Can Strep Lead to Behavior Problems? /PANDAS article in the New York TIMES/

[Guest guest]

Can Strep Throat Lead to Behavior Problems?

By THE NEW YORK TIMES

Can a bout of strep throat lead to serious behavioral problems like obsessive

hand washing or odd tics in children?

Steve Kagan for The New York Times

Obsessive hand washing sometimes follows strep infections; are the two

related?The condition, known as Pandas, for pediatric autoimmune

neuropsychiatric disorders associated with streptococcal infection, remains a

controversial topic among child health experts. Dr. King and Dr.

Leckman of the Yale Child Study Center, who recently joined the Consults blog to

answer readers' questions about Tourette's syndrome, here respond to readers

concerned about the link between strep and obsessive-compulsive disorders.

Q.If your child shows symptoms of a tic disorder, obsessive-compulsive disorder

or Tourette's syndrome, you should have them checked for strep. Pandas, could be

the cause. A simple blood test will tell if your child's " strep titers " are at

an abnormal level.

This can be treated with antibiotics. Worth checking out before you subject your

child to psychiatric medications. Not all doctors believe in Pands. But let me

tell you, it's worth finding a doctor who does.

For more info check out the Web site Saving Sammy: Curing the Boy Who Got O.C.D.

RS from N.J.

Q.The first sign of scarlet fever is obsessive hand washing, hours before the

rash; Tourette's is in the strep/O.C.D. family, or Panda. Why don't they treat

it with I.V. antibiotics and probiotics?

Bethany Brinton, Salt Lake City

A.Dr. King and Dr. Leckman respond:

Pandas, or pediatric autoimmune neuropsychiatric disorders associated with

streptococcal infections, remains a controversial topic for many experts in

Tourette's.

Two recently completed intensive longitudinal studies found little evidence to

support the existence of Pandas as presently defined. Since the onset of tics is

common in middle childhood and as many as half of young school age children may

have strep throat in a given year, the co-occurrence of new tics and a strep

infection will happen as mere coincidence, without any specific causal link, in

a certain number of children.

Furthermore, since stress, including the stress of illness, can be a cause of

tic flare-ups, it is not always clear if or when there is a more specific causal

link.

That said, some researchers, including ourselves, suspect that the label of

Pandas is probably best reserved for a subset of children with apparently

strep-related O.C.D. or tics, and that it is this subset of cases that need to

be more intensively studied. Such cases probably fall on a continuum with

Sydenham's chorea (a movement disorder that follows rheumatic fever) and other

post-infectious disorders that can lead to an inflammation in the basal ganglia,

a part of the brain involved in motor control and learning.

These more narrowly defined Pandas cases appear to have an abrupt sudden onset,

over the course of two days or less, and are marked by separation anxiety and

obsessive-compulsive symptoms, a loss of writing skills and sleep problems. Tics

are often present, but they can also confuse the picture, especially if they had

been present in some form prior to Pandas onset.

The overuse of antibiotics has its hazards, both for individuals and

communities, including allergic reactions and fostering the development of

antibiotic-resistant strains of bacteria. Hence, antibiotics — and certainly

intravenous antibiotics — are not indicated for the typical case of tic disorder

but should be reserved for cases where there is clear-cut and convincing

evidence that the onset or recurrent flare-up of tics/O.C.D. is linked to strep

infection.

Although there is at least one well done study that supports the use of

intravenous immunoglobulin for well-defined Pandas cases, this work needs to be

replicated. Plans are now under way for such a replication study in a carefully

defined group of children who meet the narrower criteria described above; the

study will again be performed at the National Institutes of Health's Clinical

Center in Bethesda, Md., by Dr. Swedo, who first coined the term Pandas

more than a decade ago.

Q.What percentage of children could be misdiagnosed as Tourette's and actually

have Pandas?

mlw, Brooklyn

A.Dr. King and Dr. Leckman respond:

Another great question. Once we have a reliable and valid way of making a

diagnosis of Pandas, we should be able to provide an answer.

As noted above, there is much controversy as to whether Pandas exist and, if so,

how should they be defined. At present, in making a Pandas diagnsosis, we focus

much more on the sudden, abrupt onset — unusually in less than 48 hours — of

severe anxiety, obsessive-compulsive symptoms, sleep problems and behavioral

regression and a marked deterioration of writing and drawing abilities. Tics may

be present, but they are probably not a key feature.