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Jan 25

Strep Infection Associated with ADHD and Autism

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus, also known as PANDAS, is a condition that can occur within a child with a diagnosis of ADHD, autism, Asperger’s syndrome, obsessive compulsive disorder, or tic disorder (such as Tourettes syndrome).

PANDAS leads to autoimmune-mediated inflammation of the brain, and usually occurs after several bouts of Strep throat, but may manifest even if the parent cannot recall a history of Streptococcal infection in their child.

PANDAS attacks a part of the brain known as the basal ganglia. The basal ganglia links the cerebral cortex (involved in rational, calm behaviour) with the primitive areas of the brain (involved in fear, anger, and uncontrolled emotion). When the basal ganglia is disrupted by the brain inflammation caused by PANDAS, serious changes in behaviour and though processes can occur.

Symptoms and Signs often associated with PANDAS

  • Tic disorder or obsessive compulsive disorder (OCD)
  • Onset of symptoms between the ages of 3 and start of puberty
  • Episodic course of symptom severity (dramatic ups and downs in the child’s behaviour)
  • Associated with a group A beta hemolytic strep infection (positive throat culture for Strep or history of Scarlet Fever
  • Neurological abnormalities such as hyperactivity or choreiform movements
  • *The above diagnostic criteria for PANDAS are specified by the National Institute of Mental Health

  • ADHD symptoms such as inattention and hyperactivity
  • Separation anxiety
  • Mood changes which may include irritability, anger, fear or sadness
  • Sleep disturbance
  • Bed wetting or increased urinary frequency during the day
  • Fine/gross motor changes (Changes in handwriting, unusual or repetitive movements)
  • Joint pain
  • Is there a test to see if my child has PANDAS?

    There is no test available to definitively diagnose a child with PANDAS. Diagnosis can only be made clinically by the symptoms that the child presents with.

    To diagnose a current or recent Streptococcal infection the following tests are available:

  • A throat swab (rapid Strep test or throat swab culture) can identify a current case of Strep throat
  • An ASO titre (antistrepolysin titre) shows an elevation in antibodies to Strep 3-6 weeks after infection
  • An AntiDNAase-B titre (antistreptococcal DNAase B titre) shows an elevation in antibodies to Strep 6-8 weeks after infection
  • A positive result in any of these tests does not diagnose PANDAS, it just gives more information about whether the child has had a recent exposure to Strep. In addition, low Strep titres do not rule out PANDAS. If symptoms of PANDAS occur suddenly, it is useful to have the above Strep titres tested to see if a recent Strep infection could be related.

    Beyond this point, further testing for food allergies/sensitivities, as well as levels of immunoglobulins (IgE, IgG, IgA, and IgM) can be done to assess for additional burden on the immune system that is contributing to the child’s susceptibility to PANDAS.

    Treatments for PANDAS

    Treatments for PANDAS are not yet well-studied as this condition has only recently been identified. Conventional treatments may include oral antibiotics to eradicate a Streptococcal infection, and prophylactic antibiotics to prevent recurrence. Oral prednisone is also used as a potent anti-inflammatory to relieve inflammation of the brain and prevent damage. Another therapy known as intravenous immunoglobulin (IVIG) is being investigated.

    Complementary treatments support the use of antibiotics with probiotics (non-Streptococcal strains), and natural therapies to downregulate inflammation and support the brain, such as curcumin, EPA and DHA. Vitamins and minerals to support immune function (vitamin C, B vitamins, zinc, and selenium) should be administered intravenously. Intravenous glutathione, a potent antioxidant, can be used to protect the brain from being damaged from inflammation.

    Investigation should be done to rule out or treat other non-Streptococcal infections that may be present such as Candida (yeast), parasites, viruses (EBV, CMV, HSV), Lyme disease, or pathogenic bacterial overgrowth. Food allergy and food sensitivity testing can be done, and foods should be eliminated from the diet that may be placing additional burden on the child’s immune system.

    Lifestyle modifications are also important. Children with recurrent Strep infections may be constantly re-inoculated with the Strep bacteria through an asymptomatic family member. Some people are carriers of Streptococcus, and special care must be taken to prevent spread from carriers to the susceptible child. A child may also be re-exposed to Strep through skin infection (impetigo), urinary tract infection or ear infection. Immune system support to prevent recurrence of these conditions is important in long-term management of PANDAS. The tonsils and adenoids may harbor Streptococcal bacteria and some evidence suggests tonsil and adenoid removal in cases of PANDAS; however, careful consideration of the role of the tonsils and adenoids in fighting infection should be made before making this decision.

    26 Comment to “Strep Infection Associated with ADHD and Autism”

    1. Jason vanKuijk
      Aug 23, 2012

      Can pandas exist without OCD?

    2. admin
      Aug 23, 2012

      Jason,

      PANDAS can exist without OCD. Often times, the main presenting symptom of PANDAS is a tic disorder without obsessions or compulsions.

      -Dr Wilson

    3. Sandra Brownlee
      Aug 25, 2012

      My daughter was diagnosed with OCD PANDAS 2 years ago. We also suspected mild asperger’s when she was little. She has been on antibiotics for almost 2 years, the times she went off the antibiotics she was exposed to strep in school and ended up back on the antibiotics. I had my tonsils out when I was 3 years old and I have never had strep. Could I be a carrier? How do I find out? Is there any naturopathic alternatives. We have considered a naturopath to fight off strep and possibly hypnotherapy for the OCD.

      Any information would help. She was going to be in the Yale study, but her first doctor had temporarily put her on prednisone, so she did not get to participate in the IVIG treatment study.

      Thank you,

      Sandra

    4. Jason
      Aug 30, 2012

      Dr Wilson, Thank you for your repply my soon was diagnosed with a autism spectrum disorder and after a year we decided with our psychiatrist we decided to remove the diagnose.
      My son had a strep infection at aprox 3 years of age. He’s 7 years of age and I can’t see any signs of tic disorder without obsessions or compulsions. He does have sensory integration issues
      We do notice a change in behaviour when he is sick. When he is on antibiotics he seem to be better ( a longer fuse…)

    5. admin
      Aug 30, 2012

      Sandra,

      You can find out if you are a Strep carrier by having a Strep throat swab done when you are not sick.

      Strep carriers will always produce a positive Strep throat swab result, regardless of whether or not they have a true Strep infection at the time.

      -Dr Wilson

    6. karen Rose
      Sep 8, 2012

      Hi

      I found out i am a strep B carrier when my 4th child was still born at 38 weeks…. i had three sons before then with no problems. My youngest son is now 12 and ever since year 4 (so he was 8 – 9 years old) he was diagnosed with ADHD and just recently he has developed a tic both are being medicated. He has never has strep throat but im wondering if the the fact that im a strep B carrier and it was undiagnosed if this be the reasons for the above…. Along with the above he also has
      increased urinary frequency during the day
      Separation anxiety
      Mood changes which may include irritability, anger, fear or sadness
      Sleep disturbance

      look forward to hearing your reply

      regards karen

    7. vicki Philpott
      Sep 8, 2012

      I was a strep B carrier though my pregnancy, My son was born very quick and no antibiotics was given to me during labour or to him after.

      He is now 7 and showing a lot of the signs of ADHD, does PANDAS affect growth??

    8. admin
      Sep 9, 2012

      Vicki,

      PANDAS does not necessarily affect growth, but may occur concomitantly with conditions that lead to delayed growth or failure to thrive.

      Many children diagnosed with PANDAS also have an ADHD or autism spectrum diagnosis. ADHD and autism are both linked to chronic digestive issues, malabsorption, defects in metabolism, nutrient deficiency, recurrent infections, and allergies, all of which can contribute to delayed maturation and height/weight measurements in the lower percentiles.

      -Dr Wilson

    9. admin
      Sep 9, 2012

      Karen,

      The symptoms your son is experiencing, along with the ADHD diagnosis and tic disorder, may very well be linked to Strep.

      Your son’s symptoms may not be due to contracting GABHS at birth, as PANDAS symptoms generally begin to occur shortly after the initial infection; however, if you are a Strep carrier, it is possible that you passed this bacteria on to him at some point later on in his life.

      Many children who develop PANDAS are exposed to Strep, yet do not develop an active Strep throat infection.

      -Dr Wilson

    10. Caroline
      Nov 4, 2012

      My 5 year old son was diagnosed with aspergers . Could it be pandas? What is the difference between the two?
      Thank you

      • admin
        Nov 5, 2012

        Caroline,

        PANDAS and Aspergers syndrome can exist in conjunction with one another, but in order for the diagnosis of PANDAS to be considered, the following criteria should be met:

        PANDAS symptom onset includes primary ONSET of OCD (obsessive compulsive disorder) and/or severe anxiety
        along with at least two other following symptoms:

        Tics or other abnormal movements
        Severe separation anxiety, Generalized anxiety
        Irritability, Emotional lability, Aggression, Personality Changes
        ADHD, Inability to concentrate
        Sensory sensitivities
        Deterioration in learning abilities and school performance
        Developmental and age regression (inc. Deterioration in handwriting)
        Sleep and night time difficulties
        Urinary Frequency or Daytime or night-time secondary enuresis

        The criteria above was outlined by the PANDAS Network, a compilation of research, information and case studies of PANDAS.

        -Dr Wilson

    11. Jenny
      Nov 5, 2012

      so my daughter was diagnosed with aspergers, adhd and sensory processing disorder and gets strep throat 7 months out of the year they are removing her tonsils and adnoids in december would this help if it was PANDAS?

      • admin
        Nov 5, 2012

        Jenny,

        Removing her tonsils may help if her behavioural disorders are related to chronic Strep infection. Be advised though that the tonsils and adenoids are an important part of the immune system’s line of defence, so supporting her immune system will be very important for her after she has the surgery.

        -Dr Wilson

    12. Jenny
      Nov 5, 2012

      do you have any suggestions on how to do that? she is my kid who is always sick as it is!

      • admin
        Nov 6, 2012

        Jenny,

        Although I cannot give any specific advice as your daughter is not my patient, I did mention some general strategies in the article for supporting the immune system.

        These include removing obstacles to the proper functioning of the immune system. You would want to consider testing for food sensitivities and a yeast overgrowth (Candida albicans). I use this test in my practice. Food sensitivities pose an ongoing stress on the immune system, leading to frequent infections and chronic inflammation. Yeast overgrowth, viruses, and bacterial dysbiosis (bacterial imbalance in the gut) also contribute to poor immune function.

        A high dose probiotic supplement is essential for anyone with recurrent infections, and past or current history of antibiotic therapy. Intravenous vitamins and minerals to support immune function are ideal as they offer the best absorption and highest dosing, but if IV therapy (administered by a naturopathic physician) is not an option for your daughter, they can be given orally. IV hydrogen peroxide therapy (also administered by a qualified naturopathic physician) is also beneficial for killing bacteria, yeast, and viruses.

        If her behavioural issues are related to Strep as in PANDAS, and she suffers from Strep infections 7 months of the year, she should most likely be on prophylactic antibiotics (and probiotics!) as chronic Strep infection and brain inflammation can lead to permanent damage.

        I strongly recommend that you seek out a physician who has experience treating PANDAS so that your daughter can receive individualized care.

        -Dr Wilson

    13. Aubrie Fairbanks
      Nov 15, 2012

      Dr. Wilson,

      My son is nine years old and has been a tad different his entire life. I have three boys and he is very different. He was diagnosed with Anxiety and OCD. I am now having him looked at for Autism. Upon a trip to the Dr., he had blood work done which came back positive for strep (he has already had tonsils and adenoids removed). Could he have PANDAS?

      • admin
        Nov 16, 2012

        Hi Aubrie,

        The symptoms your son is exhibiting can be related to PANDAS, but not necessarily. Both anxiety and OCD are hallmark symptoms of PANDAS, but usually the onset is abrupt and can be severe. This means that one day your son was a typical child, and the next day he was not the same (anxious, obsessive-compulsive, tic disorder develops, aggression, hyperactivity, irritability, personality change, etc).

        A case of PANDAS will be either preceded by a Strep infection (4-6 months before symptoms develop), or you will notice an exacerbation of symptoms when Strep is present. If your son had a recent positive test for Strep, this means that he was recently (within the past month or so) exposed to and infected by Strep. Did his symptoms worsen with this exposure?

        If it is PANDAS, symptoms should respond quickly to antibiotic therapy. If you can find a qualified physician to assess your child, consider PANDAS, and prescribe a trial of antibiotics, that will be your best bet!

        -Dr Wilson

    14. kim
      Nov 21, 2012

      My son was diagnosed with Pandas ten years ago. He was textbook, woke up one day with severe motor tics and OCD. He had to be strongly medicated for three years to control the tics, and we had to be vigilant with strep infections, which he was getting over and over again.

      Fast forward to a nineteen year old who had had eight strep infections in the past nine months, as well as increasing problems that we have thought are psychiatric in nature. Anger problems, depression, OCD. I strongly believe that his current problems must be related to his chronic strep infections. Sometimes his symptoms will exacerbate and he will have rage, and self control issues, and then wake up the next morning strep positive. I feel like the ball was dropped somewhere with this diagnosis of Pandas, and now I have a son with issues and I am not sure who should take control of this. Pandas is primarily a pediatric disorder, and his started clearly in childhood, but who can we take him to now at this age? I feel he would be very interesting to a doctor who is doing research on Pandas, but where do I turn with him?

      • admin
        Dec 2, 2012

        Kim,

        It does sound like a reactivation of his pediatric PANDAS symptoms when your son comes in contact with Strep. The immune system does not always ‘outgrow’ this disorder, and Strep exposure can lead to a resurgence of antibodies that activate brain inflammation in the frontal cortex leading to exactly the symptoms your son is going through.

        My best advice for finding a PANDAS friendly physician in your area, or to participate in a research study, would be to check out http://www.pandasnetwork.org .

        -Dr Wilson

    15. Tracey
      Nov 24, 2012

      I have a 9 year old daughter who has suffered from sensory issues her entire life. About a week ago she came down with hiccups that have now turned into, for lack of a better phrase, guttural tics. We have had 2 trips to the er. The first ended with them prescribing Atavan for anxiety. She had an adverse reaction and it ended in hallucinations, hyperactivity and a very scary day. We ended up in the ER again and they sent us home with Reglin. That has not worked either. She now goes all day with these tics, cant sleep and is having a hard time eating and is achy all over from these. We have an appointment on Tuesday with the Pediatrician but not sure if she should wait that long and if not, where to go. Any suggestions would be much appreciated!! We are scared to death!

      • admin
        Dec 2, 2012

        Tracey,

        Sounds like what you are going through with your daughter is very scary. Some questions to ask yourself are if she shows any signs of OCD (obsessions or compulsive behaviours)? and has she had a recent Strep infection in the past 6 weeks? Please also be advised that PANDAS symptoms can occur even without an obvious history of Strep infection.

        Take a look at the list below that is some preliminary diagnostic criteria for PANDAS that has been compiled by the PANDAS network:

        Symptom onset includes Primary ONSET of OCD and/or Tics
        along with at least two other following symptoms:

        Tics or other abnormal movements
        Severe separation anxiety, Generalized anxiety
        Irritability, Emotional lability, Aggression, Personality Changes
        ADHD, Inability to concentrate
        Sensory sensitivities
        Deterioration in learning abilities and school performance
        Developmental and age regression (inc. Deterioration in handwriting)
        Sleep and night time difficulties
        Urinary Frequency or Daytime or night-time secondary enuresis

        If you feel that your daughter satisfies this criteria, finding a PANDAS friendly physician in your area is warranted as your daughter may benefit from starting antibiotic therapy right away. In my opinion, the PANDAS network is a good resource for finding out more information, and for locating a physician in your area that will treat your daughter.

        -Dr Wilson

    16. Amie Lempin
      Nov 30, 2012

      Dr. Wilson,

      My Son Gregory is six. He developed Tics overnight about 2 months after a strep infection. He was irratable, had tantrums and was day dreaming in school. He was very angry but I would not describe him as anxious. I thought he was developing a tic disorder and was just going through a behavioral phase.

      About a month ago, Gregory developed an odd pimple on his chest that quickly became infected-looking. The Peditrician put him on an antibiotic and his symtoms have almost disapeared. He can still be moody. also, I had watched a lecture online about PANDAS in which a patient was asked to close their eyes and hold out thier hands. The little boy moved his fingers like he was playing the piano. I asked my son to do this just this morning. Even with all the improvements, he does display these movements (sorry, forgot what they call them). Could this be PANDAS?

      • admin
        Dec 2, 2012

        Amie,

        Thank you for sharing this description of your son. What you are describing is very classic for PANDAS. Symptoms occur suddenly about 6-8 weeks following a Strep infection, and both tics and irritable behaviour are hallmark. The fact that your sons symptoms drastically improved following antibiotic therapy is also a sign that the behavioural issues are Strep related.

        The finger movements you are describing are known as choreiform movements. These involuntary movements of the arms, legs, or face are also classic for PANDAS, and if your son is still experiencing this symptom, that is a sign that brain inflammation could still be present.

        Given your son’s age, he is susceptible to having a relapse should he come in contact with Strep again. I would highly recommend that he see a physician that is familiar with treating PANDAS. If you are in the USA, there is a list here.

        -Dr Wilson

    17. jodi
      Dec 23, 2012

      MY child is now 10 and has development delayed issues..as well as adhd.
      He was born with a bacteria infection. I had strep b . I had a c -section and was not given an antibiotic before birth. My first child, I was given an antibiotic and he is fine.
      The hospital kept my son for 3 days extra and did not make a big deal about it, so I never followed thru…stupid me
      I believe strep b , if not followed up with baby can cause delays like my son. My son cried for 1 year and all doctors did was change formula…Now he is 10 and on the level of a 5 year old.
      Be your own dr. If you test positiv for strep, please check your child out every few months to see if the bacteria infection grew in him/her. Doctors won’t agree with me and may give you a hard time..but I am living proof, thru my son that strep b can cause problems if not followed thru after leaving hospital.

    18. Phil
      Jan 3, 2013

      Dr. Wilson,

      First I want to thank you for such a great website and for sharing your thoughts and time so generously. I have just come across PANDAS in my research for the first time and you certainly seem to be at the forefront of embracing it and giving it the attention it seems to deserve.

      My question is about PANDAS in adults. I’m currently 32 years old and have felt like something has been off since I was in my teens. My symptoms seem to run the gamut from GAD to OCD to ADHD to depression and I even think it may be Asperger’s. Upon doing research I have come across PANDAS and I do remember that I had strep quite a bit as a child and young teenager. I had my tonsils out when I was about 14 years old I believe – maybe slightly younger.

      The only thing I don’t notice in myself within the list of symptoms you mentioned are tics. I’m somewhat encouraged having come across the information you have provided here as an explanation for some of the reasons I feel this way as maybe it can help me to start to address these issues head on as opposed to what I’ve been doing which is running from doctor to doctor, being prescriped countless Psychiatric Meds (SSRI’s, anti-anxiety meds, nonconvulsants, etc.) and trying countless natural supplements and what not.

      I was wondering what you think the best course of action for me to take is? Do you have any general advise? What type of doctor should I see? I wish you were closer – would love to work with you. Do you have any references you respect on this topic in the Baltimore, Maryland area?

      One last thing, a couple years ago I went to an ears nose and throat doctor who put a scope up my nose to look at my throat and we noticed a growth on the back of my throat. I never followed up to have that removed but do you think that’s something worth pursuing?

      This makes me a little hopeful that maybe there’s been an infection of some sort going on this whole time and that I don’t fall into one of these other categories which seem much harder to cure and for which recommended medicines simply do not work for me. Any advice would be greatly appreciated. Thanks again, Dr, Wilson.

      – Phil

      • admin
        Jan 4, 2013

        Hi Phil,

        Thank you for your comments and for sharing your story.

        It is possible for post-streptococcal disease to manifest in adults, yet PANDAS is more commonly seen as a pediatric disorder. Given that what you have tried in the past (psychiatric medications, supplements, etc) has not made a difference to your condition, the issue may not be based on neurotransmitter function but rather on brain inflammation (like PANDAS).

        Given your symptoms, the best thing to try at this point would be a trial run of antibiotics under the care of a qualified physician, using concurrent probiotics to prevent dysbiosis or yeast overgrowth.

        Using other strategies to manage inflammation in the body such as IgG food sensitivity testing and immunoglobulin testing can also be helpful in determining which parts of the immune system are overactive and which parts may be deficient.

        Unfortunately I am not familiar with anyone in your area, however the PANDAS Network lists 2 physicians in Maryland here.

        As for the growth on the back of your throat, if it is confirmed to be benign and not causing any issues with breathing or swallowing, then it may not be an issue for you. If it is malignant or suspected to be malignant, you should be following up immediately for a biopsy or to have it removed.

        -Dr Wilson