I’ve had a few questions and comments recently about PANDAS. I wanted to put together a collection of resources for PANDAS and PANS so that families, teachers, therapists, grandparents, and caregivers can easily find everything they need to know about this disorder. The links below are sites that describe more about PANDAS and PANS, including diagnostic information, signs and symptoms of PANDAS, information on clinical trials, and places to find more help. PANDAS/PANS can be a confusing diagnosis, happening overnight and with dramatic and substantial outcomes. Use the information below as a starting point when looking for information on PANDAS.
This information is not meant to be a diagnostic tool or means for intervention. It is essential that concerned individuals seek consult from the child’s pediatrician. This information is strictly a collection of information and a starting point when seeking out resources.
What is PANDAS?
PANDAS is an acronym standing for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. The disorder appears suddenly following a strep infection like strep throat or scarlet fever and results in obsessive compulsive disorder, behaviors, tics, and similar symptoms.
PANS, or pediatric acute-onset neuropsychiatric syndrome, refers to children with sudden onset of obsessive–compulsive and other neurobehavioral symptoms, including children with PITAND (pediatric infection-triggered autoimmune neuropsychiatric disorder), children with PANDAS, and children with exacerbations that are due to environmental or metabolic triggers.
Symptoms of PANDAS and PANS
There is not a predictable sequence of symptoms, but a child with a diagnosis of PANDAS/PANS may present with the following symptoms:
These books may help kids with PANDAS or PANS to better understand the disorder and symptoms. Children with siblings or friends who are experiencing symptoms of PANDAS or PANS would benefit from information relayed in easy-to-understand children’s books with pictures. Also included in this list of books about PANDAS are books that can be referred to parents and teachers of children who are experiencing PANDAS or PANS.
Affiliate links are included in this post.
In a Pickle Over PANDAS is a children’s book about a young boy who wakes up one morning with new and strange things happening in his body. They symptoms of PANDAS are described in a way that kids will understand and relate to. This book is a great resource for kids who are struggling to understand what PANDAS is and that they are not alone.
Saving Sammy is a book written by a mother of a boy with a sudden onset of PANDAS and describes her fight against the medical establishment to prove the link between infection-triggered PANDAS and her son’s sudden-onset OCD and Tourette syndrome.
PANDAS and PANS in School Settings is a handbook for teachers, administrators, school professionals, school based Occupational Therapists, and anyone who works with a child who is struggling with PANDAS or PANS. This handbook can help identify challenges and offers strategies to incorporate into the learning environment.
A Child’s Introduction to Understanding PANDAS is a book that parents can work through with their kids as they struggle to explain what exactly PANDAS is and how it’s affecting the child. This workbook is a resource for identifying a individualized strategy plan using the book’s journal sheets and strategy plans.
How to take the Grrr out of Anger is a book that can address one of the common symptoms of PANDAS and PANS. For kids that are experiencing behavior and emotional challenges as a result of PANDAS/PANS, the new feeling changes can be confusing and overwhelming. This book is a guide to helping kids understand anger-management tips strategies that can be used in healthy ways. This book can help kids understand and deal with the anger and emotions they feel.
What to Do When Your Brain Gets Stuck is a book that addresses the obsessive compulsive tendencies that are common with PANDAS and PANS. This book helps kids understand the obsessions or compulsions they may feel and act on and guides kids and parents through strategies that can help. The book has a lot of activities, tools, and guided instructions that can help kids take control of their OCD actions or thoughts.
Janice Trigilio Tona, Sutanuka Bhattacharjya, Denise Calaprice; Impact of PANS and PANDAS Exacerbations on Occupational Performance: A Mixed-Methods Study. Am J Occup Ther 2017;71(3):7103220020P1-7103220020P9. doi: 10.5014/ajot.2017.022285.
Tona, J., & Posner, T. (2011, November). Pediatric Autoimmune Neuropsychiatric Disorders: A New Frontier for
Intervention. OT Practice, 14-19.
PANDAS—Questions and Answers. (2016, Sept) Retrieved from: https://www.nimh.nih.gov/health/publications/pandas/index.shtml
A child is over responding to sensory input from the classroom environment. The fluorescent lights are too bright, the janitor is rolling his cart down the hallway, a new pair of socks are too tight, and a fly is buzzing near a window. The combined sensations are too much.
The classroom is an environment that is a place where over-responsiveness can easily interfere with learning, self-confidence, or social emotional development.
Having a toolbox of sensory strategies to address over-responsiveness can be invaluable in the classroom.
Calm Down Strategies for School
Below are sensory strategies for school that can be used with children who over-respond to sensory input, have difficulties with anxiety, or struggle with attention or executive functioning difficulties.
Get a printable version of this list HERE.
A child who needs self-regulation strategies to better learn or function in the classroom can benefit from one or more of these strategies. Every child is different and each will respond in different ways. Not all of these sensory strategies will help every child. Consider underlying issues and consult a school-based occupational therapist for assessment and interventions.
Sensory Strategies to help children calm down at school:
Use a predictive schedule Limit close seating Minimize auditory stimulation (Utilize earbuds, sound-minimizing headphones, white noise, whisper phones) Increase space between children Movement breaks Sensory seating Provide a calm down zone Weighted lap blanket Try tactile tools at the desk Decrease visual distractions (trifold, work standing at an easel, single color bulletin boards) Use a visual schedule for transitions Provide a warning before fire drills or bus evacuation drills Plan an accomodate for school-wide assemblies Provide a calm down portion of the day build into the schedule with deep breathing and soft music Yoga breaks Stretches before desk work or tests Add wall push-ups or chair push-ups into the daily schedule Water bottles with a straw at each desk (ask parents to send in sports bottles) Allow gum during tests or quiet work time Quiet fidget toys Movement learning with the whole classroom
When a child sits down to write at a desk, it can be easy for everything to go awry and messy, illegible handwriting to result. It might be poor carryover of handwriting skills, difficulty with letter formation, visual motor skills that are not up to par, or weak fine motor skills and pencil grasp struggles. The issue with sloppy handwriting is that there is a LOT going on! One tip to check as soon as a child sits down to write, is their posture. Everything from head positioning and visual view of the writing space to positioning of the arm and hand on the paper stems from the midline and base of support. Because of this, I wanted to share ways that core strength impacts handwriting.
Core Strength and Handwriting
The child with weak core strength may have sloppy handwriting that just can’t be fixed. Band-aides of pencil grips, specialty lined paper, and handwriting modifications can help improve written work, but when a weak core is holding up the child, the handwriting struggles will never be fully fixed.
It is so important to start with the midline and base of support when it comes to handwriting. That proximal beginning of assessing the child can make a world of difference with just a few adjustments in posture and strengthening.
When there are handwriting problems, there are underlying issues that cause them. Core strength is a big cause of handwriting struggles.
Here are 6 ways that core strength impacts handwriting legibility and neatness:
1) When a child has a weak core, they may tend to sit with a modified base of support. They might slump over at their desk and lean on their elbows. You might see a slouched back, knees and legs sticking out between the rows of desks. You might see kids who are slumped over their papers or are leaning on one hand as they write. You might see the child lying forward on an extended arm that reaches over the front of their desk. An inefficient posture can lead to poor handwriting. Read more about a 90/90/90 posture and how to promote that posture using cue cards.
2) Classroom teachers will say they often times see students who are not active and alert during school tasks. A weak core can transition to inattention and inability to focus on learning or handwriting tasks. A core strengthening plan can help this problem.
3) When the core is not engaged, the child’s non-dominant hand can not support the paper. When this happens, the paper isn’t stabilized and legibility can suffer. Coordinating both hands together with an engaged midsection requires a strong core. Read here about tricks for holding the paper when writing.
4) A weak core can lead to a child who can’t engage their muscles over a period of time. This looks like a child who wiggles, moves in their seats, jumps up, and slouches. With all of that wiggling and moving, handwriting can suffer!
5) Copying a list of words from a smartboard, book, or homework assignment center across the classroom or desk requires visual shift and the ability to quickly scan using visual perceptual skills. When a child who has weak core tries to copy a list or sentences, they might present with a slouched upper back and neck over their desk. Looking up and back down again can be really difficult for these students with the repeated flexion and extension of the neck. This can result in skipped words, letters, and phrases as well as poor margin use, line awareness, and spatial awareness when writing and copying written work.
6) A weak core leads to weak fine motor skills distally. The engaged and strong muscles of the abdomen and upper body allow for strength and engagement of the upper arm, and in turn leads to dexterity and motor control of the hands. When the core is weak the hands can not effectively do their job to hold the pencil and manage tasks such as in-hand manipulation.
What should you do when weak core muscles impact handwriting?
Strengthening the core can have a HUGE impact in handwriting!
Use the strategies and tips to give kids the strong core foundation they need to improve handwriting.
As kids, we used to hop from couch to couch and make a flying leap across the living room to the corner chair. We would hop from one surface to another with one thing on our minds…
The living room floor had turned into boiling hot lava!
When my kids started hopping around from pillow to pillow and landing with a roll onto the couch with claims of the floor turning to lava, I had to smile.
The Floor is Lava is Back!
What is so cool about the floor being lava (besides the nostalgic sentiments from parents?) A great game of The Floor is Lava has some major motor movements and sensory play components!
From jumping, leaping, hopping, rolling, and crashing, The Floor is Lava is a fun and creative way to encourage movement and sensory motor play, both indoors and out!
The Floor is Lava Games
Here are some fun ways to use The Floor is Lava Games to promote sensory input and motor movements:
Place pillows and couch cushions on the floor. Kids can hop from pillow to pillow on one foot or two. Move the pillows further and further apart to promote movement coordination and motor planning. Don’t touch the carpet, it’s lava!
Place paper plates in a line on the floor. Use them as a balance beam to address vestibular sensory input. Hop from plate to plate without touching the ground, it’s burning up!
Play a stop and go game that promotes auditory processing skills like auditory figure-ground discrimination. Call out, “The floor is lava!” and everyone has to hop off the ground onto something besides the hot, hot ground!
Use boxes like milk crates, stools, or dining room chairs to add height components to The Floor is Lava game.
Add a learning component by asking kids questions when they land on a safe space. Think about incorporating spelling words, math facts, or memorization facts.
Play The Floor is Lava at the playground to add vestibular sensory components to the game. Don’t touch the ground, it’s hot! Read more about the sensory benefits of the playground.
Make a Safe Island when playing a lava game. Use a hula hoop and all kids can hop in the hoop to stay safe from that burning hot lava. Don’t hop out of the other side of the hoop to stay safe and to work on motor control.
Develop Skills While Playing The Floor is Lava
When playing these lava games, kids are developing and building so many skills!
Gross motor coordination
Visual motor skills
Vestibular sensory tolerance
Proprioceptive sensory tolerance
Do your kids play The Floor is Lava? Did you play as a child? Introduce your kids to some of these versions of the lava game and boost movement and development skills at the same time!
For kids who struggle with executive functioning skills,
there are parts of the day that require more intentional focus in order to successfully progress
through the day. Identifying high-stress or high-processing times during the day can help parents, teachers, and therapists come up with a plan of action for executive functioning skills and kids’ daily activities.
Executive Functioning Skills and Kids Daily Activities
These are times of the
day that involve multiple executive functions or periods of transition:
Transitions to the car or school bus
Start of the school Day
After school at home
After school activities
Social experiences (parties, play groups, group activities)
Community interactions (library, shopping, meals out in a
During these periods of the day, it can become overwhelming
for the child who struggles with executive function skills, particularly if the
child is also challenged with sensory processing difficulties, attention or
hyperactivity, or communication challenges.
So why are these transition periods a high target period for inefficient use of executive functions? There are a few theories to consider:
1.) Executive functioning depends on the frontal lobes of the brain. These high-stress times of the day may be impacted by a busy environment, multiple tasks that need to be completed, and other frontal lobe tasks such as judgment, abstract reasoning, planning, and other thinking functions, management of body
movement (motor function), emotions, attention, or motivation.
2.) Each of these high-executive function periods of the day require multiple actions of the body and brain. There are many tasks that make up the period of before-school routines, for example. Each of those tasks can throw a child off task and interfere with getting out the door on time, with a jacket, lunchbox, homework, school supplies, notes for the teacher, snack, and whatever else is needed for a typical school day. A lot of steps with a lot of opportunities for impulsive actions can derail progression of steps to get a job done.
3.) Within the main areas of executive functioning are many smaller scaled steps that go into every task and particularly tasks that include several steps and processing, prioritization of steps:
a. Forming ideas to do an action.
b. Starting an action.
c. Maintaining an action until the step is finished (knowing when a step is done).
d. Switching behaviors to do the next step needed.
e. Regulating, controlling, and adjusting body actions to deal with changes and
new information along the way.
f. Planning a tactic down the road to deal with a new issue or new direction.
g. Holding details in the working memory.
h. Controlling emotions.
i. Thinking abstractly.
j. Knowing when the whole task is finished, stopping that task, and moving onto a
different task or activity.
4.) It’s possible that time of day can have an impact on an individual’s ability to process tasks. Difficult tasks might be easier for some to accomplish earlier in the day when we are at optimal attention and focus and not fatigued.
When executive function skills interfere with so many parts
of the day, it can be overwhelming for a child! As a result, behaviors, or meltdowns
So what to do about about children who struggle with task initiation, task
completion, working memory during these high stress-low executive functioning skill
times of the day?
When kids struggle with weak fine motor skills, they can have difficulty in so many areas! This post includes ideas for using clothespins and busy bags to improve fine motor strength.
Developing hand strength is an important skill for kids who struggle with manipulation of small items like buttons or zippers. A child who struggles with handwriting can many times present with weak hand strength. Trouble maintaining a pencil grasp, very light handwriting, switching hands when coloring or writing, using the whole arm to write, a closed thumb web space, and a distorted grip on the pencil are signs of weakness in the hands.
But the trouble with working on improving hand strength is that many times, kids just don’t want to correct their pencil grasp or work on tasks that are hard to do like practicing zippers over and over again.
One simple strategy to fix these strength issues is making the work fun. Here are creative ways to use clothespins to improve fine motor hand strength.
Putting the activities together in a busy bag form can be helpful for therapists who need to quickly pull a strengthening activity from their therapy bag. The fine motor busy bags below can be passed on to teachers to encourage development of fine motor strength in the classroom and at home.
These fine motor strengthening activities are busy bag ideas that can be used in therapy home programs or as part of fine motor activities that the whole class can benefit from!
Clothespin Busy Bags Fine Motor Strength Activities
We talked before about the fine motor strength benefits of clothes pins. There are SO many ways to develop the specific grips needed for functional tasks using clothes pins. Work on lateral pinch, tip to tip pinch, three jaw chuck using clothes pins. Read more about the different pinch grips and how clothes pins help with strengthening by clicking the link above or this image:
These fine motor strength activities use clothes pins. Clothes pins are something that you can grab at the dollar store and easily adapt to activities of all sorts. Make a busy bag that builds on learning concepts like math, literacy, colors, or patterns with activities that can be done over and over again in a busy bag! Try these clothespin busy bag activities to strengthen the hands:
Match colors with a neat pincer grasp using very small clothes pins in this super fine motor busy bag from Powerful Mothering.
Address letter recognition while building fine motor strength in a busy bag using letters like Learn Play Imagine.
Making busy bags that work on specific skills WHILE addressing educational concepts such as math or reading are a powerhouse tool for therapists and teachers! Make the busy bag ideas above and pass them on to teachers or parents who want to build hand strength. Busy bag ideas like this are perfect for centers or home programs.
Occupational Therapists are always looking for activities that build specific skills and can be easily incorporated into the classroom. Fine motor busy bags like these can be a powerful tool for the school based OT!
Looking for more ways to create fine motor busy bags for parents, teachers, or classrooms? The Busy Bag Book is a new book written by my friend Megan at Coffee Cups and Crayons. The e-book is PACKED with activities that develop specific skills in a fun way. The bonus for busy bags are that they can be packaged up and used time and time again in centers or while on-the-go.
As a reader of The OT Toolbox, you get to use a special discount code so you can grab The Busy Bag Book and get tons of ideas for building hand strength with busy bags. Use the discount code OTFRIENDS.
This code expires in thirty days, so be sure to use the code while you can! It’s the perfect time of year to create your busy bags for back to school! (Affiliate links are included in this post.)
Click HERE to learn more about The Busy Bag Book and to get started on creating your own busy bags that will help the kids develop fine motor skills at home and in the classroom.
Thank you for downloading the Christmas Occupational Therapy Activity sheets. Use these activities in a month of play based on developing the underlying skills needed for function and independence. Each activity promotes underlying areas such as fine motor skills, sensory processing and exploration, visual processing, visual attention, visual motor integration, bilateral coordination, eye-hand coordination, direction following, and so much more.
The activities can be cut out and glued to clothes pins for increased fine motor strengthening. Ask children to move the clips when they’ve completed an activity as they countdown to Christmas.
This will be a month-long time of memory making while promoting healthy development that will foster function on into the new year.
Explore the season while addressing Sensory Processing issues using this Christmas Sensory Processing guide. It’s got activities for the whole season and sensory coping strategies to help kids who struggle with sensory processing difficulties.
Have fun this holiday season!
SALE! Save 25% on Modified Christmas Paper NOW THROUGH CYBER MONDAY.
Coupon code is HOLIDAY25
Use the Christmas modified paper handwriting pack to work on handwriting, letter size, letter formation, and legibility with meaningful and motivating activities:
Children with ADHD, ADD, or even just difficulties with focus and attention can have resulting struggles with executive functioning skills. There are many executive function skills tied to attention and focus that interfere with success in the classroom, home, extracurricular activities, and community. Consider all of the areas that make up executive functioning skills. These are abilities that develop through maturation and developmental progression. For some, these skills develop more easily than others. For the child who struggles with attention, these executive functioning abilities may lack, causing difficulties in all areas of life.
Executive Function Skills and Attention
There are many executive functioning skills that allow us to complete tasks. On this executive functioning skills page, I’ve linked to several of the skill areas that we’ve covered here on the site. Be sure to stop back, because I’ve got more activities and information in store for you.
When kids have trouble with attention, there are executive functioning skills that lack.
Does any of this sound familiar?
Emotional Control- Kids with attention issues may not be able to attend for extended periods of time on a situation that enables them to control their emotions. They can perseverate on the emotions of a specific situation or may not be “up to speed” on the situation at hand or be able to process their emotions as they attend to a different situation. Issues with emotional control can then lead to behavioral responses as they struggle to keep their emotions in check.
Task Initiation– Children with attention difficulties can be challenged to start tasks. It can be difficult to pull out the starting point or the most important parts of a multi-step project so that just starting is a real struggle.
Task Completion- Similar to the initiation of specific tasks, completing a task or project can be a real challenge for the child who is limited in attention. Reading a multiple chapter book can seem overwhelming and quite difficult and just never is finished. Cleaning a room can be a big challenge when there are visual, auditory, or other sensory-related distractions that make up the project.
Working Memory– Attending to past situations and pulling that information into a current situation is a difficulty for some kids with attention issues. Attention issues can interfere with parts of working memory including encoding, storage, and manipulation of information. This can result in safety issues when it comes to skills like crossing a street or even conversations.
Prioritizing- Planning out and picking the most important tasks of a project can be a struggle for the child with attentional issues. It can be easy to become overwhelmed and distracted by the options for importance.
Processing Speed- Processing speed refers to the ability to receive, understand, and process information in order to make a decision or response. It also involves using working memory in a situation or experience. Children who experience attention struggles may experience difficulty in retrieval of information (using working memory) and responding using that information (initiation). This carries over to missed information, difficulty keeping up with a conversation or lesson in school, or a fast-moving game or activity.
Organization– A child with attention challenges can easily become disorganized with tools, books, clutter, and trash. Focusing on a project such as cleaning out a desk or locker is a multiple-step task that might not ever happen without intervention from a teacher or support person. Organization requires attention to detail and separation of pieces into sections, whether that be folders of a similar subject in school or matching colors of socks. It’s easy to see how the child with attention issues can get off track very easily with organizational tasks
Self-Monitoring- This executive functioning skill goes hand in hand with attention and focus. Self monitoring allows us to keep ourselves in check in a situation. We need to stay on task and focus on that a person is saying and respond in appropriate ways. If the child with attentional issues can not focus on what a person is saying for more than a few minutes, than the ability to respond appropriately can be a real issue.
Impulse Control– Attention and impulses are another set of executive functioning skills that are very closely related. When the distracted child can not focus on a specific task or conversation, or situation, then the tendency to impulsively respond is quite likely. A great tool for assessing and monitoring impulses in the child with attention struggles is the impulse control journal.
Cognitive Flexibility- The ability to think with flexibility is what makes the human brain superior to other species. We are able to think in the future and assess different situations using cognitive flexibility. Cognitive flexibility is the ability to stop a thought process and change a way of thinking. When the child who struggles with attention can not focus on a thought or process for a period of time, they are distracted by things in their environment or thoughts, limiting the ability to focus on flexible thinking patterns.
Foresight- This skill is also related to distractibility and focus. Interference from outside interruptions can limit the thoughtful foresight that allows us to make safety decisions. For the child with impulsivity and hyperactivity, being on-the-go, or constantly in motion can interfere with the ability to pause and consider consequences from a single action.
Hindsight- Similar to thinking ahead, the ability to process that “20/20” vision of our our past mistakes and actions is what allows us to use experience to make better decisions.
Self-Talk– The skill used for assessing situations and monitoring our behaviors related to consequences is a difficult task for the child with attention issues. Distractions interfere with self-talk and the positive result of our inner mind.
Problem Solving- When distractions and impulsivity are at the forefront of thought processes, it can be difficult to solve problems as they are presented to the child with attention difficulties. This area is closely related to working memory.
Persistence- For the child with attention struggles, it can be very difficult to persist through a lengthy task or assignment. Distractions, impulsivity impact the ability to power through a task. A tendency of ADHD is the difficulty in follow through during tasks like homework, reading, chores, or duties.
Shift- Switching through processes in order to problem solve or attend to various tasks can be quite difficult for the child with attention struggles.
You can see how all of these areas are related and work cohesively with one another in typical daily tasks. It makes sense that the child who struggles with attention and sustained focus will have difficulty with a multitude of executive functioning skills.
More tools for addressing attention needs in kids
HUGE Sensory Resource
There are so many strategies to address attention in kids and activities that can help address attention needs. One tactic that can be a big help is analyzing precursors to behaviors related to attention and addressing underlying needs. The Attention and Sensory Workbook can be a way to do just that. The Attention and Sensory Workbook is a free printable resource for parents, teachers, and therapists. It is a printable workbook and includes so much information on the connection between attention and sensory needs. Here’s what you can find in the Attention and Sensory Workbook:
Includes information on boosting attention through the senses
Discusses how sensory and learning are connected
Provides movement and sensory motor activity ideas
Includes workbook pages for creating movement and sensory strategies to improve attention
A little more about the Attention and Sensory Workbook:
Sensory processing is the ability to register, screen, organize, and interpret information from our senses and the environment. This process allows us to filter out some unnecessary information so that we can attend to what is important. Kids with sensory challenges often time have difficulty with attention as a result. It’s been found that there is a co-morbidity of 40-60% of ADHD and Sensory Processing Disorder. This workbook is an actionable guide to help teachers, therapists, and parents to help kids boost attention and focus in the classroom by mastering sensory processing needs. You will find information on the sensory system and how it impacts attention and learning. There are step-by-step strategies for improving focus, and sensory-based tips and tricks that will benefit the whole classroom. The workbook provides tactics to address attention and sensory processing as a combined strategy and overall function. There are charts for activities, forms for assessment of impact, workbook pages for accommodations, and sensory strategy forms.
Adi Stern, Adina Maeir; Validating the Measurement of Executive Functions in an Occupational Context for Adults With Attention Deficit Hyperactivity Disorder. Am J Occup Ther 2014;68(6):719-728. doi: 10.5014/ajot.2014.012419.
“Attention-Deficit/Hyperactivity Disorder (ADHD): The Basics.” National Institute of Mental Health. Retrieved from https://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder-adhd-the-basics/index.shtml
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