Untitled, p.14
Untitled, page 14
separate intervention. Finding the root cause and addressing foundational
health first is essential. Investigating and treating Strep, Mycoplasma,
viruses, yeast/mold, Lyme, and co-infections (especially Bartonella), as
well as metabolic triggers such as anesthesia and pesticide exposure, are
essential to successfully treating the abrupt onset of any of these
symptoms.
Treating Tics
Natural Medicine
Magnesium
In the realm of vitamins and minerals, magnesium is a powerful
natural intervention to help allay tics. Some children with tics triggered
by autoimmune encephalitis have less than optimal magnesium levels.
While not quite at “deficiency” status, magnesium insufficiency is very
138
Nancy O’Hara, MD, MPH, FAAP
real and can be very serious, leading to musculoskeletal pain,
constipation, and a heightened sense of anxiety.398
Start with the diet first, if possible. Some of my favorite
magnesium-rich foods include almonds, Brazil nuts, pumpkin and
sunflower seeds, spinach, avocados, and even dark chocolate. Chocolate
almond butter smoothies with a handful of spinach thrown in for good
measure work wonders for less adventurous eaters! Our chapter on diet
and nutrition and our mentoring program on nutrition and autoimmune
encephalitis can provide other fun and effective dietary concepts and
recipes.
Often children with tics require more magnesium than can be found
with nutritional interventions alone. Magnesium glycinate is quite gentle
on the gastrointestinal tract and fairly well absorbed, so that it may be a
good initial supplement choice. If a child is constipated, consider
magnesium citrate, a sometimes more irritating but cleansing preparation,
to improve both bowel function and increase magnesium stores. If brain
fog and memory seem to be an issue, magnesium threonate might be a
good choice, as this form has been shown to calm the brain more
specifically. Magnesium taurate and magnesium oxide can also be good
choices, depending on the child’s presentation, including Autism.399
Dosing depends on the weight and age of the child, as well as blood levels
(RBC magnesium and ionized calcium), which should be periodically
checked.
Finally, other administration forms, such as IV and topical, can also
be considered.400 Because magnesium is well absorbed through the skin,
Epsom salt (magnesium sulfate) baths are often included in my treatment
plans for children averse to taking oral medicines. Magnesium baths
combined with baking soda can promote healthy detoxification. Adding
one-half to one cup of each to a warm bath just before bed can become a
139
Demystifying PANS/PANDAS
soothing part of a family’s nighttime routine. The calming bath helps to
induce a good night’s sleep, which is critical for not only everyone’s
sanity but also for restorative detoxification support. If a child does not
take baths, this can also be done in a foot bath or in a spray bottle (putting
one-quarter to one-half cup of Epsom salt in a large spray bottle of water)
and using this during a shower or after a swim or exercise.
CBD
Cannabidiols, especially hemp oil, can help decrease tics and manage
inflammation and anxiety, as described in other chapters. Although it is
expected that cannabis may help any anxiety-based disease, cannabis has
been shown to specifically reduce motor and verbal tics due to Tourette’s
(and, by extension, PANS/PANDAS).401 As this intervention has gained
in popularity, there are hundreds of brands available to consumers, each
featuring varying amounts of CBD, THC, or full-spectrum cannabinoids.
It is essential to work with a qualified practitioner and utilize a trusted,
researched, and effective brand to safely administer this supplement.
Nutraceuticals and Herbs
N-acetyl cysteine, or NAC, as discussed in greater detail in our
chapter on OCD, is a “semi-essential” amino acid, meaning the body
makes some amount naturally. Still, it must also be consumed in the diet
to maintain optimal levels. This amino acid increases glutathione,
promotes natural detoxification and antioxidant support and is also an
important respiratory tract decongestant. As with OCD, research shows
that NAC, at doses of 600-2700 mg daily (depending on age, weight, and
symptoms), can alleviate anxiety402 and tics.403
Other remedies to consider with tics include the following:
• GABA (gamma-aminobutyric acid): is an inhibitory
neurotransmitter that helps to reduce neuronal excitation and
140
Nancy O’Hara, MD, MPH, FAAP
excitability.404 Because exogenous GABA does not easily cross the
blood-brain barrier, L-theanine can often help its transport.405
• Adaptogens, such as ashwagandha and rhodiola, help to alleviate
adrenal stress, which may impact the occurrence of tics (refer to
chapter on Anxiety for more information and research)
• Methylated folate, especially in those with Cerebral Folate
Deficiency or significant MTHFR defects (refer to chapter on
Anxiety for more information and research)
• Calming agents and sleep aides such as valerian,406 chamomile,407
and passion flower (also refer to chapter on Anxiety for more
information and research)
Pharmaceuticals
In addition to the foundational interventions that reduce inflammation
and stabilize brain function discussed in other chapters, consider these
targeted medicines. Antihypertensives can help in multiple forms: alpha-
blockers like Clonidine408 and Guanfacine409 can help reduce tics and help
with ADHD symptoms, and beta-blockers such as Inderal and
Propranolol can reduce tics and anxiety, as well as confounding
symptoms of dysautonomia (more in the Anxiety chapter).
Neuroleptics or antipsychotics such as Risperidone, Pimozide, or
Aripiprazole can be used, too. A 2011 study found Risperidone as
effective as Haloperidol in treating tics. It may also effectively treat
PANS/PANDAS
comorbidities
like
obsessive-compulsive
and
aggressive symptoms.410 Keep in mind that side effects for this entire class
of drugs include drowsiness, shakiness, weight gain, blurred vision, dry
mouth, constipation, and exacerbation of twitches, as in tardive
dyskinesia. Discuss these negative effects with families before
141
Demystifying PANS/PANDAS
prescribing to manage expectations better. As always, start low and
increase slowly, only as tolerated and necessary.411
Anticonvulsants such as Levetiracetam are usually used to treat
partial-onset, tonic-clonic, and myoclonic seizures but can also be used
to decrease tics. It may be necessary to order an EEG in children with tics
before considering an anticonvulsant for treatment.412
SSRIs such as Sertraline and Fluoxetine have been used in the past
but often do not specifically address tics. If they are not helpful in other
ways, such as reducing anxiety, they may only cause sedation and can
even exacerbate tics. For these reasons, this class of drugs is not among
my top picks to consider for tics associated with PANS/PANDAS.413
Movement disorder treatments like Tetrabenazine affect dopamine,
serotonin, and norepinephrine levels in the brain. Although this drug is
most often used in people with Huntington's Disease or other conditions
with rapid repetitive movements, it has also been shown to improve motor
and vocal tics.414
Lastly, Botox. Experimentation on Botulinum toxin injections’
effects on movement disorders predates its use in cosmetic medicine, and
multiple decades of research have shown these injections into the eyelids,
neck, and vocal cords can reduce uncontrollable winking, blinking, head
shaking, and vocalizations. Although these are not licensed uses for
branded Botulinum toxin injections, they may be administered by an
experienced practitioner with a signed informed consent. The effect is
transient, lasting up to 3 months, but may still be worth consideration in
select patients.415
142
Nancy O’Hara, MD, MPH, FAAP
Lifestyle Factors and Complementary Therapies
Diet
“Food is medicine” is a theme of our practice and goes well beyond
treating tics, OCD, anxiety, or any of the behaviors or symptoms we
discuss in this guidebook. Healthy eating is important for the entire
family. Eating as many whole, unprocessed, unrefined foods as possible
is critical. A diet high in healthy oils, vegetables, fruits, and protein is
key, but a diet high in protein can be especially important for children
with tics. Encourage meals that include meats, eggs, nuts, seeds, and even
protein powders if necessary. Children in my practice have found
significant benefits with chicken, beef, and calves' liver, and our families
have found creative ways to get them to eat it! Our mentoring program
includes recipes and handouts with multiple kinds of wonderful
suggestions.
One key nutrient in a protein-rich diet is choline. This essential
nutrient can decrease tics by supporting the growth and myelination of
brain cells, producing phospholipids (a major component of cell
membranes), and making acetylcholine (to support mood, memory, and
muscle control), and encouraging methylation as a precursor to betaine.
The best source of choline is eggs, but if your child is intolerant of eggs,
consider other animal protein sources, such as brussels sprouts,
cauliflower, and nut butter, to meet choline needs.416
In general, we want to focus on foods that actively decrease
inflammation and minimize foods that can exacerbate it, such as gluten,
dairy, eggs, corn, high fructose corn syrups, and artificial chemicals,
colorings, and additives. Often elimination diets are the best way to figure
out if a food may be exacerbating a child’s symptoms. Although testing
can be done to identify and address food allergies, intolerances, and
sensitivities, elimination trials are a cost-effective, more accurate, and
143
Demystifying PANS/PANDAS
truly effective way to pinpoint foods that may be exacerbating a child’s
tics. Elimination diets involve removing one food or category of food for
a period of time to see how symptoms are impacted and reintroducing it
carefully, often in an overindulgence or “pig-out,” to confirm its impact
on sensitivities. Of course, with true IgE allergies, RAST or skin testing
may be necessary, and a pig-out is not appropriate or safe. Thus, it is
important to ensure that you and your families understand the difference
between IgE allergies and IgG sensitivities or intolerances when
discussing and attempting elimination diets and reintroduction. The
elimination period for food sensitivities and intolerances is often one to
two weeks, but for dairy, it should be three weeks, and for gluten, three
months.417
Tips for a successful elimination diet:
• Keep a meticulous food diary/log to track effects and responses.
• Be aware that as tics may wax and wane, it may take a few attempts
of removing and reintroducing food to determine its effect on
symptoms.
• After the period of elimination, especially if you are not sure if the
removal helped, overindulge on the offending food (we’re talking
two to three servings per day for two to three days) when you
reintroduce it to see if this aggravates the tics. This is the pig-out
phase!
• If you find no change in symptoms when you remove the food and
no aggravation when you reintroduce it, then this food or category
is most likely not a factor for that child.
• With any concerns about eating disorders, be extremely cautious
with elimination trials or diets and work with a qualified
practitioner.
144
Nancy O’Hara, MD, MPH, FAAP
Therapy
I would highly recommend working with a therapist trained in dealing
with children with tics, particularly a Cognitive Behavioral Therapist
(CBT). Please refer to the Neurotherapy chapter and our mentorship
program for more information. As a practitioner and parent myself, I can
recommend some helpful therapeutic tips I have picked up along the way,
such as:
• As much as possible, reduce stress, anxiety, boredom, and most
especially, fatigue. A good night’s sleep is critical!
• Ignore tics as much as possible; focusing on them only accentuates
the stress and involuntary movements. Do not punish tics or use
bribery to try to control them.
• On the other hand, do not “feed the beast.” A child does not get a
pass on chores or household or school responsibilities because of
their tics, anxiety, or OCD.
• Reassure the family and the child. Do not blame or shame a child
with tics.
• Let teachers, coaches, and other adults know about tics so they're
aware of them and know how to react or not to react when they
occur.
Countering Tics
Replace or counter tics with appropriate interventions, such as playing
the drums (you’ll be pleased to learn that there are electric and soft drum
pads to minimize the noise), chewing gum, humming, or whistling.
Engaging in intentional activities that keep your hands busy, such as
knitting and hand play (as with squeezing stress balls or finger knitting),
can help engage children and minimize tics.
145
Demystifying PANS/PANDAS
Electromagnetic Frequency
Consider reducing EMF exposure and decreasing computer and
electronic use as much as possible. Even minimal use of electronics or
exposure to WiFi can aggravate a sensitive child, and tics can be impacted
greatly by areas high in electromagnetic radiation. When using electronic
devices, we encourage families to reduce exposure to stimulating blue
light by wearing blue-light-blocking glasses and to consider utilizing
well-researched EMF protective products. For further information, see
www.ewg.org.
Acupuncture
Acupuncture is founded on the concept that the body’s life force, or
qi, flows freely in healthy individuals. When there is illness or imbalance,
the pathways qi follows, known as meridians, are blocked. Unblocking
them by stimulating meridian access points through acupuncture or
acupressure is an excellent way to naturally rebalance a child’s energy.418
As with any practitioner or intervention discussed, look for a licensed
practitioner (LAc) who has experience with children and who can
individualize treatment.
Meditation/Mindfulness and Hypnosis
I have found particular success with teaching children breathing
techniques, slow and intentional alternating nasal breathing, mantras, and
other forms of relaxation and stress management. Hypnosis is another
behavioral approach that can help a child to identify the triggers and urges
that precede a tic. Hypnosis can teach patients how to control and prevent
and gain control over the tics. Learn more in the Neurotherapy chapter.
146
Nancy O’Hara, MD, MPH, FAAP
Physical Medicine
Massage or intentional muscle relaxation with heat can be soothing to
overused and tense muscles and can increase serotonin and dopamine
while decreasing cortisol, thereby reducing tics. Exercise is essential for
overall health, especially outdoor activity. Moderate level exercise has
been shown to decrease the severity of the tics.419 An exercise program
that stretches and increases flexibility in overworked muscles can help
alleviate some of the pain brought on by tics.420
Homeopathy
Lastly, I recommend working with a practitioner familiar with
classical homeopathy to determine the correct remedy for a child’s unique
presentation. Although OTC combination remedies and homeopathic
detoxification kits may be helpful, one may only truly see benefits from
homeopathy when working with a trained homeopath who can
individualize and optimize this form of treatment. Because homeopathy
peels back medical complexities layer by layer, exacerbations and healing
crises may occur. A knowledgeable homeopath should guide caregivers
to determine what is healthy and normal and what needs further attention.
147
-
( )
Obsessive-Compulsive Disorder, “OCD,” is a complex group of
