Taming the Tics: Behavioral Strategies for PANDAS and PANS

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Understanding the Sudden Storm of PANS/PANDAS

CBT for PANDAS is a behavioral therapy that helps children manage the sudden-onset OCD (Rea et al., 2021), anxiety, and tics caused by PANDAS/PANS. It uses techniques like exposure and response prevention (ERP) to break learned rituals and empower both child and parent with practical coping tools.

Quick Overview: CBT for PANDAS

• What it treats: OCD symptoms, anxiety, avoidance behaviors, and tics related to PANDAS/PANS.
• How it works: Teaches children to face fears gradually and reduce compulsions.
• Parent role: Essential—you become your child’s “at-home coach.”
• Evidence: Preliminary studies show 6 out of 7 children had significant improvement.
• When to start: After acute inflammation is managed and your child can engage.
• Not a cure: Addresses behavioral symptoms, not the underlying autoimmune condition.

One day, your child is fine. The next, they are overwhelmed by symptoms. This abrupt change is the hallmark of PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections) and PANS (Pediatric Acute-onset Neuropsychiatric Syndrome). These conditions occur when the immune system mistakenly attacks the basal ganglia in the brain after an infection, resulting in sudden, severe OCD, tics, anxiety, and mood swings.

PANDAS/PANS is different from typical childhood OCD:

• Symptoms appear overnight.
• Often triggered by an infection like strep.
• Can include physical symptoms like urinary frequency or handwriting changes.
• Symptoms may relapse and remit.
• Requires both medical and behavioral treatment.

While frightening, effective treatments exist. Medical interventions address the immune response, while CBT for PANDAS helps your child regain control over behaviors. I’ve seen how CBT gives children the tools to fight back against intrusive thoughts and compulsions. Let’s explore how this science-backed approach can help your family reclaim calm.

A Parent’s Guide to CBT for PANDAS: Reclaiming Calm

When PANS/PANDAS hits, it can feel like a storm has hijacked your child’s brain, exhausting the whole family with sudden OCD, tics, and anxiety. While medical care addresses the immune piece, CBT for PANDAS—Cognitive Behavioral Therapy with Exposure and Response Prevention (ERP)—is the best-supported way to manage the behavioral symptoms and rebuild daily functioning.

Anna’s story:

A 9-year-old student, Anna went from carefree to hours of handwashing and school refusal after a sudden flare. With ERP, she named her OCD “the Brain Bully,” practiced tiny exposures (touching a doorknob, then delaying washing), and her parents reduced accommodations. Week by week, mornings got shorter, school returned, and the “bully” got quieter.

Let’s calm the brain first. While PANDAS/PANS symptoms start with a biological trigger, the resulting rituals and avoidance often become learned patterns. Your family naturally accommodates these behaviors to reduce your child’s distress. However, these patterns can keep OCD and anxiety going, even after the medical issues are addressed. CBT for PANDAS helps break these learned behaviors and gives your child back their sense of control.

Research gives us real hope. A preliminary study found that six out of seven children with PANDAS-related OCD showed significant improvement after CBT. That’s kids getting back to their lives—sleeping in their own beds and eating meals with their families again. CBT is safe, minimally invasive, and empowers your child with lifelong coping skills, building lasting resilience for the whole family.

What is CBT and How Does it Help PANS/PANDAS?

Cognitive Behavioral Therapy (CBT) helps children change the negative thought patterns and behaviors driving their difficulties. For PANS/PANDAS, it directly targets the OCD and anxiety that can linger after medical treatment.

Exposure and Response Prevention (ERP) is a specialized form of CBT that is highly effective for OCD. It involves two parts:

• Exposure: Your child gradually faces the thoughts, situations, or objects that trigger their fears in a controlled, supportive way.
• Response Prevention: They learn to resist performing the compulsive behaviors or rituals they would normally use to reduce anxiety.

For example, if a child has contamination fears, we might start by having them touch a “dirty” doorknob (exposure) and then wait before washing their hands (response prevention). Over time, their brain learns that the anxiety decreases on its own, without the ritual.

ERP helps children with PANS/PANDAS by directly addressing rituals, reducing avoidance, and empowering them to “argue back” against OCD. A study in the Journal of the American Academy of Child & Adolescent Psychiatry showed that children who responded to treatment maintained their gains at a three-month follow-up (Storch et al., 2006).

Key CBT Techniques for PANS/PANDAS-Related OCD

I tailor CBT techniques to each child, always remembering that behavior is communication. These strategies help them challenge fears and regain control.

• Naming the OCD: We give the OCD a name, like “The Brain Bully.” This externalizes the problem, so your child fights the OCD, not themselves.
• Creating a Fear Hierarchy: We list and rank triggers from least to most frightening. This creates a roadmap for therapy, allowing us to start small and build confidence.
• Gradual Exposure Exercises: Using the fear hierarchy, we practice facing fears in manageable steps while resisting compulsions. The goal is to build tolerance to discomfort.
• Arguing Back Against OCD Thoughts: Your child learns to challenge intrusive thoughts with logic. For example, responding to an OCD thought with, “That’s just the Brain Bully talking. I’m in charge, not you.”
• Habit Reversal Training for Tics: This teaches awareness of the urge before a tic and how to use a competing response that makes the tic difficult to perform.
• Focusing on Behavior Function: We explore what purpose the behavior serves (e.g., reducing anxiety) to find healthier alternatives that meet the same need.

The Parent’s Role: Your Blueprint for At-Home Support

As a parent, you are one of the most powerful parts of your child’s treatment team. I call parents “co-therapists” because the real work happens in your daily life.

Your role starts with learning the strategies alongside your child and implementing them at home. One of the trickiest parts is reducing family accommodation—the ways you may have unintentionally reinforced the OCD by participating in rituals. We work together to gradually reduce these accommodations, empowering your child to face fears independently while you offer support.

Having a core set of CBT tools is also critical for managing exacerbations or flares. You’ll know how to respond and prevent new patterns from taking root. Creating a calm, predictable home environment where small victories are celebrated accelerates progress. I also collaborate with all your child’s providers—pediatrician, immunologist, and neurologist—to ensure we are all working together for your child’s success.

This collaborative approach ensures your child receives expert guidance and consistent, informed support at home.

How CBT Fits Into a Comprehensive PANS/PANDAS Care Plan

CBT for PANDAS is a critical piece of a comprehensive care plan, but it’s rarely a standalone treatment. My philosophy is always “Let’s calm the brain first.” This means addressing the underlying inflammation with medical interventions like antibiotics or immunomodulatory therapies.

Once that inflammatory storm is calmer, behavioral interventions become much more effective. CBT serves as behavioral support for residual symptoms like OCD, anxiety, or tics that have become learned patterns. It gives children strategies to break these cycles and builds resilience.

The importance of medical stabilization first cannot be overstated. If a child is in an acute crisis, we must prioritize medical care before starting intensive therapy. The ideal time to start CBT is once acute symptoms are managed and your child can meaningfully participate. However, I can begin by working with you as parents to implement strategies at home, fostering gains even before your child is ready for direct therapy.

This multi-pronged approach requires close collaboration among all providers. The PANDAS Physicians Network emphasizes the role of Cognitive-Behavioral Therapy for PANS/PANDAS | PPN as a first-line approach for mild to moderate cases, which aligns with what we see in clinical practice. You’re not alone, and with the right team, your child can reclaim their life.

Next Steps to a Calmer Brain

Navigating PANS/PANDAS is a marathon, but you don’t have to run it alone. With the right tools and CBT for PANDAS strategies, your child can learn to manage their symptoms and build resilience. Every small step forward is a victory worth celebrating.

The long-term outcomes for children who receive comprehensive treatment are encouraging. Many experience significant symptom reduction and develop coping skills that serve them for life. When future flares occur, you’ll have a toolkit ready. I’ve spent over three decades working with families just like yours and have witnessed incredible changes. This can be your story too.

At our center, we provide “game-changing solutions” by combining neuroscience with practical, family-centered strategies. Whether at our Ridgefield, CT clinic or through virtual appointments, we’re committed to calming the brain and empowering your family.

Dr. Roseann’s Therapist Tip

In my 30+ years of clinical practice, I’ve learned that you can’t correct tics in the moment—your child’s brain needs safety, not pressure.

What I tell parents:

Focus on calming the nervous system first with predictable, low-demand routines and gentle co-regulation, because tics flare when the brain is overwhelmed, not defiant.

Try this today:

Build a ‘tic break’ into transitions—a 60-second pause where your child takes three slow breaths while you match their pace and energy.

Why it works:

Predictable pauses lower limbic arousal, which reduces tic frequency and intensity over time. Remember: when you lead with calm instead of correction, you help your child’s brain find its way back to regulation.”

At our center, we provide “game-changing solutions” by combining neuroscience with practical, family-centered strategies. Whether at our Ridgefield, CT clinic or through virtual appointments, we’re committed to calming the brain and empowering your family.

If you’re ready to move from overwhelm to action, I invite you to explore our resources. Get your PANS/PANDAS Solutions Kit today and start building your roadmap to a calmer brain and a calmer home.