autoimmune encephalitis, further testing may be recommended including brain MRI, EEG and lumbar puncture to make the diagnosis according to standard neurology and rheumatology diagnostic criteria.