Consider this case:
Jonny, (not his real name), is a third grader with a new problem – he cannot stay in class. After starting the year well the first week, he missed the almost the whole second week of school with a sore throat and a cold. When he came back to school, he was a different kid. He told his teacher he had to go home because he missed his mom. In fact, he wouldn’t stay in class. His parents would bring him to school, he went in the school but refused to go in the class room. He was sure something awful would happen to his parents if he did. When his dad came to school and convinced him to go in the classroom, Jonny bolted from the room in tears as soon as his dad left his view. This went on for a week with no progress. In desperation, Jonny’s parents called me for a consultation.
In reflecting upon the implications of PANDAS, I am remembering cases where autoimmune reactions associated with Strep may have been relevant. The case above is one of the more striking school refusal cases I encountered since there were no prior incidents of anxiety or phobia. The remission was equally striking. I saw them for three sessions and the boy’s phobia decreased dramatically.
My strategy was to ask the school if the boy and his mom could do his school work together in a room at school. I reasoned that there was some sudden onset of attachment anxiety. At the time, I wondered if for some reason the mother experienced attachment distress and communicated this in some way to the son. I wondered if the school refusal behavior was a communication to the father that perhaps Jonny wanted more time with dad. There were some corroborating findings. In this particular Autumn, dad was somewhat more busy in his work and gone a bit more. From a systems perspective, I had a working hypothesis that mom wanted the son to help bring dad home more and get more involved in the family. Dad was indeed too busy to attend sessions, so I worked with what I had and prescribed this change at the school. The school personnel cooperated and found a suitable room for mom and son to conduct school work.
Under these conditions, the youngster stayed at school and did his lessons. As predicted, mom and son soon got their fill of attachment and began to bicker some about various things. By the beginning of the second week, Jonny thought he could try the classroom again. After a couple of false starts, he was back in the classroom for good by week three.
Within a systems/solution focused framework, I had “prescribed the symptom” with the assumption that dramatically increased closeness would require a change in the mother-son relationship. Mom reported that she began to complain more to her husband about the school visitations and he was home a bit more. Somehow a more workable balance was restored to the family system. Mom and son found that when it came to closeness to each other, some was good, but more was not better.
Or did Jonny have untreated strep throat which eventually led to obsessions regarding attachment to his parents?
I will probably never know. I am very willing now to entertain the idea that the intervention I prescribed was not the source of the quick benefit. Rather, PANDAS or something like it may have gone into remission with the passing of time.
If the boy never again had related symptoms in the presence of streptococcal infection, he would not meet the NIMH criteria for PANDAS. The criteria are:
-Presence of a tic disorder and/or OCD;
-Pediatric onset of symptoms (age 3 years to puberty);
-Episodic course of symptom severity with sudden onset or acute exacerbations that are in:
-Temporal association with group A Beta-hemolytic streptococcal
infection (indicated by a positive throat culture for strep and/or elevated anti-streptococcal antibody titer); and
-Association with neurological abnormalities (hyperactivity/fidgetiness/restlessness, or adventitious movements such as the choreiform movements of Sydenham).
Even though Jonny might not have had PANDAS, it seems plausible that his reactions could have been triggered by his prior illness. The research program regarding PANDAS provides a new paradigm to consider with regard to the etiology of at least some psychiatric disorders. What other sudden onset autoimmune disorders could be related to bacteria or a virus? Mental health professionals are socialized and trained to attribute disorder to faulty family dynamics and/or trauma. I believe we should expand our thinking to include assessments of total health and environmental status. Careful observation was behind the discovery of PANDAS and may uncover additional syndromes. Susan Swedo et al describes this process:
…a subgroup of the patients experienced an explosive “overnight” onset of obsessions and compulsions followed by a relapsing-remitting symptom course. Closer observation revealed that the neuropsychiatric symptom relapses frequently occurred after episodes of streptococcal pharyngitis or scarlet fever…Longitudinal observations of the OCD subgroup and the patients with Sydenham’s chorea clearly demonstrated a temporal association between streptococcal infections and obsessive-compulsive symptoms.
In light of the PANDAS research, Swedo and colleagues recommend the following medical response in light of the research regarding PANDAS:
1. Laboratory testing: Children with an abrupt onset or exacerbation of OCD or tic disorder should have a throat culture obtained. If the symptoms have been present for >1 week, serial antistreptococcal titers may be indicated to document a preceding streptococcal infection. (Titers should be timed to catch the rise at 4–6 weeks.)
2. Use of antibiotics: Antibiotics are indicated only for the treatment of acute streptococcal infections as diagnosed by a positive throat culture or rapid streptococcal test. Clinical trials are underway to determine whether prophylactic antibiotics will be useful in the management of children in the PANDAS subgroup, but at present, they are not indicated. In the only placebo-controlled trial reported to date, penicillin administration failed to prevent streptococcal infections (14 of 35 infections occurred during the penicillin phase of the crossover trial), and thus there were no between-group differences in neuropsychiatric symptom severity.
3. Management of neuropsychiatric symptoms: Children in the PANDAS subgroup respond to treatment with standard pharmacologic and behavioral therapies. Obsessive-compulsive symptoms are treated best with a combination of medication (typically, a serotonin reuptake-blocking drug) and cognitive-behavior therapy, and motor and vocal tics respond to a variety of pharmacologic agents.
In the next article, I want to develop these recommendations a bit with application to counselors in mental health and school settings.
Read part one in this series here…