September 2026

Dear Families,

As we step into the beginning of Fall and the new school year, this unfortunately can mean a new slew of illnesses and challenges adjusting to a new academic year. For some, they will recover from these illnesses with no lasting effects. For others, sadly, they may experience new behavioral symptoms that were not present before, affecting their ability to function in school and connect with peers.

In our blog post, "What is PANDAS/PANS?", we dive deep into the complexities of these neurologically-based disorders.

In this month’s newsletter, we’re focusing on:

• Identifying the Signs: Understanding the differences and interactions between medical illness and psychiatric illness.

• The Mind-Body Connection: Recognizing how inflammation and stress manifests as physical symptoms like incontinence and insomnia.

• Pathways to Support: Exploring evidence-based interventions like therapy, psychotropics, and when immunotherapy or surgery may be an option for your family.

Please know that if your family is navigating this, you are not alone and we know much more than we did years ago. My hope is that this month’s resources offer you the clarity and compassion needed to advocate for your child’s needs.

Warmly,
Rebecca A. Fontanetta, PsyD, ABPdN
Board-Certified Pediatric Neuropsychologist
Founder, The Neuropsychlopedia

What Do We Know?

PANDAS actually stands for Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS). In 1998, criteria for PANDAS was established after several children were presenting with a particular combination of symptoms, including, OCD, tics, separation anxiety, inattention, and sometimes neurological abnormalities such as or “brain fog”, after a group-A beta-hemolytic strep infection somewhere between age 3 and puberty. These symptom were observed to have an abrupt onset and variable/episodic course, including “flare ups.”

On neuropsychological assessment, many PANDAS children had reduced visuospatial memory, reduced inhibitory control, reduced fine motor speed, and reduced sustained attention. Children diagnosed with PANS typically had more exacerbated deficits, especially within processing speed and memory measures and tended to experience incontinence more so than children diagnosed with PANDAS. Across both PANS and PANDAS the profile of strengths and weaknesses were consistent with symptoms reported, and there were minimal differences in behavioral or emotional concerns as compared to children with OCD, ADHD, tic disorder and/or anxiety who presented for testing.

Neuroimaging studies have shown inflammation in the caudate nucleus, putamen, globus pallidus, and lentiform nuclei, all parts of what is called the basal ganglia, though research on specific areas affected has been variable. The basal ganglia is a part of the brain responsible for motor learning, motor control, habit formation, and execution of behavior and emotions.

What the Research Shows

What Causes PANS/PANDAS?

Common illnesses such as: pharyngitis (fancy word for sore throat), rhino sinusitis (sinus infection), acute ear infections, obstructive sleep apnea, and tonsillitis, which are most often caused by a primary viral infection or bacterial strep, can lead to secondary infection. It has been shown that chronic adenoid/tonsil tissue inflammation can play an important role in many system illnesses including autoimmune diseases.

The leading theory is that when the body experiences either a strep or other viral infection (COVID, Epstein-Barr, Lyme Disease etc.), anti-neuronal antibodies are formed and act as a trigger against the the body and brain and affect the function and neurotransmission of certain dopamine (a type of neurotransmitter) receptors within the basal ganglia. The antibodies also may bind to acetylcholine and GABA (two more neurotransmitters) interneurons in the brain, which can result in compulsive behaviors, when these cortical circuits are disrupted.

These antibodies may cross-react with brain proteins, mostly within the basal ganglia, and cause inflammation. Impairment in dopaminergic circuits in the basal ganglia provokes neurological symptoms, similar to what is seen in Tourette’s and other disorders with repetitive behaviors. The 3-4 types of dopamine receptors that are suspected to be disrupted are together considered the “Cunningham Panel,” which is a test intended to measure immune dysfunction secondary to infection, so when a child has a positive Cunningham Panel, that is said to be potential evidence for PANS or PANDAS.

If You’d Like to Explore Further

What Should Parents Know?

In terms of the research, immunotherapy (corticosteroids, NSAIDS, IVIG, plasma exchange) has demonstrated variable efficacy in terms of creating an immunomodulatory effect. There were some studies showing improvement from IVIG; however, most did not have blinding, placebo, or control groups, and more robust studies failed to show any improvement from intravenous immunoglobulin (IVIG). There was also variable benefit from tonsillectomy or adenoidectomy, but only via individual case studies. When patients received CBT and SSRIs (Zoloft, prozac etc.) this was found to be beneficial for PANDAS, similar to individual diagnoses themselves. And finally, per a recent systemic review on PANS and PANDAS, there has been “Conclusive evidence is largely lacking regarding potential beneficial effects of anti-inflammatory, antibiotic, and immunomodulatory treatments for children with symptoms corresponding to PANS/PANDAS; however, this may meant a mismatch between diagnosis and treatment for individual cases so its not a black and white issue.

So what are the recommendations if you feel your child may meet criteria for PANS or PANDAS after a recent onset of behavioral symptoms? If your child presents with acute onset tics/OCD/food restriction, they may need a full medical workup, throat swab, blood work with blood cell count and manual differential, inflammatory markers, metabolic panel, and urinalysis. If physical exam is normal, doctors may consider antibiotics/immunotherapy in severe cases and/or corticosteroids or NSAIDS, which may be helpful during “flare ups”, to reduce inflammation (with doctor’s advice and prescription). They may also refer to psychiatry, and/or typical psychotherapeutic treatment.

All in all, this is a complex diagnosis, with many potential professionals involved, so it is important to advocate for your child and attempt to find consistent opinions across doctors. Your best bet is to treat the symptoms in front of you: if your child has a viral or bacterial infection, treat the viral infection according to the corresponding medical protocol recommended by your medical doctor, which can sometimes involve antivirals, antibiotics, or plasma exchange. If your child has repetitive behaviors/compulsions or anxiety, it may be recommended that you treat those symptoms with the aid of a psychiatrist or psychologist through CBT or appropriate psychotropic medication (SSRIs, clonidine, or neuroleptics).