A child suddenly begins to show obsessive and compulsive behaviors and have serious separation anxiety with intense mood swings. His parents noticed that these problems started quickly and unexpectedly-seemingly overnight. Their child’s behavior has changed dramatically and he is no longer functioning well at home and school.  

I recently had a neighbor in the medical field ask if PANDAS was real. It is understandable why this syndrome is confusing… and why it might be distressing for parents. There is uncertainty about the cause and there is variability in the presentation of symptoms. The idea that a child could suddenly develop significant obsessions and compulsions or a serious tic disorder after having strep throat is definitely concerning. The prevalence is not known. The connection to strep is unclear. Best practice in treatment requires both medical and psychological interventions. The diagnosis is not based on a definitive blood or “lab test”, but on the clinical presentation of symptoms. A diagnosis requires a physical exam and assessment of a child’s medical and psychiatric history to understand how and when symptoms started and what else might be going on to contribute to these behaviors or concerns.
 
What is it? PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) is a subtype of PANS (Pediatric Acute-onset Neuropsychiatric Syndrome). PANDAS typically affects children who are 3-12 years of age.  There is an acute, or sudden, onset of distressing symptoms and a significant change in a child’s behaviors during or after an episode of strep or scarlet fever (but this might be weeks after). Children suddenly exhibit new or significantly increased obsessive and compulsive behaviors or tics.  They also usually have other serious behavioral symptoms. Separation anxiety, restricted eating, aggression, intense mood changes, depression, sleep disturbances, frequent urination, ADHD symptoms (hyperactivity and impulsive behavior) and academic decline are common additional problems that might also co-occur.
 
OCD typically has a gradual progression, but with PANDAS the behaviors appear suddenly. If symptoms are present before strep, they are significantly and dramatically worse after. The PANDAS Network estimates that one in 200 children may have PANDAS/PANS, but the exact number is not known. It is important to consider that strep is common during childhood (some estimates are that children in elementary school have a strep infection 2-3 times a year), but the actual incidence of PANDAS is rare. Of children who are diagnosed with OCD, it is thought that up to 10% have PANDAS. Accurate diagnosis requires a comprehensive evaluation with an experienced physician. Again, other diseases need to be ruled out after a physical exam, medical tests, and psychiatric history.
 
What is the Treatment?  In July 2017, the PANS Research Consortium published comprehensive treatment guidelines (https://www.liebertpub.com/doi/10.1089/cap.2017.0042).
A child will need medical, psychological, and school based support. If PANDAS is suspected a throat culture is taken and antibiotics are administered. Often this results in a noticeable decrease in OCD symptoms. Treatment recommendations also involve participation in research-supported therapy to help address the immediate distress from obsessions and compulsions, anxiety, or mood changes. Cognitive Behavioral Therapy, including Exposure and Response Prevention (ERP) and parent support are recommended best practice. School support is often needed for both behavioral and academic challenges (such as the frequently observed decline in motor skills / handwriting).
 
For more information about PANS/PANDAS see the websites and fact sheets in the links below. If your child has OCD or a tic disorder and had a sudden onset of significant and distressing symptoms please talk with your physician or use the links below to find an expert in the field. If you need help navigating this process or want therapeutic support please contact our office.
 
 
REFERENCES & RESOURCES:
https://www.nimh.nih.gov/health/publications/pandas/pandas-qa 508_01272017_154202.pdf

http://med.stanford.edu/pans.html

www.pandasnetwork.org

PANDAS Frequently Asked Questions

http://www.cmaj.ca/content/cmaj/190/3/E86.full.pdf

https://rarediseases.info.nih.gov/diseases/7312/pediatric-autoimmune-neuropsychiatric-disorders-associated-with-streptococcus-infections
 
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Everyone needs a support system but sometimes it can be hard to identify those people. However, with the information provided, you’ll be able to identify your support system or gain some insight into how to create a more helpful support system.
Support systems are a network of people that provide you with practical or emotional support. They are people that help you when you are going through tough times, whether that be emotional or physical. Without healthy support systems, people often feel hopeless, helpless, lonely and overwhelmed. Research has shown that a support system helps an individual feel more confident in their abilities, increases use of healthier coping skills, decreases anxiety and depression and provides people with a longer and healthier life. So if there is so much benefit to having a support system, why do some people struggle with having one? There are several reasons but for some it’s the idea of admitting that you may need help. Some people believe that it shows weakness to ask for help but in reality it shows a lot of strength to admit that you can’t do it on your own. For others, it’s because they don’t know how to create a support system. Here are several ways in which to create a support system.

• Who do you start with?
  • You want to start with your family, friends and coworkers. These are the people that are already in your life and they already have an idea of what’s going on and how to help.
  • However, not every family member, friend and coworker is going to be a good support system.
• After looking at the people close to you, you can then begin to branch out into the community.
  • There are several support groups and organizations that you can find just by doing a Google search or searching social media groups.
  • Groups could be through churches, the city, the state or different agencies.
  • Some groups are just people going through the same experiences as you and they formed their own group.
  • Ask around. Ask your family, friends, coworkers, doctors, even children’s schools for any groups that maybe available.
  • Don’t limit yourself to just groups that you are already apart of. Try out new groups and organizations to see if there’s any support with them.
• Next, you need to look at what makes a healthy support system.
  • A healthy support system is one that builds you up, encourages you, is positive, is there for you when you need them, and decreases your stress level. A support system doesn’t mean that everything in your life is better but it does mean that you are able to manage the stress better with the support of others.
  • An unhealthy support system is one that is negative, isn’t there for you, brings on more stress, lies to you, doesn’t provide any help or drains you. These could be family, friends or coworkers. If so, those are the people you need to keep your distance from.
• Lastly, the key to having a support system is to open up to them. If you don’t open up, then your stress level will continue. It’s hard to be vulnerable to others but if they have shown the characteristics of a healthy support system, then they will accept you and make you feel safe with them. Remember that a support system is vital to having a longer, happier life.

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​The most wonderful time of the year??  It’s maybe a little of that but also a lot of stress.  Here are a few tips that can help you get through the holidays with more of the joy and less of the stress:

1. Be aware of what stresses you out.  Awareness of our triggers is key to managing our emotions and behaviors.
2. Make a self-care plan to reduce your stress.  Once you identify what stresses you out, do something you haven’t tried in past years to reduce it.  Maybe it is asking family members to help out or maybe it’s giving yourself a day off.
3. Create a goal for yourself and your family.  Really think about what is most important to you this holiday season.  Is it making sure the kids get the best gifts?  Is it making sure the family gets along? Is it about giving?  Figure out what you can do to focus on one or two goals. 
4. Ignore all of those picture perfect families you are seeing on the holiday cards and on social media.  That’s all posed and planned and chances are they all had to deal with a two hour tantrum in order to snap that one perfect picture.  Don’t compare yourself to anyone else and don’t feel like you need to have elaborate elf-on-the-shelf displays every morning to post on Facebook.  Stay connected in real-life and focus on what is best for you and your family. 
5. TAKE IT EASY ON YOURSELF.  Be kind to yourself.  That may mean throwing out a few crazy high expectations and laughing at your shortcomings.  Enjoy the nice moments and let the stressful and annoying ones go. 

Hopefully these tips can keep you centered throughout this stressful time of year so you can truly experience the joy with your family and loved ones.

The lives of many parents are often filled with managing work, childcare, activities, and household management. As a child begins to age, parents are eventually tasked with deciding at what point is their child old enough to stay at home alone while parents and caregivers are fulfilling other life duties and responsibilities. This decision has no clear-cut answer and is based upon numerous factors that are individualistic to the family’s presenting situations. However, there are some important points to consider when deciding as to whether to allow your child to manage themselves at home alone.
The National SAFE KIDS Campaign recommends that children are not to be left alone before the age of 12, and many will not be prepared until long after that. When considering an older sibling in caring for a younger child, experts have cautioned that older siblings are generally not ready for that responsibility of managing and supervising younger children until the age 15 or older.
If you are contemplating whether to allow your child to stay at home alone, some questions that families should explore before making an important decision may include:

• Does my child feel ready to be home alone in confidence and willingness?
• Does my child consistently follow the rules and guidelines of the household in order to manage the rules while being away?
• Has my child been able to exercise independent judgement and appropriate problem-solving skills in the past?
• Can my child handled unexpected events and stay calm to problem solve?
• Have I discussed with my child different scenarios that could occur while they are home alone and explore how they would handle them?
• Will my child be willing to be forthcoming in the event something occurred, and is my child generally truthful?
• Can my child demonstrate and understand basic safety rules and procedures?
• Will be child be able to make decisions to stay safe outside of being potentially influenced by other peers or adults?
• Can my child calmly provide important information, such as the home address and phone number, in the event of an emergency?
• Is my child able to physically manage safety exits, such as doors and windows?
• Can my child tell time?
• Have I developed a structured plan or routine with my child that clearly explains boundaries, limits, and expectations?
• Is my child able to independently work on tasks, such as homework?
• If there is more than one child in the home, such as siblings, can they manage to get along and solve conflicts without physically fighting or intervention from an adult?
• Have I engaged in pretend situations with myself and child in the home to practice self-care skills while pretending to be “unavailable?”
• Is our neighborhood safe, and are their neighbors that my child knows and I trust?

While this list is not exhaustive, it does provide some generally important questions and points to consider. Additional questions based upon your family’s needs and child’s needs should be explored.
 
  
If you decide to leave your child alone, parents and caregivers should begin with short periods of time and progressively increase time spent away, but also staying relatively close. This may include running short errands to the store, dropping off dry cleaning, or running to the post office. Assessing your child’s comfortability and ability to handle this time frame will allow parents to make adjustments accordingly.
The incorporation of safety planning is important when allowing a child to remain home alone. Such actions to take in order to increase safety are:

• Posting all emergency contact numbers (I.e. doctor, hospital, fire department, police department, poison control) and a trusted friend or neighbor near the phone, or programmed in a cell phone.
• Identify and show the child all fire escape plans in order to get out of the house immediately, and to vacate the home in the event that the fire alarm goes off and contact the fire department from the neighbor’s or cellphone.
• Have a first-aid kit in the home, and show the child where and what is in it. Teach the child about the items and how to use them in case of an emergency.
• Make sure that you are accessible. This includes having your contact number programmed into the phone, and explaining to the child where you will be, how you can be reached, and when you will return home.
• Prepare a snack in advance to prevent the use of appliances being used to decrease risk of accident.
• If the child arrives to an empty home, request the child contact you for a check in.
• Create house rules regarding the child’s ability to:
  • Leave the house
  • Having friends over
  • Cooking
  • Answering phone or door
  • Use of electronics and internet

If leaving your child alone is not appropriate for you and your family, consider alternative child care options. These may include a babysitter, after school care, or day camps. Err on the side of caution, and make an informed decision before leaving a child unattended to care for themselves. 

1. Keep it simple: By keeping the behavior chart simple, you are able to set yourself up for success. You want to make it easy to maintain and easy for the children to comprehend. If it’s too complicated or takes too much effort or time to maintain then you will not stick with it.
2. Keep it to 3 or less behaviors: One difficult, one easy, and one that’s in the middle. Again you want to keep it simple and not be too overwhelming for you or your children to complete.  
3. Write the behaviors in a positive manner: What do you want them to do rather than what you don’t want them to do. i.e.: write “Safe hands and feet” rather than “No hitting or kicking”.
4. Make rewards/incentives simple and not monetary or tangible items: It’s important to make the rewards/incentives that encourage positive interactions with others. For example, a reward could be they get to pick what’s made for dinner tomorrow, or they get to pick out the family movie. Asking the children what they would like to have as an incentive, helps to get them on board with the chart and creates excitement.
5. Once the behavior is achieved, chose a different one to work on: If you notice that your child is receiving the incentives quickly and it’s no longer a challenge for them, switch the behavior to something else that they need to work on.
6. Always be consistent and follow through with it: Very important to having a successful behavior chart is consistency and follow through. If you don’t follow through with the rewards or tracking, then your children will take that to mean that it’s not important.

Utilize the internet to get behavior chart templates: There are a lot of different templates online that allow you to customize it to your child’s interests. ​

All children display challenging behaviors at times. Sometimes it is difficult to understand why a child is behaving in a certain way or to know if this behavior or reaction is common for his or her age. Parents may find themselves questioning if behaviors are typical or if their children are showing age-expected skills and abilities.  (When do infants walk independently? How many words should a 2 year old say? What types of play or social interactions should I see at 3 years of age? Is a 30-minute temper tantrum about brushing teeth normal? Why is my baby trying to put that dried lizard in his mouth!?!) 
 
Development is a complex, ongoing, and rapidly changing process.  There is a range of time when skills begin and are attained or “mastered”.  There are also age-based standards when a lack of an observed skill or behavior is considered delayed and requires intervention. Understanding what behaviors are to be expected at a certain age (and “developmentally appropriate”) and when they suggest a reason for more concern and professional follow-up can be complicated. Some disabilities have early signs and symptoms that can be identified. (*In my next few blogs I will highlight early signs and screening for some of the most common early childhood developmental disabilities including autism and ADHD.)
 
When a child is not showing age expected skills or when challenging behaviors are more intense, frequent, or sustained compared to other children who are the same age, it is important to consult a professional trained in development and disability.  Again, all children can be expected to display challenging behaviors to some extent, particularly when they are tired, sick, scared or learning how to express frustration and assert independence. However, when problems are hard to manage or cause difficulty in school or at home, getting professional support can provide assistance, including increasing effective parenting and behavior management strategies, building positive parent-child relationships, enhancing learning and academic success, and determining if an underlying disability is present. Florida Early Intervention can also assist with free developmental screening and services for young children (0-3).
 
Resources
Florida Early Intervention:  http://www.floridahealth.gov/alternatesites/cms-kids/early_steps_directory/
 
Zero to Three: https://www.zerotothree.org/early-development
 
Center for Disease and Prevention: Developmental Milestones
https://www.cdc.gov/ncbddd/actearly/milestones/index.html
 
Kids Health: Growth and Development: https://kidshealth.org/en/parents/growth/?WT.ac=p-nav-growth

Children with Body-Focused Repetitive Behaviors (BFRB)
 
What are Body-Focused Repetitive Behaviors (BFRB) anyway?
 
BFRBs are when someone repeatedly touches, pulls, or picks at their skin or hair, sometimes causing themselves physical harm. 
 
At one point or another we have seen someone bite their nails, twirl their hair, or maybe chew on their cheeks or lips... Although seeing this is common, for some kids, it is harder for them to stop these behaviors and it may become more problematic.  
 
 
For kids the MOST COMMON types of BFRB are:
 
Skin Picking Disorder: causes people to repetitively touch, rub, scratch, pick at, or dig into their skin, resulting in skin discoloration or scarring
 
Hair-Pulling Disorder: causes people to pull out the hair from their scalp, eyelashes, eyebrows, and other parts of the body
 
Nail-biting Disorder: causes people to bite their nails past the nail bed and chew on cuticles until they hurt themselves, which may lead to soreness and infection
 
Some other BFRBs are: cheek and lip biting, nail picking, scab eating
 
How do you know when it’s a problem?
 
Body-focused behaviors are considered problematic for children when they are happening repeatedly over time and they result in negative physical, social, or emotional consequences.
 
Good news, there is help!!
 
Treatment such as cognitive behavioral therapy (CBT) or habit reversal training (HRT) has been shown to be very helpful for children with body-focused repetitive behaviors!
 
You can find more information and resources at: http://www.bfrb.org/index.php