Untangling PANDAS & PANS: Conversations about Infection-Associated, Immune-Mediated Neuropsychiatric Disorders
Hello and welcome to Untangling PANDAS & PANS, a podcast about two relatively unknown medical disorders characterized by the sudden and dramatic onset of obsessions and compulsions, vocal or motor tics, or restricted eating behavior -- and a whole host of other symptoms -- following strep or other bacterial or viral infection. Sometimes overnight. I have the privilege of interviewing some of the top researchers and clinicians in the rapidly growing field of Infection-Associated, Immune-Mediated Neuropsychiatric Disorders. That’s a mouthful of words that encompasses the strangely named disorders, PANDAS and PANS.
My name is Dr. Susan Manfull. I am a social psychologist, the Executive Director of The Alex Manfull Fund, and the mother of Alex Manfull, who died at 26 years old due to PANDAS, a neuropsychiatric disorder my husband and I knew next to nothing about, certainly not that our daughter could die from it.
PANDAS is an acronym for “Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus.” This disorder, first defined in 1998 at the National Institute of Mental Health, describes the acute and dramatic onset of obsessions and compulsions and/or motor or vocal tics as well as a whole host of neuropsychiatric symptoms in temporal association to a Group A streptococcal infection. PANS, which stands for Pediatric Acute-onset Neuropsychiatric Syndrome, refers to a similar symptom presentation -- with obsessions and compulsions or restricted eating being the cardinal symptoms -- due to a broader category of triggers (typically bacterial or viral infections). Both are thought to stem from a dysregulated immune system, probably leading to an over-production of autoantibodies and concomitant excess brain inflammation, particularly in the basal ganglia.
Symptoms vary from person to person and range in severity from mild to severe, and generally have a relapsing and remitting course. With early recognition and correct treatment, these disorders can be successfully treated. Today, it is no longer viewed as a diagnosis limited to the pediatric population.
Please stay tuned after each episode to listen to a one-minute public service announcement about PANDAS & PANS and The Alex Manfull Fund. To learn more, please visit our website: TheAlexManfullFund.org.
This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition.
Untangling PANDAS & PANS: Conversations about Infection-Associated, Immune-Mediated Neuropsychiatric Disorders
S2 E13: Understanding the Role of a Psychologist in PANDAS and PANS: A Conversation with Dr. Sarah O'Dor
In this illuminating conversation, Dr. Sarah O'Dor—Harvard instructor and Director of Research at Massachusetts General Hospital's PANDAS Clinic—reveals how strep infections and other triggers can cause sudden, dramatic psychiatric symptoms in children and young adults.
Dr. O'Dor paints a vivid picture of PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection) and PANS (Pediatric Acute-onset Neuropsychiatric Syndrome), conditions where infections trigger obsessive-compulsive behaviors, tics, restricted eating, and a host of other psychiatric, cognitive, emotional, somatic, and medical symptoms. Through the compelling case of "Ms. K," a six-year-old who developed severe handwashing compulsions following a strep infection, Dr. O'Dor demonstrates how these conditions often go misdiagnosed as traditional psychiatric disorders.
The conversation explores the critical role psychologists can play in recognizing these disorders and providing effective treatment. Dr. O'Dor describes how cognitive-behavioral therapy can be adapted for these patients, how families are affected by sudden behavioral changes in their children, and how psychologists can support not just the child but the entire family system. Also very importantly, she emphasizes the need for collaboration between mental health professionals and medical specialists—a multidisciplinary approach reflecting the complex nature of these disorders.
For parents, clinicians, and anyone interested in the fascinating intersection between immunology and mental health, this episode offers a roadmap to better understanding, earlier diagnosis, and more effective treatment. The discussion culminates with reflections on a growing paradigm shift in psychiatry—one that increasingly recognizes the role immune function plays in mental health.
Whether you're a healthcare provider, a parent concerned about your child's sudden behavioral changes, or simply curious about emerging understandings of brain-immune connections, this episode will transform how you think about certain psychiatric symptoms.
To read the article reference in the podcast, click here.
Disclaimer: The views and opinions expressed in this program are those of the speakers and do not necessarily reflect the views or positions of any entities they represent.
Credits: Music by Kingsley Durant from his "Convertible" album
To learn more about PANDAS and PANS and The Alex Manfull Fund, visit our website: TheAlexManfullFund.org
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Untangling Pandas and Pans is a podcast about two little-known medical disorders characterized by the sudden and dramatic onset of symptoms such as obsessions and compulsions, vocal or motor tics and restricted eating behaviors, and a whole host of other symptoms following a strep or other bacterial or viral infection. I have the privilege of interviewing some of the top researchers and clinicians in this rapidly growing area, known by various names such as immune-mediated neuropsychiatric disorders, infection-associated neuroimmune disorders and autoimmune encephalitis, or simply pandas and pants. My name is Dr Susan Manful. I am a social psychologist, the executive director of the Alex Manful Fund and the mother of Alex Manful, who died at 26 years old due to pandas, a disorder my husband and I knew next to nothing about, certainly not that our daughter could die from it.
Speaker 2:This is episode 13 of Untangling Pandas and Pans, recorded April 24, 2025.
Speaker 1:Dr Sarah Odor is an instructor in psychiatry at Harvard Medical School and for the past five years, has served as Director of Research at the Pediatric Neuropsychiatry and Immunology Program at Massachusetts General Hospital, widely known as the PANDAS Clinic. This summer, however, she will join Suffolk University as assistant professor of psychiatry, where she will launch the Child and Adolescent Brain and Behavior Laboratory to further her research into the biological underpinnings and treatment of childhood neuropsychiatric disorders. Over the past seven years, dr Odor's research has centered on pediatric neuropsychiatric conditions, including obsessive compulsive disorder or OCD, mood disorders and PANDAS. Her work has resulted in numerous peer-reviewed journal articles and book chapters, including guidelines for pediatricians on diagnosing and treating PANDAS, as well as the effects of COVID-19 infection and vaccination on children with PANDAS and PANS, relevant to today's discussion. She also works to enhance psychologists' ability to recognize and understand these conditions in clinical practice. Her contributions to the field of psychology and psychiatry have been recognized by leading organizations such as the American Psychological Foundation, the Anxiety and Depression Association of America and the International OCD Foundation. She is a licensed clinical psychologist and founder of Metro West Psychology, a pediatric neuropsychological practice based in the Boston suburbs. Neuropsychological practice based in the Boston suburbs.
Speaker 1:In her free time you might find Dr Odor hiking with her cattle dog. I had to look up cattle dog to see what or how. I would recognize Dr Odor hiking, and you should do the same thing. It's adorable. She's a taste tester for her husband's recipes who enjoys being in the kitchen quite a bit, and if she's not there then you might find her playing superheroes with her son or coaching her daughter's soccer team. Okay, dr Odor, let's get started. Welcome, dr Odor. It's really nice to have you here on Untangling Pandas and Pans and I'm very glad that you are here to talk about the role of psychologists in the field of pandas and pans, both in treatment and in research. I confess, actually and you know this that I'm on a mission to get psychologists more interested in this field, because I think that there are so many ways that psychologists can contribute and yet so many psychologists, like physicians, are not aware of these little-known disorders, so welcome.
Speaker 3:Thank you so much, susan, for having me, and feel free to call me Sarah. I've been listening to your podcast. I love learning, even from colleagues that I know already the conversations that they have with you. I've learned so much from listening to those. So thank you for having me, and thank you for realizing the importance of having psychologists in this discussion, because sometimes they do get overlooked, and so thank you for making that a priority, because I think that's really important and a great opportunity in expanding diagnosis and treatment of these conditions.
Speaker 1:So I think the first step towards getting psychologists involved in the treatment of these patients and support for the family and caretakers and parents and even grandparents who have someone who's suffering from PANDAS and PANS is to really educate them about these disorders. Look like traditional psychiatric disorders but actually the cause or the etiology is different and that requires a different approach to treatment. And although traditional approaches may also be used, it's very important, if you understand the cause, to treat that cause as well. So I thought maybe we would start out by just what is PANDAS, just in general, and what is PANS.
Speaker 3:Sure, yeah, and these terms can be confusing and also they sound so much alike. And so the first, pandas, stands for Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection, which is why we just call it PANDAS for short. And so this would be when there's a child before puberty, there's a time limit for this particular diagnosis where they exhibit a sudden onset of obsessive compulsive symptoms, of tics. They can be motor tics, like movements of their facial, there's arms or legs. They can be vocal tics, like repeated sniffling, coughing, even if they're not sick, saying words or phrases or both of those things, or those things might come in an episodic course where they kind of come on strong and go away and come on strong and go away. And in order to get a diagnosis of PANDAS there has to be kind of quote unquote a temporal association with a group, a streptococcal infection. It's not necessarily clearly defined what the temporal association is, but for many of these patients we see that it's shortly after they've had a confirmed strep infection. And then, similarly, there is PANS. And so PANS stands for Pediatric Acute Onset Neuropsychiatric Syndrome, and the kind of cardinal symptoms of this are either OCD, the obsessive compulsive disorder, and or restricted eating, and not necessarily just picky eating. This is pretty severe changes to a child's eating where they have a very restricted diet, to the point that it can be concerning for their health outcomes as well. And now for this diagnosis for PANS there's not an age time frame, and so it can also be diagnosed in adults and it does not have to follow an infection. Right, this is to kind of capture some of those kids that we don't necessarily know what might have triggered it. So there might be an infectious trigger. It might be something like Lyme, a mycoplasma infection, it might be kind of an environmental trigger.
Speaker 3:This diagnosis is much more flexible, so it's a little bit more of a gray area. But because it's grayer, then there's also the requirement that you have to have two other symptoms that come on abruptly, as they did when we were talking about pandas. And so these symptoms might be things like a sudden increase in anxiety, emotional ability or depression, irritability, aggression or oppositional behaviors, behavioral regression like I've seen kids kind of revert back to baby talk a sudden deterioration in their school performance. I've seen kids suddenly look like they have like a math learning disability.
Speaker 3:There might be motor or sensory abnormalities. It might be kind of a degradation of their handwriting. It might be suddenly they're very sensitive to even a feel of water. Again, these can look pretty broad. Or there might be other somatic signs and symptoms, like changes in their sleep, urinary frequency might increase or the kids might start wetting the bed even though they've already been potty trained. So again, for a diagnosis of PANS you would have to exhibit also at least two of these other symptoms in addition to either the OCD restricted eating or both that again kind of come on suddenly and are different than the baseline of what the child usually experiences.
Speaker 1:That was very clear, great Thank you. So, if we think about the description that you gave, the symptoms can occur in a variety of spheres. You have the basic criteria that you described with OCD and tics and ARFED eating disorder, but you can see symptoms that fall into somatic issues. You mentioned sleep. There's also more strictly medical kinds of symptoms, like gastrointestinal issues, may surface. So there's a wide variety of symptoms that can occur in addition to the requisite symptoms that you described, which is why we call this a multidimensional disorder that requires a multidisciplinary team at least to weigh in on how to diagnose and how to treat. You mentioned the acute onset, which is defined various ways, but it does come on suddenly, more suddenly than your traditional OCD, for example. And you also mentioned another key aspect that PANDAS is associated with strep, associated with strep and PANS, although the infection or the trigger may not be identified correct. Yes, yeah correct.
Speaker 1:Okay, I know you would add that the symptoms tend to ebb and flow. The symptoms may actually remit, in some cases almost completely, and then resurface, which can cause challenges in diagnosis, for example, especially if the patient has had to wait a long time to get in to see the practitioner. So it's a complicated disorder and, as you pointed out it's. I'm wondering what drew you to these disorders as a clinical psychologist or neuropsychologist, what drew you to these disorders?
Speaker 3:I was going through my training in psychology as an undergrad and then in grad school. You know, I've always been interested in the why right and we as psychologists, we often get asked this by parents why is my child dealing with this right? Is it my fault? Is it because of this situation at the school? Is that, you know, they're trying to find a reason which we all would as parents of why their child is suffering in this way. And the unfortunate thing is, for a lot of instances we don't know right. I don't know why your child is having these difficulties. But we can talk about the research and, you know, maybe part of this is hereditary, maybe part of this is situation. You know those sorts of pieces. I may be part of this situation, you know. You know those sorts of pieces, and it was very exciting to learn about pandas and pans because it feels like we're a little bit closer to answering that question than we are for other things. And I see that, while we have wonderful things that we can do as psychologists that can help many people, there's still a lot of work to be done. There's a lot of people who do not benefit from the first-line treatments, from the gold standard treatments. There's a lot of things that we're missing and I think it's very exciting to have a situation where we're focusing in many ways on children and development and putting them as the priority and saying, okay, what is going on Really, where is this coming from? To help inform the treatments so that we can not just manage the symptoms but get people better, right and heal people in a way that we have such limited abilities to do sometimes with other types of psychiatric conditions.
Speaker 3:So it's interesting my first patient was actually Kyle Williams patient. So I you know, in working with Kyle Williams at MGH, even when I was still an intern at MGH, I was assigned a patient for therapy. That was one of the patients that he was seeing for psychiatric care and that was the first PANDAS patient that I had seen. And it was amazing seeing this little boy age eight, whose symptoms would change based on other factors that people would talk about. There were not things that I usually would think to ask or to learn about a patient, right, like, oh, his symptoms are much worse this week, it's because last week he had another strep infection, right.
Speaker 3:These sorts of things that just weren't part of the way that we had talked about the psychiatric conditions in kids and I could actually see this ebb and flow of symptoms. And now certainly he still benefited from the or I hope you I don't want to give myself too much credit I'm hopeful that he benefited, or looked like he did, from the psychological care that I was also giving him in therapy as well. And there was this other element to what was happening with him that was really intriguing to see and I had to adjust what I was doing as a psychologist. I had to adjust the way that I was working with other health care providers and ultimately then now I've worked with Dr Williams in research for what, the past seven, eight years to learn more about this condition. So that was really kind of the starting point and give a lot of credit to this little kid for helping me to to learn more about this and really helped me to see where I was going with my career.
Speaker 1:Actually a light bulb went off. It sounds like when you, when you met this little boy about what's causing these, these symptoms, and how best can I treat them. So, yes, different than your initial orientation. So that's a good segue to our next question. Knowing about neuroimmune disorders, or sometimes called infection associated immune mediated disorders, can lead the psychologists or other practitioners to ask questions that have generally not been part of the assessment. You said pretty much exactly that, but they should be. I mean, once you understand what the cause may be, these kinds of questions should be included. So I'd like to bring in an article that you and well, dr Williams and a few other colleagues wrote, entitled diagnosing and treating pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections, and this drew my attention. I think I became aware of it when it was first published in psychiatristscom. The reference to this will be included in the text associated with this podcast online.
Speaker 1:As part of this article, you include what you refer to as a case vignette, and it is pretty typical case of a young girl. You refer to her as Miss K. She's six years old, and I'd like to go through that case to talk to you about how someone with your background, your understanding of pandas and pans how they would see this case. So does that sound okay? Sounds like a good plan, all right. So we've got Miss Kay. She's six years old and I'm reading here that she was in generally good health but she developed an upper respiratory infection in the summer before starting second grade. She received a diagnosis of gripe step infection from her pediatrician and she was placed on a 14-day course of amoxicillin typical treatment. Her sore throat remitted approximately three days later after being given the antibiotic, and I think I'll just insert here that, as a mother of a child growing up, I used to hope that Alex had strep, if she was going to have something because it seemed so easily treated, if she was going to have something because it seemed so easily treated. And you have the antibiotic and then it remits and you go on your merry way. But I have since learned that that is not the case for a small number of patients. Ms K would be one of them, but we don't know that yet in the story. So she had this sore throat and was treated with antibiotics. She followed the antibiotic course as prescribed.
Speaker 1:Several days after her last dose she became, and I'll count the symptoms. Maybe you can count them with me. But she became excessively worried about germs, so much so that she would wash her hands until they became raw and bled. At night she began refusing to go to bed until her mother repeatedly key word promised her that everyone in the house was safe. I imagine the mother did have to do that, as is written here multiple times. Also, she had been potty trained since the age of two and a half, but she began to experience nocturnal enuresis and related to that. Her mother reported that new worries or anxieties reported or surfaced, that she didn't want to leave the house because she wanted to be close to the bathroom and, related to that, she didn't want to attend summer camp because she wouldn't have regular access to a bathroom or to a sink, I imagine, to wash her hands. So her parents became concerned, naturally, about those symptoms and in particular that they might affect her transition to second grade.
Speaker 1:They sought guidance from their pediatrician. The pediatrician gave Kay another rapid strep test which was negative, and I'll come back to that. She was referred to for psychiatric evaluation. The psychologist that she saw diagnosed Miss Kay with obsessive compulsive disorder and began cognitive behavioral therapy. So maybe if we could stop there, if that psychologist had been you and I should make clear that this was not your case if the psychologist had been you, your case. If the psychologist had been you what would you have done differently? Beginning with seeing those, depending on how you count them, you know five or six symptoms, red flags that indicate that the treatment would be very helpful here. How would you have approached that case? In terms of questions?
Speaker 3:to begin with, yeah, yeah, that's a great question. Yeah, because it's part of our typical diagnostic intake, right, to better understand what the symptoms are. And then also, what are the things that might have contributed to what was going on. So I could imagine in Ms K's case, when they were asking about the sudden compulsions or you can call them compulsions, probably in terms of how she was washing her hands excessively Sometimes parents might describe that first as saying, well, she had been sick, she was worried about getting sick again. There's other things that you can make accountable for that, okay. But I think the things that I would be sure to ask about again, knowing about these other conditions, are some of these other symptoms that go beyond just questioning to try and figure out if that might be OCD. So, getting into those questions about has she been sick lately? Was there a recent infection? You know that's not part of our standard diagnostic interview but is a really small piece that I encourage all of the psychologists when I talk to them, and not just psychologists, licensed mental health counselors and social workers and school nurses to ask as well when they're seeing these symptoms. And then also the other questions about, in general her physical health, right, have they been noticing changes. I mean, we tend to always ask about sleep and appetite, so that'll hit on some of those pieces.
Speaker 3:But knowing that there are these conditions like PANS and PANDAS, I do always ask now about all of those ancillary criteria that I mentioned at the beginning. Even though we say you need two of seven for PANS, we often see those in kids with PANDAS too, even if they don't have to have them, and it helps us to give an indication that okay, something else is going on where we should get other medical professionals involved. So I do always ask are there changes in terms of their urination? Are they asking to go to the bathroom more often? And sometimes parents will say, oh, I didn't realize that's what it was, but I notice now at dinnertime they're always asking to leave the table. I thought they just didn't want to sit there and then they ask the child and the child is worried that they need to go to the bathroom or feel like they haven't fully went no-transcript. You know it takes a little bit of work at first, but having just the guidelines of, okay, I'm seeing a kid that either has tics or OCD or ARFID, I should definitely ask about these other things, just to rule out if it's something else.
Speaker 3:And I would encourage people in general, when they see a new patient that's presenting with some type of psychiatric difficulty, just to cast a little bit of a broader net, to kind of think open-mindedly about hey, let's just check and make sure, has there been an infection lately? How is their medical health? Have they exhibited some of these kinds of symptoms? Because if then I had had this patient and their family say yes to those, I would have done the next course a little bit differently. Right, as you talk about what they would do next, at that point I would say, hey, let's get another medical professional involved, because this might be something called PANS-PANDAS. And so then I would either refer them back to their pediatrician or potentially to a different type of medical doctor.
Speaker 3:That again, it kind of depends on the area people are in who might be mindful of PANS-PANDAS. They could be a psychiatrist, a rheumatologist, an immunologist, neurologist, and they might want to run some additional diagnostic tests, get some lab work to better understand if there might be something that's again an immunological component going on, that they might benefit from different kinds of treatment. And sometimes, even if those things don't come back positive, they might say hey, I do wonder if, even though that strep test was negative, if they should go back on an antibiotic. Maybe they didn't clear everything up, or maybe they should go on something like an NSAID, a non-steroidal anti-inflammatory medication, to help with these symptoms too. And then it opens the door to having this multidisciplinary approach. Whereas the psychologist, I can still work with them to treat the symptoms, but then I also have a medical team that's helping to determine what the cause might be and if there's an infection that needs treatment as well.
Speaker 1:Wow, Certainly, that approach would have made Ms K's life and her parents' life a little bit easier. Just to elaborate a little bit, your phrase of casting a broader net, I think, is really such a good one. You asked about previous infections, which is great, and would you ask them about or maybe it doesn't make sense at this point would you be listening for the onset of the manifestation of these symptoms? Like, did it occur quickly, did it? Yeah? Well, I guess that's the question. Well, how was it a quick onset? Because, by definition, we're of course looking for an acute onset of these symptoms.
Speaker 3:Yeah, absolutely, and I'm glad that you brought that up too, because I think it's really important to understand what the onset look like. When did they start to notice these symptoms? What type of impact was it starting to have on the child's life? Because, again, this was summertime for this child, so sometimes you don't notice the impact as much right away. So sometimes those abrupt impacts can kind of sneak up on you a little bit, because the child is able to do all of the compulsions without much disruption to their lives.
Speaker 3:So it's really important to understand what it looked like at the time, what types of things they were showing, where it was impacting them, what the parents were seeing, to get a better idea of how quickly it was actually pretty severe. And if situations had been different, is this something she still would have really insisted that she needed to do, even if it was the school year and it would have made her late to get to school to wash her hands for the germs? Would she have still done it? You know it's likely in her case, given the severity, the answer would have been yes, she would have still done it and it would have started to disrupt getting to school on time, those other sorts of pieces.
Speaker 1:So I also think it's important that what you just said, that there's usually in families there, and families are busy, there's a lot going on. There's there's soccer, there's lacrosse, there's various after school activities that are not sport related. There's a lot going on. So you may not have picked up as a parent or caregiver, may not have picked up on on until the psychologist or other practitioner brings it to your attention. How about history? I think you mentioned that as well. Is it important to ask the patient or, in the case of children, the family, about history, psychiatric or medical or more traditional medical?
Speaker 3:Yeah, absolutely. It's important to get an understanding of both previous symptoms that the child might have exhibited in the past the family history of psychiatric disorders, medical history for the child, medical history in the family as well, necessarily diagnostic. Yet to ask specifically about autoimmune conditions within the family, because more and more the research is pointing to that these kids might tend to have some type of family history, or even personal history sometimes, of autoimmune disorders. And so, again, while not diagnosed by not diagnostic, it's certainly an important element to understand the story of what might happen, what might be happening with this child.
Speaker 1:Well, you anticipated my next question and answered it with regard to autoimmune conditions. So the course of her psychiatric condition would have been different, I'm pretty confident, had you been the therapist. But let's go on. In this particular case, she began second grade and her teacher noticed that she was frequently distracted in class, brought that to the parents' attention. The psychologist who was still working with her, and the parents worked out a school-based therapy program and made some accommodations within the classroom. So that certainly helped her in the classroom and in general she appeared to be doing pretty well until she contracted another strep infection at the beginning of winter.
Speaker 1:And what happened then is that she experienced a sudden reemergence of the OCD symptoms, and this one was more complicated, actually fairly common in my experience in talking to parents.
Speaker 1:But she feared that whatever her brother touched was contaminated and thus she refused to enter rooms where her brother had been. That obviously would greatly impact the family, in that the brother is now part of this and the whole family becomes a part of this, either accommodating her fears or trying to prevent them from occurring, both of which cause conflict within the family most likely. She also began to exhibit a strong aversion to certain foods and required excessive reassurance from her family that her food was safe to eat. That's another one of the symptoms that you mentioned that there becomes a different relationship with food in some cases of PANDAS or PANS. Then the psychologist referred Ms Kay to a team including an immunologist and a child psychiatrist but it could have been a psychologist, certainly who diagnosed her with PANDAS and they gave her another course of antibiotics, as you mentioned, and also began the treatment with non-steroidal anti-inflammatory drugs, otherwise known as NSAIDs. Can you talk a little bit about why are NSAIDs given in cases of pandas and pans?
Speaker 3:Yeah, that's a great question. So part of the hypothesis around pandas and pans is that there's some type of inflammation, right? So we know that certain parts of the brain, like the basal ganglia, have been implicated in obsessive-compulsive disorder, and so part of the hypothesis is that there's something different about these kids that get these strep infections, where it's affecting them differently and then it's affecting their brains and there's potential inflammation happening. We've been trying to work on neuroimaging studies to better understand what that looks like and to kind of pinpoint what's going on. That's also kind of in the works.
Speaker 3:But we have found that giving kids anti-inflammatory medications help their symptoms to subside, which is part of where this hypothesis comes from.
Speaker 3:Right, if you're giving somebody anti-inflammatory medication and then it gets better, you know, potentially there might have been some inflammation involved, and so some of the NSAIDs have been known to be able to cross the blood-brain barrier and so they might actually be providing some effects in terms of kind of re-regulating some of these symptoms. And actually what we've seen in clinic is, for the kids who respond to these kinds of treatments, oftentimes it tends to be very quick. We've got some research going on that shows that the positive effects of adding NSAIDs to antibiotics is kind of above and beyond just the effects of antibiotics as well, because in that way you're treating both the infection but also the immune responses that the body has generated in response to that infection. So that's why we think that it might be beneficial to do these two in tandem and we'll work on research to better provide some proof around this right, rather than just anecdotal notes of what we've seen in clinic.
Speaker 1:We heard a little bit more about that in the researchers brunch that we that the Alex Manfield Fund hosted and you attended with 15 other researchers the other day when Dr Williams presented your work and it's it's pretty compelling. I'm hopeful that you will be able to continue that, and I would love to to have the Alex Manfield Fund support some of that. I think well, the results look very promising and if we can use something as relatively benign as an NSAID, I think that that's a good way to start that that's a good way to start.
Speaker 3:Yeah, and I just to add to that, I am in particular, really excited about the promise of this because I know you've spoken with other researchers and people have listened to your podcast. You know have an understanding of, in some ways, the different types of treatments that are available to kids with PANS and PANDAS. But what might be really exciting about NSAIDs is, like you said, it is generally pretty benign. I mean, people hear NSAIDs and they might not realize that it's something that they're taking over the counter already as different types of pain medicine, and so it's something that parents are familiar with. They've taken themselves, maybe their children have taken for other things.
Speaker 3:It's relatively cheap and easy to get and so it also, I think, gives an opportunity of bridging those difficulties in terms of access to care that you know it can be so hard to find some of these really specialized treatments. And wouldn't it be amazing if we actually had something that you could get at any drugstore? That might be helpful. And I don't want to oversell because, again, we don't have all the research and we don't, you know, it wouldn't be fair to the kids suffering from this if we were going entirely off of you know anecdotal pieces, but I'm glad that people are supportive of this line of researching because I do think. I do think it would help not just kids be able to have another thing to help treat their symptoms, but also because it's one in which the care could potentially be widely accessed, to be able to do so and cost efficient.
Speaker 1:Exactly. I mean, we all most of us at least have those very treatments in our medicine cabinets, so very easy access for everyone. We're talking about the importance of identifying children. In this case we're talking about children who may have PANDAS or PANS, because it's so important to begin treatment early, begin effective, appropriate treatment early, and that won't happen if we don't distinguish primary psychiatric disorders from secondary, what are referred to as secondary disorders like PANDAS and PANS. The sooner you begin the treatment, the better the prognosis, right? So let's talk a little bit about treatment, because I'd like to get into what psychologists in particular have, what kind of tools they have in their toolbox that other practitioners don't.
Speaker 1:Most psychiatrists don't have the kinds of tools that you have in your box. I think you hinted at this earlier in your article. Talks about it why it's important to work together Psychologists who don't prescribe treatments for individuals but work with another medical professional to prescribe those treatments. It makes for a great relationship. The psychologist can well do the kinds of things we're going to talk about in a few minutes and the psychiatrist can take care of the more traditionally medical treatments.
Speaker 1:And I say psychiatrist but, as you mentioned, neurologists, rheumatologists, infectious disease doctors, immunologists there's a whole range of disciplines that can effectively work in this area, and then leave the more hands-on kinds of treatments to psychologists and other types of mental health clinicians. So you mentioned, though, in terms of treatment, we mentioned antibiotics, and the rationale being that there is an infection or could be an infection, and if those don't work, then the treatment is elevated to more complex kinds of approaches, which would be IVIG, rituximab and, if it were possible to find, plasma for recess. So what, though, do psychologists bring into this, into the picture here, in terms of treatment?
Speaker 3:Yeah, and you've outlined so well that this. You know, because of this multimodal approach right and I think you know this first came from the PANS Consortium years ago that we think about the symptoms, we think about the behavioral and psychiatric symptoms, we think about the immunomodulatory treatments and then we think about how to manage the infections. And so really, aside from what we talked about earlier and potentially being hopefully a very skilled diagnostician that can help to identify some of these kids, diagnose them and get them in treatment, potentially with the providers that can help with the immunomodulatory therapies and then managing the infections, then the psychologist can really be helpful with the behavioral and psychiatric therapies and, just like with the other types of therapies, it varies in terms of how severe the child is at the time right and what their needs are. We know that different types of psychiatric treatments, like cognitive behavioral therapy and under that umbrella, exposure and response prevention, can be really helpful for things like obsessive compulsive disorder and even the OCD symptoms within this population. For kids with tics, we know that habit reversal training can be really helpful, and for eating disorders and things like ARFID there's also behavioral treatments that can be really efficacious. And so certainly psychologists and then licensed mental health counselors and social workers can help in administering those types of treatments. But there's some situations where a child cannot necessarily engage in outpatient explosion response prevention treatment right, given the severity of where they are at the time, and so there's certainly ways that those treatments can be scaled up as well. So there's some children that will be candidates for more like intensive outpatient programs around those psychiatric symptoms, even residential treatment for some children that are so severe.
Speaker 3:But then I think that psychologists and those other mental health care professionals can also be really helpful with other aspects of care right, instead of just what we think of as the typical psychotherapy types of treatments, because the advantages that the psychologists and the other mental health professionals have is we can also help work within the system in a different way. Within the system in a different way, Our treatments are not just the child takes, not just but that the child takes a pill, but also that it can take into account the whole system that the child is in to help them to function when they are dealing with this really challenging condition, and so that might include getting neuropsychological assessment to better understand how they are cognitively functioning at the time. Are there certain learning disabilities. Are there different types of sensory sensitivities, those sorts of things that can then help direct treatment towards an occupational therapist to help with sensory sensitivities, different types of school supports that the child might be getting to help with. If there's different types of school supports that the child might be getting to help with, if there's different types of almost learning impairments that have come up in the meantime. Sometimes I describe this to families as kind of like a fog. Right, your child has these abilities still, but there's different things about this condition that are kind of creating a fog over their ability to utilize them the way that they usually would in the world. So some of these other providers can help the child to access these things in the meantime, whether it be school personnel helping with supports, occupational therapists, other types of professionals that way.
Speaker 3:And then I think the other part to consider is the family system and how much this is impacting other people around them. I'm so glad that you read the part of the vignette as well that mentioned how her symptoms were directly impacting her ability to even be around her brother. For Miss K, and even if the symptoms are not such a clear line between how it's affecting a sibling. It is affecting the family system in so many different kinds of ways, and so psychologists and other mental health professionals also can serve a very important role in helping the family to manage those sorts of pieces as well.
Speaker 3:So there can be therapists that work just with the parents to help them to understand how to manage the child's new difficult behaviors that they're presenting with.
Speaker 3:They can work with the sibling essentially to help the siblings learn the way some therapists are very focused on this how to help siblings of individuals who are dealing with medical conditions. Think of siblings going to therapists if, like their sister, has cancer, right, or if their sister has some type of or brother has other types of chronic disorders. That's pulling a lot of the attention from the family. It can be really helpful to think of the needs of the other siblings and people in the family and of course you know I'm not limiting this to a traditional family, which is parents and siblings, right, and grandparents, other types of caregivers in the system, other types of people that this is affecting as well, because even if the child is not at the place that they can take in the therapeutic supports, there can be some supports for the system that can help the child to function more manageably and help the rest of the family to function in the midst of times where these symptoms can be really, really challenging.
Speaker 1:Wow, you covered so much there. Let me just reinforce some of the things that you said. Again, this is a complicated disorder that affects many systems in the body and also multiple situations are impacted by this particular disorder. So just underscoring that as you have. So just underscoring that as you have, that one size treatment, one size does not fit all.
Speaker 1:You really need to be an astute mental health professional to recognize all the ways in which this disorder is manifesting itself. So you learn which practitioners you might want to call in. Are there stomach aches on a regular basis? Should we call in a gastroenterologist? Is there constipation on a regular basis? So should we call in a gastroenterologist for that, or again consult the pediatrician? So I think you said this as well. I didn't share my notes with you, but we seem to be on a lot of the same track here. You really do need to be a very skilled diagnostician and to do that I always say that you need curiosity and you need perseverance. That those two qualities in a practitioner whether it be a psychologist or any other type of mental health professional or a physician that those two qualities are what's needed to get to the bottom of what's happening and to understand what all you should be looking at in terms of treatment and the family I think, as you mentioned, is so incredibly important.
Speaker 1:I think we have to remember that these symptoms came on suddenly. Prior to that, most parents or caregivers describe their children as being perfectly quote unquote normal and healthy and well behaved and everything that you would want in a child. And then suddenly, without explanation, they're different. So just to handle that part, I think working with the family is really important part. I think working with the family is really important. And then navigating the medical system and dealing with the misdiagnoses that are very likely to occur and the failure to diagnose at all, and how that might feel when you know that there is something wrong with your child oh, that there is something wrong with your child.
Speaker 1:The financial impact of this disorder is unbelievable. It's incomprehensible to most people. I spoke with a parent recently who said that their family spent $91,000 after insurance in one year. $1,000 after insurance in one year. This is a very complex case, but that is a staggering amount of money and how do you deal with that? How do you deal with not having the money to pay for the required treatments? There's so many different issues and if I didn't hear them directly from multiple parents and patients themselves, I wouldn't I really wouldn't be able to believe it. So having someone like you help them navigate all of these problems, I think, is incredibly important. Now you mentioned cognitive behavioral therapy and exposure response prevention. Could you give us an example of how you might approach something that Ms K had, how you would use cognitive behavioral therapy?
Speaker 3:Yeah, so the basis of cognitive behavioral therapy is that there's a cognitive piece how we're thinking about things and the behavioral piece of what we do. And so even for kids as young as Miss K, the first step that can be really helpful is psychoeducation and helping her to understand what is happening right. Especially for someone like her where this came on so suddenly. There can be so many different explanations that children can generate for why this is happening Right, and it can be really reassuring to help them to understand hey, this is something that we have some understanding about, Right, we call it OCD or, you know, in the case of PANS Pandas, we call it PANS Pandas. We've seen this before. We have some ways that we can help. That just in itself can really help kids to feel more confident in themselves, help externalize this from it being quote unquote something wrong with them that they can feel really bad about, and then helps give them some hope that the people around them can start to understand them and can help them, and so it helps with the motivation for treatment and then for the pieces that can then get more challenging. It's about helping the children to understand what's happening in their bodies so that they know to recognize that it's OCD versus the thoughts that they should listen to. Because it can be very hard when suddenly your brain is telling these things that don't seem to make sense to you or to other people, and so it takes some practice to understand what those thoughts are, to accurately identify what OCD is. So with the younger kids we often come up with some type of name for what this is right, this other thing in your head that's telling you these crazy things, so that then you can help to learn ways that you can fight back against that right. And so then it starts to learn skills about how to approach those types of either thoughts that you're getting or the urges that you're getting that we're calling OCD. That are the things that are getting in the way of your life and the things you would rather be doing. And then it's about practicing those things, not starting with the things that are the most difficult, but figuring out a hierarchy of things that bring on this OCD right, or things that this OCD looks like. And so you start with things that are challenging a little bit but still probably have a good chance of success, right.
Speaker 3:So the child then has an understanding of what's going on. They have their skills to use when they're starting to feel distressed and you try it out and you go for it. And that might be things like yes, you can wash your hands, but you can only wash your hands two times instead of five times. And how do you deal with that distress that happens when you're not able to do it the of five times? And how do you deal with that distress that happens when you're not able to do it the additional three times?
Speaker 3:And then you get used to seeing that you survive that distress, right, you understand what that looks like and you get more confident in your abilities and your skills to fight back on those types of things. And so then you just kind of up the ante and you keep working at the ladder to help the kid reach their goals about, you know, kind of reclaiming their sense that they have control over these types of symptoms, Even though sometimes OCD is like playing whack-a-mole. I mean, even with Miss K, right, it came up as a different symptom. The next time, right, she got strep. Again, it looked a little bit different, it was something different. It's also kind of helping kids and parents to recognize what's going on, to have the agility to adjust to those different ways that things like OCD can get in your way sometimes.
Speaker 1:And they're very effective approaches right.
Speaker 3:Yeah, yeah, it can be really effective, and I think what's tricky is sometimes timing right that I hear from some families sometimes of oh, this didn't really work, and when we talk about it sometimes it was a little bit more of what's going on with the child at the time, like you alluded to earlier, that there's so many different treatments available right, and parents can spend so much money doing different kinds of treatments.
Speaker 3:There's, fortunately, a lot of things out there and it can be totally overwhelming. And so I think part of the difficulty is there's not one course of what looks best for everybody, but you know it is a matter of sometimes the nuances and working closely with your providers of what's the best time to try different types of things. When are kids ready for the cognitive piece? When is it a little bit more of just parents learning more about what OCD is recognizing when they're perpetuating OCD versus when they're helping the kid fight back about it? So there's different ways that this can look for different families and so it is not going to work for everybody, but it can be really helpful and really effective for a lot of kids and families.
Speaker 1:You touched on so many things With regard to parents. They usually have no idea that their response to the given symptom may be actually reinforcing it. So I think you alluded to this. But a role that psychologists can play is just enlightening parents about that can play, is just enlightening parents about that so that they can see what and learn what they can do differently, so that it's not quote unquote reinforcing the symptoms. And I don't mean to suggest that these symptoms are a result of parents or anybody else reinforcing them. That is certainly not the case. But there is often a better response to a given symptom that parents would be glad to know. Parents and older patients in general are sometimes reluctant to bring in treatments like SSRIs selective serotonin reuptake inhibitors. Can you talk a little bit about when those are valuable, because certainly they are valuable under certain circumstances and are part of the treatment guidelines from the consortium.
Speaker 3:Sure, ssris are one of the first lines of treatment for individuals who are diagnosed with anxiety, with obsessive compulsive disorder, and so, understandably, as we think about again with a three-pronged approach, treating the behavioral and psychiatric symptoms, it's, I think, something to consider for a lot of patients. I think there's sometimes a sense that it's a psychiatric treatment and so there should be a focus instead on the quote, unquote medical treatments. Again, they're all medical treatments, but thinking about the source and the causes of it, thinking kind of from a broad lens and I love the way that they thought of this in kind of the three aspects, so we can think about how to cover different kinds of bases of how to best help a child. I do, and I mean I have seen how SSRIs can be really helpful for some children in addressing the symptoms and it doesn't undercut the other aspects of trying to help assist in the immunological aspects and treating the infection. It can be an adjunct piece that can really help some individuals to get some better control over their symptoms.
Speaker 3:Because it's interesting, because even as we talk about CBT and exposure response prevention, even in non-PANS-PANDAS patients it takes close collaboration between the psychiatrist and the psychologist or the other mental health professionals that are doing the CBT or ERP to get a balance of those sorts of things, because there's some kids that are so severe with these symptoms it is very hard to be able to engage them in any type of therapeutic work.
Speaker 3:And I have seen patients who are on an SSRI, where it helps to lessen the severity enough so then they can engage in the psychological treatment, that they can really work together in tandem so that kids are both learning kids not just kids, but kids and adults are learning the skills that can be very helpful from therapy so that they know how to address these symptoms, but then also their brain is working in a way where they're better able to do that and learn that. So it can be a really helpful combination that can make actually both of those potentially more effective for the child. Again, not for everybody, but research shows that for a good number of individuals the combination can be really successful.
Speaker 1:Right. So one more question about the role of psychologists. In our correspondence you pointed out to me that some of the symptoms or concerns that I mentioned can be reconceptualized, and I was asking about separation, anxiety or reluctance to go to school, which is often misnamed as school refusal, which is, I don't think, captures at all what's going on there, except at a very superficial level. So can you help us think about, well, either separation, anxiety or reluctance to go to school a little bit differently?
Speaker 3:Sure, yeah, because I mean you know, oftentimes when talking to parents about these sorts of things it gets framed as you know, as you're looking for the different types of anxiety or doing your thorough intake. Separation anxiety question would be something like is the child more afraid of being away from you that you would think is typical, or do they refuse to go certain places because they're worried about being away from someone? Are they having a lot of thoughts where they're very concerned about your safety or their safety, and so parents might say yes to those and then you can think about in terms of separation anxiety. But, like you alluded to, there can be a lot behind that. Right, there's a lot of these kids that I've seen with PANS-PANDAS, where they do have a lot of separation anxiety. But when you really kind of, I say, pull back the layers of the onion on this, it's potentially sometimes that they're having intrusive thoughts where there's some pieces of where they think something is going to happen to them unless their parent is there to do whatever part of they need for the compulsion. So it's more complex in terms of thinking about this is actually an OCD symptom for them that their parent is wrapped into.
Speaker 3:Or you have kids where I mean gosh, what we've talked about in terms of these sudden changes that these kids have to experience and deal with. You know, for a lot of kids that also makes them cling to things that make them feel more comfortable, right, cling to things that make them feel more comfortable, right. And so sometimes that can be what it looks like in terms of, you know, not wanting to go to school and school avoidance, because there'll be the situations that come up at school and they don't know who to turn to at school for help, or their symptoms are going to come up and you know they would feel much more comfortable if they were at home with a parent when those types of symptoms come up. And so sometimes I think I've seen kids who have potentially gotten missed because people say, oh, I don't see OCD or tics or ARFID here, when really some of these other symptoms that they're showing might really be OCD at its core.
Speaker 1:sometimes In some ways you're really a detective, absolutely yeah, which I hope piques the interests of other psychologists. This is a challenging area, but it's also a really rewarding area for those who go into it. You can really make a difference. So we're almost at the end here and I want to ask you a couple of other questions. We've talked about children for the most part, because it is children who for the most part experience and are diagnosed with pandas and pans, but young adults and or adolescents and young adults sometimes who are off on their own. In the case of my daughter, she was at college when the symptoms of pandas she was diagnosed as having pandas because it was related to a strep response, although there was also mono there too, and she's older, so someone else might have diagnosed her as having PANS. She was alone, she was by herself, so there was nobody else looking for those symptoms, and she did tell me about a few of those over the telephone. For example, she talked about being under so much pressure that if someone these are her words if someone, if something got in the way between her dorm room and her economics class, for example, that she would get frustrated because she had to go around the truck or whatever it was that was blocking the pathway, but what she didn't tell me until a few years later. She said that you remember I used to tell you on the phone how frustrated I would get, and then I'd have to start recounting my steps and I said, oh no, you did not tell me that part. And she said, oh, I'm sure I did and I know she didn't. It would have put it into an entirely different category for me and in her case I think that it also the symptoms that she eventually had also manifested slightly differently than some of the ways that we're talking about now, as it would be not surprising in an older person, in that she recognized the anxiety that she was experiencing in social situations, for example, and told me that she knew if she drank a little more, that that would reduce the anxiety, and Alex was not generally a drinker.
Speaker 1:But if I hadn't had a daughter who expressed what's going on, and even in the case of having this daughter, who was very open, I didn't hear about the counting steps. So it becomes really difficult when the young adult is not with you, and I think in her case the onset was as a young adult. But even when you have your older child going off to college, you're not there to, as the parent or as the caretaker, to make sure that they are being mindful of what to do. If they do have strep, what to be watching. Are there any guidelines that you would give parents whose children let's make it simple, children who've had PANDAS or PANS now are doing very well but they're going off to college. Are there any guidelines that you would provide them?
Speaker 3:Yeah, that's a really great question and I think, a lot of things that people are dealing with that I think. I think there hasn't been enough time and effort put in yet to understand these kids that are I still I'm calling them kids right their kids are transitioning then to take over their own care, and so I think there's models and other aspects of medicine and pediatric psychology that we should pull more into when we talk to these kids, because I think, especially for the individuals who have relapsing and remitting courses, you know there are as opposed to someone that potentially has type 1 diabetes right where they're dealing with this every day, and so they have to be knowledgeable about their condition, they have to know what to look for so that they know exactly what to do when such a symptom comes up, those sorts of things, when such a symptom comes up those sorts of things. I think there is room for having more education with kids who are susceptible to these types of conditions, so that they understand more of what's happening in their bodies, what to look for, what to do if they see different types of conditions, because I mean, you know, these are very smart individuals and it's hard for anybody to recognize things like that in yourself, but I think, the more that we can give them an understanding of okay, these are the things to look for, the way you look for some other type of chronic condition that might exert itself again. These are the things to look for, this is the course to take, this, you know, talk to your parents that you stay connected to your medical professionals, those sorts of pieces. So I would say, you know, while there's many individuals that once they reach college, they never deal with this again, and that is fantastic, right, they're unfortunately a subset of these kids that will still deal with these pieces and you know, I think it would be great to figure out a plan for them to say, okay, let's go through the education that we had.
Speaker 3:Maybe it was when they were younger so they didn't fully understand it. Let's think about how to prep you to say remember, this is a possibility, this is what to look for, this is what to do so that they have that knowledge base new in their kind of older brain. They can understand it better, they can make these connections and they're getting more autonomous and independent. Help to reinforce and empower that and give them the information that they need so that they can recognize and help take care of these things in themselves as well. And I do want to say that I am encouraged that it's almost like a generational piece where, unfortunately, you know 20 years ago the people that would have been diagnosed with this there was so much less knowledge, there was so much less as they were kind of going into adulthood Now.
Speaker 3:I am so encouraged that I meet so many young adults who have dealt with this at different points in their lives, who have dealt with this at different points in their lives, and they are so, I guess, passionate about helping other people who have had to deal with this that I've talked to people where they've presented in their college classes and other people have spoken up and said, hey, I have this too that it's amazing how I feel like there actually could potentially be support networks in this emerging adulthood period of time that we can also help to build and utilize as well, so, as someone making that difficult transition to be able to handle these types of medical conditions and psychiatric conditions that they have independently, that there might be even more of kind of a grassroots effort to help them find the connections to know how to navigate that where they may not be totally on their own the way they might have a long time ago, because so many individuals have had to deal with this and there might be a way, even within you know, college campuses or something similar to help them to be able to find supports where they're at and people who understand what might be going on and can help them.
Speaker 1:I completely agree with you. It's radically changed since Alex died with her, her symptoms, which were on the mild side, which in many respects makes it more difficult to to diagnose. But the most parsimonious explanation was that Princeton University is a stressful place, as are all college campuses, and so the symptoms that she surfaced with made sense within that broad category of pandas and pans the infection part, for example, and the relatively sudden onset and the lack of history of psychiatric disorders or in her or in her family. We might have looked at it really differently, but I agree.
Speaker 1:I think that there's there are many reasons to be hopeful that it will be much less likely for people to slip through the cracks. More people need to be educated general public, physicians, psychologists, everyone. But it's so much better now. So that brings me to my last question. Dr Juliet Medan, who's the co-founder of the Neuroimmune Psychiatric Disorder Clinic at Dartmouth, spoke at the recent dinner that the Alex Manfo Fund had and you were there and she spoke about a paradigm shift that she sees happening in psychiatry. Do you see a paradigm shift happening in the understanding of psychiatric disorders?
Speaker 3:I do. Yeah, I'm really hopeful. I mean, it used to be when I would present on this years ago. Everyone would be scribbling quickly to take notes right, just even to talk about what PANS Candles was. And now I feel like people come up afterwards and they're like, oh yeah, I've had a lot of cases too. Can we talk through these? It's very different.
Speaker 3:I think that a lot of the education has gotten out there. I do think the American Psychiatric Association has done a nice job in that they do require APA approved clinical psychology programs to have brain and behavior classes that everybody has to take. So there is an educational piece in terms of helping psychologists to understand the integration of, you know, brain and behavior. And I think the COVID pandemic has also helped us to see a little bit about how different types of infections can lead to psychiatric symptoms and how to, you know, ask those questions differently and how to help support patients on that.
Speaker 3:I do feel like the paradigm shift is happening and people are being open minded about what's the best way I can support my patients, right? I heard somebody say once on a PANS consortium call that you know, when someone was like, oh, I don't believe in pandas, they said well, it's not a religion, it's not a do you believe or you don't believe, and so that's what I encourage people to think of. It's being open-minded, it's asking questions, it's being the detective to say what might be going on with my patient, and let me not rule out anything that could be something that would have been, or that could be, a benefit to them or could give us another avenue that we might be able to help address treatment.
Speaker 1:Great, I hope you're right and I would like to continue our conversation about what specifically we can do to help psychologists become more knowledgeable about this subject, and I know that there are a lot of other psychologists who are interested and you've been so informative today and so interesting. I thank you from the bottom of my heart for being here and for sharing your knowledge.
Speaker 3:Thank you very much, dr Adore, thank you very much Susan for having me and thank you for helping to promote this knowledge. I mean, I think, like you said, this is such the key for so much of this it's helping to promote the knowledge and the education. And so thank you again for seeing the value in the voice of psychologists as part of this discussion and thank you for all of the work that the Manful Fund has been doing to help support the research and to help educate families and other providers about this condition so that, like you said, we can catch it earlier and then kids can have a better prognosis because of it kids and young adults and then the kids can have a better prognosis because of it, kids and young adults.
Speaker 1:Thank you for those kind words and thank you for all your help, and I look forward to continuing to work together. Yes, me as well.
Speaker 2:This concludes Episode 13 of Untangling Pandas in Pants. Thank you for listening. For more information about Pandas and Pans and the Alex Manful Fund, please visit thealexmanfulfundorg. The content in this podcast is not a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition.
