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When Neurology & Psychiatry Overlap, More on Tics and Tourette's, Plus PANDAS/PANS · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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Do you want me to mention a few other questions I'm going to ask beforehand
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or we'll just kind of. You know, it'll be more fun if it's spontaneous. Okay.
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Maybe I'll regret that when we're done.
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Click on the link in this podcast for free credit that includes CME,
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MOC, or ethics credit, depending on our topic or podcast.
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I'm so excited today because joining us here in the podcast studio is Dr. Sheldon Gross.
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Dr. Gross, thank you so much for being here.
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Sheldon, when should a pediatrician refer a child to neurology versus psychiatry or both?
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I would probably say if you feel like the overwhelming underlying problem has to do with psychiatry.
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If you have a child with a history of profound anxiety and depression,
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a child who talks about hurting himself, I would have them go see a psychiatrist first.
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Because as we said earlier, if you can fix underlying depression,
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stress, anxiety, a lot of times the tics are no longer a problem.
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On the other hand, if you don't hear that, and especially if there's any history
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of neurological problems,
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whether it's severe headaches or seizures or head trauma, or you just know a
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neurologist who's interested in seeing tick patients, I would send them at that point to a neurologist.
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Is there a typical order of evaluation you recommend? For patients with Tourette's syndrome? Yes.
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I would say history, history, history.
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In fact, it's funny because usually the way we're trained to see patients is
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you take a history, you do a
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neurological exam, and then you talk with the family about what you think.
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I reverse that in patients that I think have Tourette's syndrome.
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Because in 42 years, I've never had a patient with Tourette's syndrome who had
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an abnormal neurological exam. It hasn't happened once.
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Maybe tomorrow it will, but it hasn't happened in 42 years. So I changed the order of things.
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And some people may agree with this or disagree with this. I take a history.
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And when I'm convinced that someone has Tourette's syndrome,
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I go directly to talking to the parents.
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I tell the parents, I'm going to examine your patient, your child shortly,
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but I want to talk with you about some things first.
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And I will delve right into what I'm trying to explain what ticks are,
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trying to explain what Tourette's syndrome is, trying to ask them,
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are they doing any of the things that I have said make things worse instead of better?
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And going through all the different ways of helping people with Tourette's syndrome.
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Because like I say, this is a condition where I spend a short period of time
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with the child and a great deal of time with the family.
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And then after that, that's when I'll usually do a routine neurological exam,
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which has been 100% normal so far in every patient I've seen with Tourette syndrome.
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And with all the advances in AI and the future of AI in medicine,
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there will never be a substitute for talking to the patient and it will be more important than ever.
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And I think it's really telling how you're talking about that right now.
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Well, let me tell you what I've learned over 42 years. I know a lot of very good doctors.
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I know a small number that are superlative.
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And usually the difference between who are those real wizards compared to the
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rest of us is not how good a neurological exam they can do.
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It's how well they can elicit a history.
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How well can you listen to people?
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How well can you understand what people are trying to say, perhaps non-verbally?
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How well can you pursue things? What questions to ask? Those are the wizards.
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And this is not just true for neurology.
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This is true for every type of interaction that involves people.
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The history is crucially important, especially in neurology and especially in
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patients with tics or Tourette's syndrome.
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Sheldon, it's such an honor to be here with you today, and I thank you so much for being here.
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What are some of the most common misperceptions you see among families or even
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clinicians about tics and Tourette's syndrome?
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Probably the biggest misconception is these patients have something terribly
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wrong with them. That's a huge misconception.
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And typically the first thing people think of when they hear the term Tourette's
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syndrome is, oh my God, my child's going to blurt out obscene words in the middle of class.
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This gets into the media and what role does the media play.
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I think a lot of people that are well-intentioned will make a made-for-TV movie
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about someone with Tourette's syndrome, and they take the absolute worst,
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most severely affected person they can find, someone who's disabled by it,
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someone who shouts out obscene words,
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They may have good intentions, but that's the image people end up when they
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hear the word Tourette's syndrome.
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So one of the big misconceptions people have is how horrible a condition it
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is when, in fact, a large number of these patients, I just say, you're fine, go home.
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Most of the patients, they're fine. A big number of them.
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And I try to convince families that this is a condition.
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Maybe we have to put them on medicine, but these are healthy kids.
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We didn't talk about the long-term prognosis. I don't want to go off the air before I do that.
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Such a huge percentage, much greater than 50%, as they grow older,
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the ticks either go away completely or they become so mild that they're just not an issue anymore.
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So I'm fortunate to be able to tell parents that when they're very concerned
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about their children, that that's what happens with the bulk of patients.
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It's very reassuring. And can a cough be a tick or a nervous habit?
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Absolutely. I've had patients referred to me by lung specialists that say,
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this child's had a chronic cough.
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I've done 30 chest x-rays.
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There's nothing there. I've used every medicine I can think of.
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And in fact, you're absolutely right. A cough can be a tick.
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And if it's bad enough, you give them the same medicine you would give to anyone
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with Tourette's syndrome.
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And I've seen those patients dramatically improve.
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And if it's not that bad, it's just something that you live with?
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It's just part of it? Just like what I've told you, you have to talk to the
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family to ask them how big a problem it is.
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And if they say it's not that big a deal, then you just don't worry about it.
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Dr. Gross, if a parent brings in video footage of their child's movements,
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what should pediatricians look for during the evaluation?
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Well, you want to look and see, does the child remain awake and alert?
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And probably what's just as important is you look and see what the video shows,
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and then you say to the patient, okay, I want to watch you do it.
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And as I told you, if they can just do exactly the same thing on demand,
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99% of the time, that's a tick.
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Obviously, if someone's having what you think is an obvious seizure,
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or if you're very concerned that it's a seizure, that's when you would want
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to call in a neurologist and ask him to get involved and possibly do an EEG.
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I can tell you I've done a bunch of EEGs on a lot of tick patients, and 95% are normal.
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That's great to know. A lot of our listeners see 40 patients a day.
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In those precious moments in the exam room, how can pediatricians gently guide
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families who are anxious or embarrassed about their child's tics?
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Any language that you find that's helpful?
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Well, if you can, you want to tell people that they need to do something,
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but at the same time, try to reassure them.
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So I would suggest you say, You know, I don't think these are anything serious
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or dangerous, but I have a friend who's very interested in this,
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so I'd like you to see him.
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And if it's Sheldon Gross, that's wonderful. There's a bunch of very good child
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neurologists in San Antonio.
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But I wouldn't put it to him in a way that you're very concerned,
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and this is a potentially very dangerous condition.
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I would use the language to say, I think we're in good shape,
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but I would feel much better if one of my friends took a look.
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I'd like you to call, and then whoever your child neurologist is, you work with.
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And of course, you see patients at our UT Health San Antonio Clinic on Wurzbach
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in Fredericksburg, and also at University Health's Clinic at University Hospital.
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That's correct. We do both, and we have wonderful staff at both places.
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We have wonderful doctors and medical students and residents who go to both places.
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And I'm very fortunate that I work in a situation and an environment where I
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just absolutely love the people that I work with. Well, it definitely shows.
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Sheldon, what's the current evidence on behavioral therapies,
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comprehensive behavioral intervention for ticks?
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There's no doubt in my mind that what we call CBIT, cognitive behavioral intervention
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therapy, that has been shown over and over again, not necessarily to help all
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patients with tics or Tourette's syndrome, but to help a lot of them.
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And I don't think there's any doubt that that's the case. And I don't think
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there's any doubt that if someone has profound stress and anxiety making their
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tics worse, and if you can have another type of cognitive therapy more geared
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at helping them deal with anxiety,
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I have no doubt that that's been shown to be effective as well.
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And Sheldon, we've talked about medications. When those are indicated,
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what are some key points for pediatricians to know before referring to neurology or psychiatry?
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What I would say is if you're going to treat these patients,
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and I think it's fine for pediatricians to treat these patients as long as you're
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willing to read about the medicine and be comfortable with it and listen to
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people, you start with the small dose.
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You don't go to the maximum dose right off the bat.
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And in fact, I tell people, I'm intentionally starting a child on a small dose
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because I want to use as little medicine as possible.
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Most people agree with that and they feel the same way, but you have to warn
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them, this may not be enough.
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So if you call me in three weeks and say, there's no difference,
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please don't throw it away and give up.
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Remind yourself, I'm starting very small and we just may need to go up on the dose.
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You really have to tell people that right off the bed and emphasize that with
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people or else they may decide this medicine's a waste of time, forget it.
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That's happened so many times in my practice and I try real hard to convince
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people not to do that. That's great advice.
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Sheldon, are there lifestyle factors that you want to say anything more about
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sleep, stress, and diet that we've talked about that can meaningfully affect
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tick frequency and severity?
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I'm reluctant to tell people how to run their life. I can just tell you these
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are the things that we know can make tics worse.
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Stress and anxiety. Lack of sleep.
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Chaotic situations that people can't predict what's going to happen,
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and they're just constantly worried.
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In terms of what they do to fix that, I usually put that on the parents.
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I say, you have to figure out a way of dealing with those issues.
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If it's two parents going through a separation or divorce and
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they're incredibly hostile to each other in front of a child who loves both
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of them i'll try to point out that could be a big part of the problem maybe
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you need to work with a marriage counselor to help your son i typically don't
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go into specifics i tell people these are the things you have to try to work on,
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and i usually say it's up to the parents to figure out how to do that our community
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pediatricians have so much on their plates.
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Do you have advice or what advice, if so, do you have to give pediatricians
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on partnering with schools to support children with tics in the classroom?
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Would it something as simple as a note from a pediatrician?
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Yes, I think that might be very helpful. There may be some teachers that just
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don't know what the child is doing, or they think they're making noises on purpose
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to intentionally distract people.
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So having a note that says, You know, little Johnny has Tourette's syndrome
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and may make noises in the middle of class. This is not intentional on his point,
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on his side. He's not doing this on purpose to distract the classroom.
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This is something I have to work on.
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Usually teachers respond if you ask them to help you.
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They feel like they're included that way. I guess we're dealing with just how do you deal with people.
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But telling a teacher, instead of, no, you're making a horrible mistake,
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stop doing that, you're making things worse.
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Try to explain what a tick is, how they can take the form of making noises,
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how you're working with the family, possibly with medicine.
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And I'm going to depend on you to help me make progress. I'm going to depend
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on the teacher's input to help me do a better job. then I think people respond much better.
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And can it be in general a child needs more attention or wants more attention?
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That can sometimes be a factor?
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That can take several different forms. I guess it might be tics,
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but that can also be headaches, abdominal pain, pretty much anything you can imagine.
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What messages of hope or reinsurance would you share with families who are just
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beginning this process where they've come in, they're talking to the pediatrician
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about a tic, what advice would you have for pediatricians to say?
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Let me repeat what I said earlier. The first thing is to convince the parents,
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and this may take a while. You may have to spend 20, 30 minutes talking to them.
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Convince the family that this is not a brain tumor. This is not some god-awful, horrible disease.
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These are normal, healthy people.
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That's the first thing. And then after that, you go on and say,
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you know, there's many different approaches we can take.
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Let's try a non-medical approach first. If that doesn't work, we'll try medicine.
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There's many different medicines we can do. And most of the time,
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these just go away with age.
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This is what I'm spending my 30 minutes with the parents when I say I spend
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30 minutes with the parents and five minutes with the kid.
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Sheldon, beyond tics and Tourette's, where else do we see psychiatry and neurology
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intersect in pediatrics?
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Some of it you've already heard about. Let's just take migraine, for instance.
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Most people think all migraine is headache, nausea, vomiting, photosensitivity.
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In fact, migraine can take many different forms.
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I tell the medical students I can see 12 patients in a row with migraine,
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and they've all got 12 different chief complaints.
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Now, one of them is confusional spells. We spoke about that earlier.
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People that just have episodes of confusion or disorientation,
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or in rare cases, going into full-blown psychosis.
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There's another fascinating syndrome called the Alice in Wonderland syndrome,
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which is where people have episodes of everything looking either very large
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to them or very small and far away. That sounds terrible.
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I've had two neurology residents that never knew they had this until they heard me talk about it.
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One of them said she used to look at her hands, and she remembers as a kid that
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her hands would sometimes look three times as big as ordinary,
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and she never knew why. How long can those episodes last?
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They vary. That's like asking how long can a migraine last.
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I would say usually not more than 20 to 30 minutes, possibly longer than that.
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But if people don't know that this is a type of migraine, there could be real
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concern that these people are crazy or that they've got something major wrong
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with them from a psychiatric standpoint.
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So it's very important to know that. Again, it's a neurological condition presenting
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with what could be interpreted as psychiatric problems. We've talked about.
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Confusional migraine, temporal lobe epilepsy, like the girl I told you about,
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can present with panic attacks.
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There's a type of a seizure called gelastic seizure where you just go into a laughing spell.
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And the only problem is there's nothing funny. No one told you a joke.
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Nothing happened. You just started laughing uncontrollably for 10, 15, 20, 30 minutes.
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Which could be a huge problem in a lot of situations such as in school.
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And people can be very suspicious that that, in fact, is a psychiatric problem.
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We talked about seizures. We've
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talked about migraine. There's another condition that I will mention.
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Teachers will notice behavioral changes at school in an otherwise previously
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very sweet, well-behaved kid.
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And then after three to four weeks, they may notice some unusual movements involving their hands.
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Patients that have this condition called Sydenham's chorea can have rheumatic
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fever, which can affect the heart and cause really life-threatening complications.
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So it's very important that you pick those patients up and diagnose them,
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get them referred to a cardiologist.
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They'll typically put them on daily antibiotics every day until they're 21,
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and that can make the difference in someone surviving or having chronic heart disease or not.
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So Sydenham's career is very important to know about. We have become more and
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more interested in what we call autoimmune encephalitis.
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We have seen for years, as long as there's been child psychiatry,
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there have been people who come in with acute dramatic personality change,
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whether that's anxious and irritable, whether that's aggressive,
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whether that's hallucinating.
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And in the past, that patient would go directly into a psychiatric hospital.
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But what we've learned is that in some of those instances, there's an autoimmune
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phenomenon taking place in their brain.
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We call it autoimmune encephalitis. Some people say limbic encephalitis.
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And those are patients you can help. You can help them with steroids or other
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IVIG or things that suppress the immune system.
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So that's become much more prevalent.
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We have much better testing we can do. We know what things to look for.
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And we've had many patients that were initially seen by psychiatry and placed
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on psychiatric medicines who turned out to have autoimmune encephalitis.
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One other thing I want to mention, and this again is kind of the melding together
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of both psychiatry and neurology, is a condition called PANDAS, P-A-N-D-A-S.
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I wrote it down because I always forget what that stands for.
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Pediatric autoimmune neuropsychiatric disorder associated with strep.
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So these are patients who can have the streptococcal pharyngitis and then a
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month or two months later start having tics in a patient who never had tics
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before, or they can have dramatic personality change.
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And again, this is felt to be an autoimmune type of phenomenon.
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I can think of one particular individual who never had tics.
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She had some type of respiratory syndrome, and a week later she went into this
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explosive amount of tics when she'd never had them before.
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It's not always after a strep. There's PANDAS, but there's something else called
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PANS, which is the same type of thing, but it doesn't have to be streptococcus.
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So again, the more you look, just the more and more prevalent it is to see psychiatry
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and neurology kind of merging together in the same patient.
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Dr. Anthony Infante called me the other day,
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and he was talking about a patient who was sent to him, and it was a teenager
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who suddenly stopped being willing to wear a clothing or even go to the bathroom.
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And he would stay in his room for.
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Such a long time, wouldn't come out of his room. His parents had to bring meals
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to him in his room and all of these really strange behaviors and had been seen by so many specialists.
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And it ended up being PANDAS.
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And he said once the teenager got the right medication, he's back to normal now.
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And the family, hopefully we'll have them on the show because they want to talk
20:41
about what a huge difference medication made and the right diagnosis.
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Well, that's exactly correct. Let me, first of all, put in a plug for my friend.
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San Antonio is very fortunate to have Dr. Infante here. He is the one that I
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refer all of my patients.
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I just referred a patient last week to him.
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If there's questionable PANDAS or possible PANS, he has a special clinic for
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that, and we're just fortunate to have him mirror.
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And his clinic for that is at University Hospital. I believe so. That's correct.
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And Dr. Anthony Infante is a pediatric rheumatologist. And immunologist. And immunologist.
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So, Dr. Gross, sometimes in children, they can come in with what look like seizures,
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but testing shows no electrical activity.
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And I know we've probably covered some of this, but can you explain how neurologists
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and psychiatrists work together in cases of psychogenic, non-epileptic seizures.
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The first thing I have to say is be very careful when you do that because children
21:48
with real epilepsy can have normal EEGs between seizures.
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So it's easy to make the mistake of calling something non-epileptogenic.
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You have to be cautious with that.
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And typically, before we would do that, we would admit patients to the hospital,
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monitor them for 24 to 48 hours, hopefully capture one of the episodes that
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they're concerned about and see what the EEG looks like.
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If it's normal, then we would use to turn a non-epileptic event.
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Now, that's a great question because I think the answer is no one exactly knows
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what to do. For non-epileptic events, for some people would say pseudo-seizures
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or psychogenic seizures, we know what doesn't work.
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We know that seizure medicine doesn't work.
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And when you discuss this with the family, you have to be very cautious.
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I've learned over the years how you say things is sometimes just as important
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as what it is you're saying.
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So there may have been a time when I said, these aren't real seizures, your child is faking it.
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And then all you do is alienate the family, and you just end up butting heads with each other.
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So that's not how you word it. When I come in and talk with someone for the
22:59
first time about non-epileptic events, I'll say right off the bat,
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I've got wonderful news for you.
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Wonderful news. I was afraid I was going to tell you your child had epilepsy
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and was going to have to take two or three medicines for the next 10 years,
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which may be an exaggeration, I admit.
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But instead of telling you that, I'm going to tell you instead,
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I don't think your child has epilepsy, and I'm delighted to tell you that.
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Now the question is, okay, if it's not epilepsy, what is it?
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That's what we have to dig into.
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That's what we have to explore. And typically, I wouldn't refer them to a psychiatrist.
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I would refer them more to a family therapist.
23:37
Again, for someone to dig into what is their life like, why are they doing this?
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One thing that I will have to say, especially for young girls,
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is a certain number of those patients have sexual abuse going on.
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That's been well documented.
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So it just requires someone to sit down and explore what is that child's environment
23:56
like And what are the things in that environment that are resulting in a child
24:00
having a pseudo-seizure or psychogenic event?
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And then, if need be, get child abuse pediatrics involved. If you think that's what's needed, yes.
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Functional neurological disorders are being recognized more often in kids.
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How do you approach helping families understand that the symptoms are real even
24:18
when brain imaging looks normal?
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I'm going to kind of give you the same type of answer that I just gave you.
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You first of all try to put as much as you can a positive spin on things.
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You try to say, I was worried about this neurological condition.
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I'm so glad that that's not what this is, but something is causing this.
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Something is causing either your child to say they're blind.
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Something is causing your patient to say, okay, my left leg is paralyzed.
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You don't use the word faking it. You don't use the word your daughter's trying to lie to us.
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That becomes accusatory, and again, that just doesn't help anybody.
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You use the language. Your child is having these problems are obviously real
25:03
for her. We have to figure out what is causing them.
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We have to figure out why does she say she can't see?
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Why is she saying she's paralyzed?
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And when someone doesn't move, I mean, you can say, yeah, they're paralyzed. They're not moving.
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So you try the best you can to work with families and explain to families that
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there is something wrong. Something's not right.
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These episodes are not normal. We have to figure out what's going on.
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And people are very, usually when you put it in those terms,
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they're very responsive.
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They say, you're darn right. That's what we're trying to do is figure out what's going on. Right.
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And they're on your side and you're on their side. And that's how you want to
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make progress with families.
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I think that's great advice. And another question I have is,
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after concussions or head injuries, some children develop mood or behavior changes.
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How can pediatricians tell when those symptoms might need a psychiatric evaluation?
25:59
I would say when those symptoms are starting to be very intrusive in the patient's life.
26:05
Or if you ask the patient, do these symptoms bother you enough that you would want to take medicine?
26:11
Or if you ask the parents, do you think your child is struggling enough with
26:15
her anxiety or depression that we should start medicine.
26:19
I guess the underlying thought is you try to include the family as much as you
26:24
can in the decision-making.
26:27
Now, I'm not just talking about neurology. I'm talking about life in general.
26:32
In the first place, as soon as people leave your office, they're going to do
26:34
what they want to anyway.
26:36
So doctors are kidding themselves if they think, I can just tell them what to
26:39
do and they're automatically going to do it.
26:41
But if you include people, and if the parents say, I want to hold off and wait,
26:46
or if they say, yes, we think she's suffering, we would like something to help
26:50
her now, your compliance rate with medicine just goes through the roof.
26:54
You get such a better response.
26:58
So I would say you send them to a psychiatrist if you think that they're being
27:03
very severely impacted by things, and if the family's willing to go to a psychiatrist,
27:08
or not necessarily start with a psychiatrist.
27:11
You can start with a therapist, family therapist, and see if that works first.
27:15
Sheldon, finally, and before we go over just a couple of questions from some
27:21
community pediatricians,
27:22
but first, what do you wish pediatricians knew about the relationship between
27:26
the brain and the mind, and how addressing both can change outcomes for patients?
27:33
I guess the one thing I would say, and some people might disagree with me,
27:39
We have separated our specialty into neurology and psychiatry.
27:45
Sometimes that's appropriate.
27:47
There's many times where that separation is artificial and there is no separation.
27:53
And I've just gone through so many instances where there really is a very strong
27:57
correlation between psychiatric problems and neurological problems.
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I guess the one thing I'd want them to know is it's not always two separate specialties.
28:07
And there are times when one condition benefits from being seen by both doctors.
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That's why I'm trying to get that clinic started. I hope I can do it.
28:16
And when you do, please come back on the show. Will you promise me that? I will be glad to.
28:22
So a couple of questions that came in late this afternoon from pediatricians,
28:27
and we've probably covered some of this, but...
28:31
This is from a community pediatrician here in town. What is your opinion regarding
28:36
the medical consensus of the effect of stimulant medications for patients who
28:40
have ADHD on their motor and verbal tics?
28:43
What does the evidence and science show? Can you reiterate that for us?
28:48
Well, clearly, we know that in many individuals that makes their tics worse.
28:53
I think that's beyond any question. But the question is, suppose you've tried
28:59
every medicine you can think of and nothing helps.
29:02
There are some patients where you can start with very, very small doses of stimulants,
29:08
much smaller than you would usually use, and very slowly and gradually increase the dosage.
29:15
Sometimes you can get away with that. I've had patients with a tick disorder
29:19
that took stimulants and they were fine.
29:21
That's just not the first thing I would do. That would be something to do if
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you're out of tricks. if you have tried every non-stimulant medicine and nothing has worked.
29:30
Then pick one, go very low dose, see if they can tolerate it.
29:35
This other pediatrician is asking what we covered at the beginning,
29:39
but it would also be great talking
29:41
directly to parents or what the pediatrician should say to parents.
29:46
When should you be concerned about twitches? If it lasts longer than a year?
29:51
I would say you should be concerned when it's affecting the child and affecting the family.
29:57
You may know that something is benign, but if the family is really tense, really upset,
30:06
you have to delve into it, whether it's you or whether that means referring
30:10
them to a neurologist or a psychiatrist. You have to do that.
30:15
Twitches can be nothing or they can be something very serious.
30:18
Like my patient that I almost sent out the door with tics who ended up with
30:22
a big brain cyst that had to be operated on.
30:24
You go largely by what your gut is telling you.
30:28
How big a family, how big a problem do I think this is? And remember,
30:32
you have to ask a bunch of questions.
30:35
You have to determine, is this the type of patient who's at a high risk for seizures?
30:41
Is this an autistic patient? Is this a patient with Down syndrome or who's had a head injury?
30:47
Is this a patient who has episodes and then afterwards he's sleepy for five
30:51
or ten minutes? That doesn't happen with ticks. That happens with seizures.
30:56
Those are all questions that you have to ask. And if you have any question,
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it's much better to refer to a neurologist.
31:03
If you're going to make a mistake, it's better to refer someone who didn't need
31:07
to be referred as opposed to letting someone slip by that should have been referred.
31:11
That's a much bigger mistake.
31:13
And you could even say to the family, just to be safe, I would like you to see a neurologist.
31:19
That's the approach that I think works the best.
31:21
You don't really want to scare people more. People can come in wired as it is.
31:26
You don't want to say things to them that make them even more anxious.
31:30
So take that approach of, I think we're in good shape, but I would feel better
31:33
if we had so-and-so look at your child.
31:36
And then one other thing I would say, am I allowed to do an advertisement here?
31:41
Yes. Well, we'll see. What is the advertisement?
31:44
We started what's called a fast clinic.
31:48
And it was my idea, I'm happy to say. We have a clinic one afternoon during the week is held open.
31:55
And this is at our gateway clinic. We don't schedule patients there.
31:59
It is specifically designed for people that have children that need to be seen
32:04
quickly and cannot wait three weeks or a month or two months for an appointment.
32:08
Someone with new onset seizures.
32:11
Someone where you're not sure if someone's having tics or seizures.
32:15
Someone where the family is just coming apart because they're so upset and so anxious about this.
32:22
I'm very glad that I came up with a good idea that we hold a clinic open and
32:27
we try to use our judgment to see who should be seen.
32:30
Some people that have had problems for two years don't need to be seen in a week.
32:34
Other patients do. And it's a nice way to keep people out of the hospital.
32:38
Kids that might otherwise have to be admitted to the hospital.
32:42
Dr. Sheldon.