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[(th)22.2(e)-356(v)13.1(ar)27.6(ia)19.8(b)13.1(i)0(l)24.6(i)0(t)24.6(y)-353.6(in)-344.5(th)22.2(e)-349.7(c)0(o)23.9(u)0(r)23.7(s)0(e)-344.1(o)13.1(f)-356.2(P)14.6(AN)19.7(S)14.6(/)0(P)23.7(A)0(N)19.7(D)0(A)26(S)0(,)-342.4(c)0(l)19.8(i)15.4(n)13.1(i)0(c)19.8(i)15.4(an)17.5(s)-348.5(s)0(h)18.8(o)13.1(u)13.1(l)0(d)]TJ
T*
[(b)13.1(e)-387.6(ca)21.4(u)13.1(t)0(i)18.2(o)13.1(u)13.1(s)-386.4(ab)23.9(ou)19.9(t)-389.2()67.4()16.9(c)0(h)23.9(a)0(s)22.7(i)0(n)22.2(g)13.1()67.4()-387.8(th)22.2(e)-387.6(i)0(l)18.2(l)15.4(n)13.1(e)0(s)22.7(s)-392.7(b)13.1(y)-385.2(re)21.2(ac)21.4(t)15.4(i)0(n)22.3(g)-385.2(to)-376.1(te)19.8(mp)22.7(o)13.1(r)0(a)21.2(r)0(y)]TJ
0 -1.2266 TD
[(sy)25.1(mp)22.7(to)22.2(m)-470.9(e)0(x)23.9(a)0(c)21.4(e)0(r)21.2(b)13.1(at)19.8(i)15.4(o)13.1(ns)-461.8(or)-463.2(in)22.2(cr)21.2(ea)27.8(si)21.1(n)13.1(g)-473.7(me)20.3(d)13.1(i)0(c)26.2(a)0(t)19.8(i)0(o)22.2(n)-473.7(d)13.1(o)13.1(s)0(a)22.7(g)13.1(es)-464.2(b)13.1(e)0(f)21.2(o)13.1(re)]TJ
0 -1.2203 TD
[(ma)20.3(x)13.1(i)15.4(mu)22.7(m)-256(b)13.1(en)23.9(e)18.9(t)15.4(s)-259.9(o)13.1(f)-255(t)15.4(h)13.1(e)-261.2(d)13.1(ru)23.7(g)-252.4(a)0(n)23.9(d)-258.7(o)13.1(t)15.4(he)23.9(r)-255(m)0(e)20.3(d)13.1(ic)19.8(al)-239.4(in)22.3(te)19.8(r)16.9(v)0(e)17.5(n)13.1(t)15.4(i)0(o)22.2(n)13.1(s)-259.9(h)13.1(av)23.9(e)]TJ
T*
[(b)13.1(e)0(e)21.4(n)-442.1(re)21.2(al)26.2(iz)19.8(ed)23.9(.)-439.2(T)0(h)20.1(e)-438.2(fo)23.7(ll)24.6(ow)23(in)22.2(g)-442.1(r)0(e)21.2(c)0(o)23.9(m)0(m)25.5(e)0(n)23.9(d)13.1(at)19.8(io)22.3(n)13.1(s)-443.3(ar)27.6(e)-444.5(b)13.1(as)22.7(ed)-431.4(o)13.1(n)-442.1(th)22.2(e)]TJ
T*
[(au)23.9(th)22.2(o)13.1(r)0(s)22.5()-330.9(ex)23.9(te)19.8(n)13.1(s)0(i)21.1(v)13.1(e)-330.7(c)0(l)19.8(i)15.4(n)13.1(i)0(c)19.8(a)0(l)-321.6(e)0(x)23.9(p)13.1(er)21.2(i)15.4(e)0(n)23.9(c)0(e)-326.3(a)0(n)23.9(d)-328.3(ar)21.3(e)-330.7(i)0(n)22.2(t)0(e)19.8(n)13.1(d)13.1(e)0(d)-317.6(t)0(o)-319.2(s)0(e)22.7(r)0(v)23.7(e)-337(as)]TJ
0 -1.2266 TD
[(g)13.1(u)13.1(i)0(d)22.2(e)0(l)19.8(i)15.4(n)13.1(e)0(s)-274.5(f)0(o)23.7(r)-280.3(mi)18.7(n)13.1(i)15.4(mi)18.7(zi)26.2(n)13.1(g)-284(d)13.1(i)0(s)21.1(t)15.4(re)21.2(ss)-273.3(an)23.9(d)-284(d)13.1(y)13.1(s)0(f)22.5(u)13.1(n)13.1(c)0(t)19.8(i)15.4(on)-270.9(of)-273.5(af)21.2(f)16.9(e)0(c)21.4(t)0(e)19.8(d)-284(ch)23.9(i)15.4(l)0(-)]TJ
0 -1.2203 TD
-.014 Tc
[(dr)-14(e)7.2(n)-.9(.)-371(E)-14(d)6.1(u)-.9(c)-14(a)7.4(ti)-14(o)8.3(n)-.9(,)-377.3(s)-14(u)11.1(ppor)-14(t)5.6(i)1.4(v)-14(e)-363.2(a)-14(n)9.9(d)-373.9(b)-.9(e)-14(h)9.9(a)-14(v)9.9(i)-14(o)8.2(r)-14(a)7.2(l)-371.6(t)-14(h)8.3(e)-14(r)13.6(a)-14(pie)-14(s)8.7(,)-371(a)-14(n)9.9(d)-373.9(ps)-14(y)4.8(c)-14(h)9.9(o)-.9(-)]TJ
T*
0 Tc
[(ac)21.4(ti)24.6(v)13.1(e)-318.1(me)20.3(d)13.1(i)15.4(ca)21.4(ti)24.6(on)19.9(s)-316.8(a)0(r)27.6(e)-318.1(th)22.2(e)-318.1(m)15.9(ai)19.8(n)13.1(s)0(t)21.1(a)0(y)23.9(s)-316.8(o)13.1(f)-318.3(sy)25.1(m)15.9(p)0(t)22.2(o)13.1(ma)20.3(ti)24.6(c)-318.1(t)15.4(re)21.3(at)19.8(m)15.9(e)0(n)23.9(t)-319.7(fo)23.7(r)]TJ
0 -1.2267 TD
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[(PA)-13.7(N)6(S).9(/)-13.7(P)10(A)-13.7(N)6(D)-13.7(A)12.3(S)-13.7(.)-292.9(An)-13.7(t)8.5(i)-13.7(m)11.3(i)-13.7(c)6.1(r)-13.7(o)10(b)-.6(i)-13.7(a)12.5(l)-13.7(s)-289.8(a)-13.7(n)10.2(d)-304.1(i)1.7(m)-13.7(m)5.5(unom)-13.7(o)9(dul)-13.7(a)6.1(t)1.7(or)-13.7(y)-293.5(t)1.7(he)-13.7(r)7.6(a)-13.7(p)10.2(i)-13.7(e)6.1(s)]TJ
0 -1.2203 TD
0 Tc
[(al)19.8(so)-329(ma)20.3(y)-340.9(b)13.1(e)-343.4(i)0(n)22.2(d)13.1(ic)19.8(at)26.2(ed)23.9(,)-344.4(a)0(s)-331.4(d)13.1(is)21.1(cu)23.9(ss)23.9(ed)-336.6(i)15.4(n)-340.9(Pa)18.9(rt)26(s)-342.1(2)-347.3(an)23.9(d)-340.9(3)-347.3(o)13.1(f)-343.6(t)15.4(h)0(i)22.2(s)-342.1(se)22.7(ri)19.6(es)]TJ
T*
-.0131 Tc
[(\()-13.1(B)12.2(r)-13.1(o)10.6(w)-13.1(n)-274.7(e)-13.1(t)-265.2(a)-13.1(l)6.7(.)-281.6(2017)-13.1(;)-269.1(C)-13.1(o)8.4(ope)-13.1(r)8.1(s)-13.1(t)8(o)0(c)-13.1(k)-267.5(e)-13.1(t)-271.5(a)-13.1(l)6.7(.)-281.6(2017\))-13.1(.)]TJ
/F10 1 Tf
0 -2.447 TD
0 Tc
(Safety)Tj
/F6 1 Tf
1.1128 -1.8337 TD
[(A)-306.3(comprehensive)-305.5(diagnostic)-310.4(evaluation)-311.6(should)-305.8(be)-304.9(the)-308.5(rst)-301.6(step)]TJ
-1.1128 -1.2203 TD
[(in)-401.4(the)-403.3(treatment)-406.8(of)-406.3(children)-403.6(with)-401.4(PANS/PANDAS,)-407.7(as)-407.3(described)]TJ
0 -1.2266 TD
[(in)-287.6(Chang)-295.6(et)-290(al.)-292.9(\(2015\).)-289.7(When)-286.9(taking)-292.1(the)-295.8(childs)-289(history,)-289.5(particular)]TJ
0 -1.2203 TD
[(attention)-301.1(should)-299.5(be)-304.9(paid)-295.3(to)-300.2(symptoms)-300.4(that)-305.7(pose)-298.8(a)-299.1(risk)-303(to)-300.2(the)-302.1(child)]TJ
T*
[(or)-418.9(his)-421.1(family,)-421.3(such)-419(as)-419.9(impulsivity,)-420.7(physical)-421.1(violence)-422.4(or)-418.9(aggres-)]TJ
T*
[(sion,)-303.4(refusal)-309(to)-306.5(eat)-310.9(or)-305.1(drink,)-304.3(and)-304.5(suicidality;)-308.8(if)-302.8(found,)-306.6(they)-308(should)]TJ
0 -1.2266 TD
[(be)-425.1(immediately)-429.7(addressed)-431.5(with)-426.7(appropriate)-432.4(environmental,)-426.7(edu-)]TJ
0 -1.2203 TD
[(cational,)-479.9(and)-475.2(pharmacological)-484.5(measures.)-476.4(Crisis)-482.7(management)-477.4(in)]TJ
T*
[(PANS/PANDAS)-215.1(is)-206.6(similar)-214.4(to)-205.4(that)-210.8(of)-210.3(other)-208.9(disorders)-212(presenting)-207.8(risk)]TJ
0 -1.2266 TD
[(of)-279.8(self-harm)-282.6(\(AACAP)-284.8(2012\).)]TJ
1.1128 -1.2203 TD
-.0211 Tc
[(Inpati)-5.7(ent)-378.7(h)4.7(ospi)-5.7(tali)-5.7(zation)-374.7(m)1.2(ay)-374.7(be)]TJ
13.0631 0 TD
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[(r)4.6(e)-1.6(qu)7.2(ir)4.6(e)4.8(d)-378.5(to)-372.2(con)7.2(t)3.2(ain)-378.5(a)4.8(nd)-372.2(ad)7.2(dre)4.8(s)-.3(s)]TJ
-14.176 -1.2203 TD
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[(dangero)5.4(us)-242.4(behaviors)-242.4(o)-.9(r)-237.5(i)1.4(f)-243.8(t)1.4(h)5.4(e)-243.6(patient)]TJ
14.1949 0 TD
-.0193 Tc
[(need)6.5(s)-241.3(c)4.1(lo)6.5(ser)-242.7(m)2.9(ed)6.5(ical)-244.1(mo)6.5(nito)6.5(ring)]TJ
-14.1949 -1.2266 TD
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[(while)-390.2(starting)-387.7(p)-2(sychiat)-6.1(r)1.7(ic)-390.2(medi)-6.1(ca)]TJ
13.0884 0 TD
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[(tions)-388.3(\(e.)-4.8(g)4.9(.)-4.8(,)-384.2(borderline)-389.6(Q)1.6(Tc,)-390.5(o)-1.4(r)-389.7(d)4.9(e-)]TJ
-13.0884 -1.2203 TD
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[(hyd)7.2(ratio)7.2(n)-239.4(seco)7.2(ndary)-233.1(to)-233.1(re)]TJ
9.7246 0 TD
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[(s)-4.2(t)-.7(ri)-7.1(cte)-5.5(d)-237(or)-5.6(al)-241(inta)-5.5(ke)-5.5(\).)]TJ
7.8657 0 TD
-.0212 Tc
[(Ideally,)-239.1(t).6(he)-238.1(child)-242(woul)-5.8(d)]TJ
10.4075 74.5598 TD
-.0206 Tc
[(be)-408.2(hospitalized)-405.8(on)-405.8(a)-408.2(p)-1.1(edi)-5.2(a)2.8(tric)-408.2(beha)]TJ
14.0748 0 TD
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[(vioral)-403.1(unit)-409.4(s)4.4(taffed)-411.7(b)5.6(y)-405.4(person)5.6(nel)]TJ
-14.0748 -1.2203 TD
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[(comfortable)-382.6(w)2.2(ith)-380.2(m)2(edical)-384.2(p)5.5(r)-3.4(oced)5.5(ur)]TJ
13.8978 0 TD
[(es)-381.5(and)-380.3(i)1.4(nterventions)-381.5(and)-380.3(e)-3.4(x)5.4(p)-.9(eri-)]TJ
-13.8978 -1.2266 TD
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[(enced)-227.9(i)2.1(n)-227.9(t)2.1(he)-224(use)-224(o)-.2(f)-224.1(b)-.2(eh)6.1(avior)-224.1(m)2.5(odication)-227.9(t)2.1(echniq)6.1(u)-.2(es)-222.7(and)-227.9(c)3.7(ontainment)]TJ
0 -1.2203 TD
[(of)-382.3(aggres)4.8(sive)-375.8(or)-382.3(s)4.8(e)-2.8(lf-h)6(armin)6(g)-379.7(beha)]TJ
13.8092 0 TD
-.0203 Tc
[(v)5.5(i)-4.9(o)5.5(r)-3.4(.)-377.3(I)2.9(n)-380.2(a)-3.3(dd)5.5(itio)5.5(n,)-383.6(th)5.5(e)-382.6(unit)-377.9(w)2.2(ould)]TJ
-13.8092 -1.2203 TD
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[(allow)-390.5(p)-1.5(arents)-394.7(to)-387.2(rem)-5.1(a)2.4(in)-393.6(at)-391.3(the)-389.7(c)-4(h)]TJ
13.3856 0 TD
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[(ilds)-394(b)5.5(e)-3.3(ds)4.3(ide)-389(t)-4.9(h)5.5(r)-3.4(ou)5.5(gho)5.5(ut)-390.6(the)-389(s)-2(tay)5.5(,)]TJ
-13.3856 -1.2266 TD
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[(since)-230.4(s)-1.5(eparation)-234.3(a)3.6(nxiety)-228(i)2(s)-235.5(p)-.3(res)4.8(e)-2.8(nt)-232(in)-228(mo)6(re)-230.4(than)-228(90%)-230.1(of)-230.6(patients.)-231.4(S)1.1(u)6(c)-2.8(h)]TJ
0 -1.2203 TD
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[(units)-421.4(are)-422.7(r).8(ar)-5.5(e,)-417.3(a)-5.4(n)3.4(d)-420.3(c)1(li)-7(nic)-5.4(i)-.6(a)-5.4(n)3.4(s)-421.4(o)3.4(f)-5.5(t)]TJ
12.8735 0 TD
-.0208 Tc
[(en)-418.7(mus)3.8(t)-416.3(decide)-414.7(between)-412.3(a)-414.8(general)]TJ
-12.8735 -1.2203 TD
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[(ped)5.6(i)-4.8(atrics)-280.1(ward)-272.6(an)5.6(d)-278.9(a)-275(pediatric)-275(p)-.7(sy)]TJ
13.4615 0 TD
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[(chiatric)-276.1(unit.)-277.1(Whil)-5.9(e)-276.1(p)-1.8(ediat)-5.9(r)1.9(ic)-276.2(units)]TJ
-13.4615 -1.2266 TD
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[(allow)-345.8(p)-1(arents)-343.7(t)-5.1(o)-342.5(room-in)-342.5(w)2(i)-5.1(t)1.3(h)-342.5(t)1.3(he)]TJ
13.6322 0 TD
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[(child)-342.2(and)-342.2(o)-.7(ffer)-344.8(more)-344.6(expertise)-344.6(i)1.6(n)]TJ
-13.6322 -1.2203 TD
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[(m)-4.4(e)3.1(dical)-472.8(p)-.8(rocedures)-476.2(and)-475.1(i)]TJ
10.3 0 TD
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[(nvasive)-471.7(i)1(nterventions,)-472.6(t)1(hey)-475.6(a)-3.8(re)-478(often)-475.6(ill-)]TJ
-10.3 -1.2203 TD
-.0212 Tc
[(equi)-5.8(pped)-254.7(t)-5.8(o)-254.7(deal)-258.7(w)-5(ith)-261(the)-257.1(p)-1.7(roblem)]TJ
13.2022 0 TD
-.0197 Tc
[(atic)-255.6(behav)6.1(i)2.1(ors)-254.4(o)-.2(f)-255.8(P)1.2(ANS/PANDAS,)]TJ
-13.2022 -1.2203 TD
-.02 Tc
[(such)-468.4(as)-463.3(severe)-464.5(agitation)5.8(,)-465.5(phys)4.6(ical)-472.5(combativ)5.8(eness)4.6(,)-471.8(and)-468.4(c)3.4(ompu)5.8(ls)4.6(ive)]TJ
0 -1.2266 TD
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[(r)-5.4(itual)-6.9(s)-453(\()-5.4(e.g.,)-455.2(r)-5.4(ef)-5.4(us)-4(a)-5.3(l)-455.8(to)-451.8(w)-6.1(e)1.1(a)-5.3(r)-454.4(c)-5.3(l)-.5(ot)]TJ
13.158 0 TD
-.0239 Tc
[(hi)-8.5(ng)-4.4(\).)-463.1(Fur)-7(t)-2.1(h)-4.4(e)-.5(rm)-8(or)-7(e,)-456.8(m)-8(e)-.5(d)-4.4(i)-2.1(c)-6.9(a)-.5(l)-457.4(u)-4.4(n)-4.4(its)]TJ
-13.158 -1.2203 TD
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[(are)-427.7(o)-1.6(ft)-5.7(en)-425.3(overly)-425.3(b)-1.6(right,)-428.7(n)4.7(oisy,)-422.4(a)-4.1(nd)-431.6(lled)-431.6(w)1.4(ith)-425.3(interruptions,)-422.4(w)-4.9(hich)]TJ
T*
-.0205 Tc
[(aggravate)-281.7(t)1.3(he)-281.7(sensory)-279.2(s)-2.2(ensitiviti)]TJ
12.317 0 TD
-.0217 Tc
[(es)-288(of)-283.1(children)-280.4(w)-5.5(ith)-280.4(PA)-5.5(NS/PAN)-5.5(DAS.)]TJ
-12.317 -1.2266 TD
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[(In)-210.1(contrast)-5.5(,)-207.2(w)1.6(hile)-212.5(chi)-5.5(l).9(d)-210.1(p)4.9(sychiatric)]TJ
13.2844 0 TD
[(units)-211.2(have)-206.1(established)-210(p)-1.3(rotocols)-211.2(for)]TJ
-13.2844 -1.2203 TD
-.0196 Tc
[(dealin)6.2(g)-297.3(w)-3.4(ith)-297.3(disruptive)-299.7(o)6.2(r)-299.9(d)-.1(an)6.2(gerou)6.2(s)-298.5(beh)6.2(a)-2.6(viors,)-294.4(the)-299.7(p)-.1(s)5(y)-.1(ch)6.2(iatric)-299.7(nu)6.2(rs)5(-)]TJ
T*
-.0214 Tc
[(i)-6(n)4.4(g)-444.5(s)3.2(t)-6(a)2(ff)-440.8(m)-5.5(a)2(y)-438.2(h)-1.9(ave)-447(little)-440.6(experi)-6(ence)-440.6(w)-5.2(ith)-438.2(i)-6(n)4.4(vasive)-440.6(procedures)-445.7(and)]TJ
0 -1.2266 TD
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[(treatments)4.5(,)-288.6(s)-1.8(uch)-285.2(a)-3.1(s)-286.4(l)1.7(umbar)-281.5(puncture)]TJ
14.2518 0 TD
-.0198 Tc
[(o)6(r)-287.5(adminis)4.8(t)-4.4(ration)-284.9(of)-287.5(in)6(trav)6(eno)6(u)-.3(s)]TJ
-14.2518 -1.2203 TD
[(immuno)6.1(globu)6.1(lin)6.1(.)-300.8(In)-297.4(such)-297.4(cases)4.9(,)-300.8(th)]TJ
13.3477 0 TD
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[(e)-300.3(c)-3.2(h)5.6(i)-4.8(ld)-297.9(might)-301.9(be)-300.3(tran)5.6(sferred)-304.2(t)1.6(o)-297.9(t)1.6(he)]TJ
-13.3477 -1.2203 TD
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[(gen)5.2(e)-3.6(ral)-251.8(p)-1.1(ediatrics)-248.9(unit)-251.8(a)-3.6(ccomp)5.2(a)-3.6(nied)]TJ
14.0685 0 TD
[(by)-254.2(s)3.9(t)1.1(aff)-256.8(from)-251.4(t)1.1(he)-256.6(p)5.1(s)-2.4(ychiatric)-256.6(u)-1.2(n)5.1(i)-5.3(t)]TJ
-14.0685 -1.2203 TD
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[(or,)-249.8(i)2.5(f)-249(n).2(eces)5.3(sary,)-249.8(t)2.5(o)-252.8(a)4.1(n)-252.8(i)2.5(ntensive)-248.9(ca)]TJ
12.9809 0 TD
[(re)-248.9(unit)-250.5(w)3.2(here)-248.9(th)6.5(e)-255.2(p).2(roced)6.5(u).2(res)-253.9(c)4.1(an)-246.4(be)]TJ
-12.9809 -1.2266 TD
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[(perfo)6(r)-2.9(med)-202.7(und)6(er)-199(sedation)6(.)-206.1(In)-202.7(rare)-205.1(cas)4.8(e)-2.8(s)4.8(,)-206.1(admissio)6(n)-202.7(to)-202.7(an)-196.4(in)6(tens)4.8(iv)6(e)-205.1(c)3.6(are)]TJ
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[(unit)-459.7(m)-4(ay)-462(be)-458.1(in)5.9(dicated)-462(t)1.9(o)-462(a)3.5(ddres)4.7(s)-463.2(l)1.9(ife-threatenin)5.9(g)-462(d)-.4(eh)5.9(ydration)-462(a)3.5(nd)]TJ
T*
-.0203 Tc
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1.1128 -1.2266 TD
0 Tc
[(Th)20.1(e)-204.3(m)0(a)20.3(j)0(o)15.9(r)0(i)19.6(t)0(y)-192.7(o)13.1(f)-204.4(c)0(h)23.9(i)0(l)18.2(d)0(r)17.3(e)0(n)-191.1(w)0(i)18.9(t)0(h)-192.7(P)0(A)18.1(N)0(S)18.1(/)15.4(PA)18.1(ND)19.7(AS)-196.9(re)21.2(q)13.1(u)0(i)15.9(r)0(e)-193.7(s)0(o)18.8(m)0(e)-188.3(t)0(y)15.9(p)13.1(e)]TJ
-1.1128 -1.2203 TD
[(of)-204(sc)16.3(ho)19.9(ol)-205.4(ac)21.4(co)17.5(mm)19.2(o)13.1(d)0(a)17.5(t)0(i)18.2(o)13.1(n.)-204.8(An)16.6(x)13.1(i)0(e)19.8(t)0(i)18.2(e)0(s)16.3(,)-211.6(OC)18.2(D)-211.5(s)0(y)18.8(m)0(p)16.4(t)0(o)22.2(m)0(s)21.5(,)-217.9(ti)24.6(cs)16.3(,)-211.6(f)0(r)14.7(e)0(q)23.9(u)0(e)17.5(n)0(t)]TJ
T*
[(ur)17.3(in)22.3(at)13.5(io)22.3(n)13.1(,)-496.1(at)19.8(te)19.8(nt)15.9(io)22.3(n-)17.3(d)13.1(e)0()19(c)0(i)19.8(t)-496.7(di)22.2(so)18.8(rd)17.3(er)-484.6(sy)18.8(mp)22.7(to)15.9(ms)21.5(,)-496.1(h)13.1(an)17.5(d)13.1(w)0(r)14(i)0(t)24.5(i)0(n)15.9(g)-492.7(di)22.2(f)18.8(-)]TJ
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[(cu)17.5(lt)18.2(ie)19.8(s,)-300.8(p)13.1(o)0(o)19.9(r)-311.9(co)17.5(g)13.1(n)0(i)15.9(t)15.4(iv)15.9(e)-311.7(a)0(n)23.9(d)-309.3(ph)19.9(ys)18.8(ic)19.8(al)-302.6(st)21.1(am)20.3(in)15.9(a,)-295.7(di)15.9(f)18.8(cu)23.9(lt)18.2(ie)19.8(s)-310.5(w)0(i)18.9(t)0(h)-300.2(m)0(a)20.3(t)0(h)]TJ
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[(an)17.5(d)-322(p)0(r)17.3(o)13.1(ce)15.1(ss)23.9(in)15.9(g)-322(s)0(p)25.1(e)0(e)15.1(d)13.1(,)-325.4(m)0(e)20.3(m)0(o)22.7(r)0(y)-311.4(i)0(s)14.7(s)0(u)25.1(e)0(s)16.3(,)-319.1(pa)17.5(in)22.3(,)-325.4(a)0(n)23.9(d)-322(fr)14.7(eq)23.9(ue)17.5(n)13.1(t)-326(ab)23.8(se)16.3(nc)17.5(es)]TJ
T*
[(ea)15.1(ch)-172.2(ca)15.1(u)13.1(s)0(e)-173.3(t)0(r)19.6(o)0(u)19.9(b)0(l)15.9(e)-179(an)17.5(d,)-173.1(in)-173.8(co)17.5(mb)22.7(in)22.3(at)13.5(i)15.4(o)0(n)19.9(,)-186.3(cr)21.2(ea)15.1(te)-169.9(gr)17.3(ea)21.4(t)-186.9(c)0(h)17.5(a)0(l)19.8(l)0(e)19.8(n)13.1(ge)17.5(s)-184.1(t)0(o)-173.8(t)0(h)22.3(e)]TJ
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0 -1.2203 TD
[(pe)17.5(rs)16.2(is)21.1(te)19.8(nc)17.5(e,)-371.6(as)22.7(se)16.3(rt)19.6(iv)22.3(en)17.5(es)16.3(s,)-364(an)17.5(d)-378.9(c)0(r)14.9(e)0(a)21.4(t)0(i)18.2(v)13.1(it)18.2(y)-378.9(i)0(n)-369.8(t)0(h)15.9(e)-375(sc)16.3(ho)19.9(ol)-369.8(an)17.5(d)-378.9(f)0(a)21.3(m)0(i)18.7(l)0(y)]TJ
T*
[(wi)18.9(ll)-165.1(yi)15.9(el)19.8(d)-170.2(b)0(e)17.5(t)0(t)18.2(e)0(r)-162.1(o)0(u)19.9(t)0(c)19.8(o)0(m)16.4(e)0(s)22.7(.)-173.6(A)-173.5(S)0(t)17.3(u)0(d)19.9(e)0(n)17.5(t)-174.3(S)14.6(t)0(u)15.9(d)13.1(y)-176.6(T)13.3(ea)15.1(m)-173.8(m)0(e)20.3(e)0(t)19.8(i)0(n)15.9(g)-170.2(to)-161.1(ar)14.9(ra)21.3(ng)19.9(e)]TJ
T*
[(fo)17.3(r)-425.7(t)0(h)22.2(e)-425.6(im)18.7(p)13.1(l)0(e)19.8(m)0(e)14(n)13.1(ta)19.8(ti)18.2(o)13.1(n)-423.1(of)-412.6(ei)13.5(th)22.3(er)-415(a)-425.6(5)13.1(04)-416.3(p)13.1(l)0(a)19.8(n)-423.1(\(S)18.8(ec)21.4(ti)18.2(on)-416.3(5)13.1(0)0(4)-416.3(o)13.1(f)-425.7(t)0(h)22.3(e)]TJ
0 -1.2266 TD
[(Re)12.8(h)13.1(a)0(b)17.5(i)0(l)18.2(i)15.4(ta)13.5(t)15.4(i)0(o)15.9(n)-239.8(Ac)20.5(t\))-226.9(o)13.1(r)-242.4(in)22.2(di)15.9(v)13.1(i)0(d)22.3(u)0(a)17.5(l)0(i)18.2(z)0(e)21.4(d)-239.8(ed)17.5(u)13.1(c)0(a)15.1(t)0(i)18.2(o)13.1(n)13.1(a)0(l)-233.1(p)13.1(la)19.8(n)-239.8(\()0(I)21.1(E)0(P)15.2(\))-236.1(ma)20.3(y)-239.8(b)13.1(e)]TJ
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T*
[(Th)13.8(e)-311.7(I)0(E)23.8(P)-314.2(sh)18.8(o)13.1(u)0(l)15.9(d)-309.3(pr)17.3(o)13.1(v)0(i)15.9(d)13.1(e)-311.8(s)0(p)18.8(e)0(c)15.1(i)15.4(c)-303.5(in)15.9(d)13.1(i)0(v)15.9(i)15.4(du)19.9(al)13.5(l)15.4(y)-315.7(ta)19.8(il)18.2(o)13.1(r)0(e)14.9(d)-309.3(ac)21.4(co)17.5(mm)19.2(od)19.9(a-)]TJ
0 -1.2266 TD
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[(fr)14.7(o)13.1(m)-230.7(sc)16.3(h)13.1(o)0(o)19.9(l)0(.)-221.4(L)0(e)17.7(g)0(a)17.5(l)0(l)18.2(y)13.1(,)-230.5(t)0(h)15.9(e)-229.6(5)13.1(0)0(4)-220.3(o)0(r)-222.9(I)0(E)17.5(P)-232(mu)22.7(st)-219.2(be)-222.7(pe)17.5(ri)19.6(o)13.1(d)0(i)15.9(c)0(a)21.4(l)0(l)18.2(y)-233.5(re)21.2(vi)22.2(ew)14.2(ed)17.5(,)]TJ
T*
[(us)18.8(ua)17.5(ll)18.2(y)-410.5(a)0(n)23.9(n)0(u)19.9(a)0(l)13.5(l)15.4(y.)-400.8(PA)18.1(NS)-399.3(ch)17.5(il)18.2(d)13.1(r)0(e)21.3(n)0()17.3(s)-411.7(n)13.1(e)0(e)15.1(d)13.1(s)-411.7(c)0(h)17.5(a)0(n)23.9(g)0(e)-399.8(d)0(a)17.5(y)-410.5(to)-401.4(d)13.1(a)0(y)-399.8(a)0(n)17.5(d)]TJ
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T*
[(da)17.5(ti)18.2(o)13.1(n)0(s)-430.2(w)0(i)18.9(t)0(h)22.3(o)0(u)19.9(t)-439.8(re)21.2(v)13.1(i)0(s)14.7(i)0(t)24.5(i)0(n)15.9(g)-435.8(th)22.3(e)-438.2(5)13.1(04)-429(o)13.1(r)-438.4(IE)17.5(P)-434.4(p)0(r)17.3(o)13.1(ce)15.1(ss)-425(o)13.1(f)0(t)19.6(e)0(n)17.5(.)-439.2(T)13.3(y)0(p)20(i)0(c)19.8(a)0(l)]TJ
T*
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[(General)6.6(Excusing)-253.2(the)-255.6(c)-2.7(h)6.1(i)2.1(ld)6.1(s)-254.3(ab)]TJ
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[(assignments)-337.1(or)-330.4(tests.)]TJ
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[(Separation)-517.4(anxietyallowing)-521.9(a)-514.1(parent)-520.7(to)-515.2(be)-519.9(in)-515.2(or)-513.8(near)-524(the)]TJ
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T*
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[(Urinary)-441.5(urgency/frequencyleaving)-454.1(the)-447.6(class)-445.1(without)-448.2(asking)]TJ
.0885 -1.2203 TD
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[(Dysgraphia)-567.5(or)-570.7(handwriting)-565.1(difcultieshaving)-570.6(a)-571(note-taker)]TJ
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[(in)-395.1(class,)-403.7(dictating)-395.9(tests)-402.4(and)-393(homework,)-402.9(enlarging)-396.8(worksheets,)]TJ
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[(writing)-414.5(o)-3.5(n)-408.2(l)-1.2(arge)-416.9(grid)-414.5(paper,)-417.9(an)]TJ
13.7334 0 TD
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[(d)-414.2(u)-3.2(sing)-414.2(a)-416.6(k)3.1(eyboard,)-411.3(voice-)]TJ
-13.7334 -1.2203 TD
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[(recognition)-331.1(s)2.8(oftware,)-328.2(or)-327.4(audi)6.3(o)-337.4(r)1.4(ecorder.)]TJ
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[(Dyscalculia)-374.9(and)-367.7(math)-368.4(difcultiesusing)-373.8(a)-368.7(calculator)-373.5(or)-374.7(times)]TJ
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[(table)-332.9(and)-336.1(working)-335.3(with)-331.9(a)-337(resource)-332.2(teacher)-341.7(or)-330.4(tutor.)]TJ
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(2)Tj
44.4501 0 TD
[(THIENEMANN)-336.8(ET)-338.7(AL.)]TJ
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[(Slowed)-429(processing)-426.3(speeddecreasing)-432.5(the)-428.6(number)-429.3(and)-430.9(length)]TJ
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[(sign)11.8(m)-9.7(e)3.6(nts,)-269.3(and)-265.9(g)-.4(iving)-272.2(d)-.4(irections)-267.1(in)-265.9(written)-272.2(a)-2.8(nd)-265.9(oral)-269.9(form,)-269.3(a)-2.8(nd)]TJ
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[(Poor)-328(physical)-332.6(and)-329.7(cognitive)-328.6(stamina,)-333.2(painshorter)-329.1(school)-333.5(day)]TJ
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[(with)-344.5(reduced)-347.9(academic)-344.5(load,)-342.5(less)-348.3(homework,)-346(rest)-343.4(periods)-341.9(dur-)]TJ
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[(adapting)-331.4(physical)-339(education)-333.4(requirements.)]TJ
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[(When)-312.2(acute)-318.7(exacerbations)-314.8(of)-311.4(PANS/PANDAS)-316.3(symptoms)-313.1(have)]TJ
-1.1128 -1.2203 TD
[(abated,)-352.7(these)-349(accommodations)-354.2(should)-350(be)-342.9(re-evaluated.)-357.5(Attending)]TJ
T*
[(school)-308.2(and)-304.5(doing)-305.1(school)-301.9(work)-307.5(may)-308(be)-304.9(part)-304.3(of)-305.1(an)-304.9(appropriate)-306(psy-)]TJ
0 -1.2266 TD
[(chotherapeutic)-285.5(plan.)-273(As)-275.4(the)-276.9(childs)-276.4(function)-274.7(improves,)-278.3(the)-276.9(accom-)]TJ
0 -1.2203 TD
[(modations)-314.3(can)-313.2(be)-304.9(peeled)-318.2(back)-306.4(as)-312.4(symptoms)-313.1(improve)-306.3(and)-310.8(to)-312.9(align)]TJ
T*
[(with)-281.3(therapeutic)-284.5(goals.)]TJ
/F10 1 Tf
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[(Family)-340.3(Support)-331.1(and)-335.7(Education)]TJ
/F6 1 Tf
1.1128 -1.8336 TD
[(The)-184.1(emo)14.5(tio)12.4(nal)-182(and)-184.3(beh)18(avi)14(oral)-184.1(sy)12.4(mpt)12.9(oms)-180.3(of)-191.3(PAN)15.2(S/P)12.9(AN)13.3(DAS)-187.1(can)]TJ
-1.1128 -1.2203 TD
[(str)12.6(ess)-268.9(pat)14(ie)13.5(nts)-269.3(and)-266.5(th)15.9(eir)-266.8(fam)11.9(ili)14.7(es.)-264.8(Ofte)14.9(n)-271.4(one)-266.5(par)15.4(ent)-264.2(must)-259.7(sta)12.8(y)-277.7(h)0(o)13.6(m)0(e)]TJ
T*
[(fro)15.2(m)-199.1(wor)14.5(k)-195.5(t)0(o)-192.7(pro)17.8(vide)-181.5(roun)18.3(d-t)13.8(he-)15.4(clo)14(ck)-191.1(car)13(e)-197.9(for)-187.1(the)-188.3(chi)14(ld)-186.4(with)-186.4(PAN)15.2(S/)]TJ
0 -1.2266 TD
[(PAND)18.8(AS.)-345.3(In)-349.4(addi)20.8(tio)12.4(n)-353.6(t)0(o)-344.5(prov)18.3(idi)12.4(ng)-346.8(com)14.5(for)15.2(t)-351.3(and)-348.7(car)13(e,)-346.3(the)-346.4(par)15.4(ent)14(s)]TJ
0 -1.2203 TD
[(must)-183.8(als)12.8(o)-201.8(nd)-186.8(and)-190.6(coo)18(rdi)13.8(nat)14(e)-197.9(med)14.5(ica)11.6(l)-199.5(car)13(e)-197.9(and)-190.6(int)12.4(era)13(ct)-195.1(wi)12.6(th)-192.7(scho)17.3(ols)]TJ
T*
[(to)-274.9(sec)14.4(ure)-262.8(nece)13.7(ssa)15.6(ry)-273.5(acc)13.2(omm)19.7(odat)14.5(ion)16.4(s)-272.6(\(and)-262.3(car)13(e)-273.8(for)-269.3(sib)15.2(lin)12.4(gs)12.4(\).)]TJ
1.1128 -1.2266 TD
[(Cl)23.8(in)22.2(ic)26.2(ia)19.8(n)13.1(s)-487.6(sh)18.8(o)13.1(u)13.1(l)0(d)-477.3(e)0(n)23.9(s)0(u)25.1(r)0(e)-478.3(t)0(h)22.2(a)0(t)-479.7(f)0(a)21.2(m)15.9(il)24.5(ie)19.8(s)-487.6(u)13.1(nd)19.9(er)21.2(st)27.4(an)23.9(d)-492.7(t)15.4(h)13.1(e)-495.1(cl)26.2(in)22.2(ic)26.2(al)]TJ
-1.1128 -1.2203 TD
-.0143 Tc
[(c)-14.3(o)9.6(u)-14.3(r)9.4(s)-14.3(e)-529.1(of)-534.9(PA)-14.3(N)5.4(S).3(/)-14.3(P)9.4(A)-14.3(N)11.7(D)-14.3(A)5.4(S,)-535.7(i)-14.3(n)7.9(c)-14.3(l)11.9(ud)-14.3(i)7.9(n)-1.2(g)-538.6(i)1.1(t)-14.3(s)-524.4(unpr)-14.3(e)6.9(d)-1.2(i)-14.3(c)5.5(ta)-14.3(bly)-532.3(e)-14.3(pis)-14.3(o)10.8(di)-14.3(c)]TJ
T*
0 Tc
[(pa)23.9(tt)18.2(er)27.6(n.)-287(In)-279.8(se)22.7(v)13.1(e)0(r)21.2(e)-292.8(ca)21.4(se)22.7(s,)-288.1(i)15.4(t)-294.4(is)-282.4(n)13.1(o)0(t)-287.6(u)13.1(n)13.1(c)0(o)23.9(m)0(m)25.5(o)0(n)-283.6(f)0(o)23.7(r)-299.3(a)-292.8(c)0(h)23.9(i)0(l)24.6(d)-296.7(t)15.4(o)-296.7(in)22.2(si)21.1(st)-282.4(o)13.1(n)]TJ
0 -1.2267 TD
[(ob)19.9(se)22.7(ss)23.9(i)15.4(v)0(e)-210.1(c)0(o)23.9(m)0(p)22.7(u)13.1(ls)21.1(i)15.4(v)13.1(e)-223.2(r)0(i)26(t)0(u)22.2(a)0(l)19.8(s)0(,)-206(t)15.4(o)-220.8(r)0(e)21.2(s)0(i)27.4(s)0(t)-212.9(a)17(ny)-207.7(se)22.7(p)13.1(a)0(r)21.2(a)0(t)19.8(i)15.4(o)13.1(n)-220.8(fr)21.1(o)13.1(m)-218(h)13.1(i)0(s)-206.6(p)0(a)17.5(r)16.9(en)23.9(t)]TJ
0 -1.2203 TD
[(at)-188.8(al)19.8(l)15.4(,)-198.9(or)-191.3(t)15.4(o)-201.8(b)13.1(e)0(c)21.4(o)13.1(me)-188.3(en)23.9(ra)21.2(g)13.1(e)0(d)-191.1(a)0(t)-188.8(w)16.2(it)24.5(ho)19.9(u)13.1(t)-199.5(ap)23.9(p)13.1(a)0(r)21.2(e)0(n)23.9(t)-199.5(p)13.1(r)0(o)23.7(v)13.1(oc)17.5(a)17(t)0(i)18.2(o)13.1(n)13.1(.)-198.9(At)-189.7(su)25.1(ch)]TJ
T*
[(ti)18.2(m)15.9(e)0(s)22.7(,)-287.4(in)22.2(te)19.8(r)16.9(v)0(e)17.5(n)13.1(t)15.4(i)0(o)22.2(n)13.1(s)-291.6(s)0(h)25.1(o)13.1(u)13.1(l)0(d)-281.3(b)13.1(e)-292.8(a)17(im)18.7(ed)-273.3(at)-283.7(k)13.1(e)0(e)21.4(p)13.1(i)15.4(n)13.1(g)-290.4(t)0(h)22.2(e)-292.8(c)17(h)0(i)22.2(l)0(d)-281.3(s)0(a)22.7(f)16.9(e)-292.8(u)13.1(n)13.1(t)0(i)24.5(l)]TJ
T*
[(th)22.2(e)-248.5(a)0(n)23.9(x)13.1(ie)19.8(t)15.4(y)-246.1(o)13.1(r)-248.7(ra)21.2(g)13.1(e)-248.5(su)25.1(b)13.1(s)0(i)21.1(d)13.1(es)22.7(.)-243.2(M)12.4(in)22.2(im)25(iz)19.8(in)22.2(g)-246.1(t)15.4(ra)21.2(n)13.1(s)0(i)21.1(t)15.4(io)22.2(n)13.1(s)-247.3(an)23.9(d)-246.1(n)13.1(um)22.7(b)13.1(e)0(r)21.2(s)-247.3(o)13.1(f)]TJ
0 -1.2266 TD
[(ac)21.4(ti)24.6(vi)22.2(ti)24.6(es)22.7(,)-300.1(p)0(r)23.7(o)0(v)19.9(i)15.4(di)22.2(n)13.1(g)-303(re)21.2(st)-288.8(ti)24.5(me)20.3(s,)-288.1(d)13.1(e)0(c)21.4(r)0(e)21.2(a)0(s)22.7(i)15.4(n)13.1(g)-303(n)13.1(o)0(x)19.9(i)15.4(o)13.1(u)0(s)-291.1(s)0(e)22.7(n)13.1(so)18.8(r)16.9(y)-303(st)21.1(i)15.4(m)0(u)22.7(l)0(i)24.5(,)]TJ
0 -1.2203 TD
[(an)23.9(d)-239.8(r)0(e)27.6(m)0(o)22.7(v)13.1(in)22.2(g)-233.5(o)0(b)19.9(j)15.4(ec)21.4(ts)-225.5(th)22.3(at)-220.4(mi)18.7(g)13.1(h)13.1(t)-237.5(h)13.1(u)13.1(r)0(t)-220.6(t)0(h)22.2(e)-235.9(ch)23.9(il)24.6(d)-239.8(o)13.1(r)-236.1(o)13.1(t)15.4(h)0(e)17.5(r)16.9(s)-241(m)15.9(ay)-222.7(h)13.1(e)0(l)19.8(p)-233.5(to)]TJ
T*
[(de)23.9(cr)21.2(ea)21.4(se)-186(th)22.2(e)-197.9(n)13.1(u)13.1(m)0(b)22.7(e)0(r)-181.1(a)0(n)23.9(d)-195.5(se)22.7(ve)17.5(r)16.9(i)0(t)18.2(y)-195.5(o)13.1(f)-191.8()61.1()16.9(me)20.3(l)15.4(t)0(d)22.2(o)13.1(wn)23(s.)21.7()67.4()-198.1(On)23(ce)-180.9(th)22.3(e)-197.9(e)0(p)23.9(i)0(s)21.1(o)13.1(d)13.1(e)]TJ
0 -1.2266 TD
[(ha)23.9(s)-215.7(s)0(u)25.1(b)13.1(si)21.1(d)13.1(e)0(d)23.9(,)-205.2(pa)23.9(re)21.2(n)13.1(t)0(s)-200.2(s)0(h)25.1(o)13.1(ul)22.2(d)-208.2(b)13.1(e)-210.6(e)0(n)23.9(c)0(o)17.5(u)13.1(ra)27.6(ge)17.5(d)-208.2(t)15.4(o)-208.2(r)0(e)21.2(s)0(u)25.1(m)0(e)-201(t)0(h)22.2(e)0(i)26.2(r)-210.8(n)13.1(o)13.1(r)0(m)20.1(a)0(l)26.2(l)0(y)]TJ
0 -1.2203 TD
[(ef)21.2(fe)21.2(ct)26.2(iv)22.2(e)-280.1(p)0(a)17.5(r)16.9(en)23.9(ti)18.2(n)13.1(g)-277.7(st)21.1(ra)21.2(t)15.4(e)0(g)23.9(i)0(e)19.8(s)0(,)-269.2(i)15.4(nc)17.5(l)15.4(u)13.1(d)13.1(i)0(n)22.2(g)-284(se)22.7(t)15.4(t)0(i)24.6(n)0(g)-270.9(n)13.1(ec)21.4(es)22.7(sa)22.7(ry)-267.2(li)18.2(m)15.9(i)0(t)24.6(s)0(,)-269.2(r)0(e)21.2(-)]TJ
T*
-.0137 Tc
[(i)-13.7(n)8.5(f)-13.7(o)10(r)-13.7(c)7.5(in)-13.7(g)-335.2(d)-.6(e)-13.7(s)9(ir)-13.7(a)7.5(b)-.6(l)-13.7(e)-335.3(be)-13.7(h)10.2(a)-13.7(v)10.2(i)-13.7(o)8.5(r)-13.7(s)8.8(,)-339.1(a)-13.7(n)10.2(d)-342(i)-13.7(g)8.6(nor)-13.7(i)5.9(n)-.6(g)-342(o)-.6(r)-344.6(puni)-13.7(s)7.4(h)-.6(i)-13.7(n)8.6(g)-342(unw)-13.7(a)6.8(n)-.6(t)-13.7(e)6.1(d)]TJ
0 -1.2267 TD
0 Tc
[(be)23.9(ha)17.5(v)13.1(i)15.4(or)23.7(s)-241(b)0(y)-233(r)0(e)21.2(m)15.9(ov)19.9(i)15.4(n)13.1(g)-246.1(p)13.1(ri)26(v)13.1(i)0(l)18.2(e)0(g)23.9(e)0(s)22.7(.)-236.9(Of)20.4(te)19.8(n)13.1(,)-236.9(th)22.2(e)-242.2(a)0(f)21.2(f)0(e)21.2(c)0(t)26.2(e)0(d)-229.1(c)0(h)17.5(i)15.4(ld)-230.7(ca)21.4(n)-239.8(h)13.1(el)19.8(p)]TJ
0 -1.2203 TD
[(pa)23.9(re)21.2(n)13.1(t)0(s)-358.3(t)15.4(o)-366.2(d)13.1(is)21.1(ti)24.6(n)13.1(g)13.1(u)0(i)22.3(s)0(h)-354.3(u)13.1(nd)19.9(es)22.7(i)15.4(r)0(a)21.2(b)13.1(le)-353.2(be)23.9(ha)17.5(v)13.1(i)15.4(o)13.1(r)0(s)-356.9(r)0(e)21.2(q)13.1(u)13.1(i)0(r)19.6(i)15.4(n)13.1(g)-366.2(in)22.3(t)15.4(e)0(r)21.2(v)13.1(en)17.5(t)15.4(i)0(o)22.3(n)]TJ
T*
[(fr)21.1(o)13.1(m)-502.6(th)22.2(o)13.1(s)0(e)-489.5(t)0(h)22.2(a)0(t)-486(a)0(r)21.2(e)-501.4(an)-488.3(u)13.1(n)0(f)23.7(o)0(r)23.7(t)0(u)22.2(n)13.1(at)19.8(e)-501.4(m)15.9(an)17.5(i)15.4(f)0(e)21.2(s)0(t)21.1(a)17(ti)18.2(o)13.1(n)-499(o)13.1(f)-501.6(h)13.1(i)0(s)-491.1(P)14.6(AN)19.7(S)14.6(/)]TJ
T*
-.0145 Tc
[(P)-14.5(A)3.6(ND)-14.5(A)5.2(S)-278.2(s)-14.5(y)4.3(mp)-14.5(t)7.7(o)-1.4(m)-14.5(a)5.8(to)-14.5(l)7.7(o)-1.4(g)-14.5(y)-272.8(\()-86.2(M)-2.1(ot)-14.5(l)10.1(u)-14.5(c)9.4(k)-285.9(2013)-14.5(\))9.2(.)]TJ
1.1128 -1.2266 TD
0 Tc
[(Parents,)-358.5(themselves,)-354.4(suffer)-356.2(with)-350.8(the)-352.7(burden)-356.2(of)-349.4(caring)-356.3(for)-351.5(their)]TJ
-1.1128 -1.2203 TD
[(PANS/PANDAS)-404.8(aficted)-398.3(children.)-400.2(Many)-399.5(report)-400.7(feeling)-404.1(trauma-)]TJ
T*
[(tized)-238.1(by)-239.3(the)-232.6(sometimes)-239.2(lengthy)-241(course)-233.3(of)-241.9(seeking)-234.2(medical)-236.7(care)-241.8(and)]TJ
0 -1.2266 TD
[(from)-253.4(seeing)-247.4(their)-250.9(child)-248.3(ill;)-248.1(they)-251.1(often)-246.9(live)-255.1(fearing)-250.9(relapse.)-248.5(National)]TJ
0 -1.2203 TD
[(and)-253.9(regional)-251.8(support)-251(networks)-256.2(have)-249.5(formed,)-251.4(which)-253.9(may)-251.1(be)-248(helpful)]TJ
T*
[(to)-281.3(address)-284.6(this)-285.5(trauma)-283.9(and)-279.2(skills)-283.4(groups)-285.4(for)-282(PANS/PANDAS,)-287.6(par-)]TJ
0 -1.2266 TD
[(ents)-283.9(are)-284.2(also)-277.6(being)-282.2(piloted.)]TJ
/F4 1 Tf
0 -2.7189 TD
[(Behavioral)-336.7(and)-338.2(Pharmacological)-332.3(Interventions)]TJ
0 -1.2266 TD
[(for)-337.3(PANS/PANDAS)]TJ
/F6 1 Tf
1.1128 -1.8336 TD
-.0199 Tc
[(Cogn)5.9(itiv)5.9(e)-274.7(b)-.4(ehav)5.9(io)5.9(r)-274.9(t)1.9(herapy)-272.3(\(CBT)]TJ
12.9873 0 TD
-.0202 Tc
[(\))-275.2(\()3(specically)-272.6(expos)4.4(ure/res)4.4(pon)5.6(se)]TJ
-14.1001 -1.2203 TD
0 Tc
[(prevention)-225.6([ERP]\))-216.7(and)-222.3(minimizing)-223(family)-222.3(accommodation)-220.8(to)-218(OCD)]TJ
T*
[(behaviors)-507.8(have)-508.7(been)-508.7(repeatedly)-508.6(shown)-507.9(to)-508.9(be)-507.3(among)-503(the)-510.8(most)]TJ
T*
[(effective)-385.3(interventions)-378.8(for)-376.8(pediatric)-377.9(OCD)-382.9(\(OCD)-378.7(2004,)-374(Lebowitz)]TJ
0 -1.2266 TD
[(et)-435.4(al.)-425.7(2011\).)-433(While)-433.6(large-scale)-432.1(studies)-433.1(of)-431.6(these)-431.2(interventions)-429.4(in)]TJ
0 -1.2203 TD
[(PANS/PANDAS)-404.8(have)-401.2(not)-400.9(been)-401.2(conducted,)-401.8(pilot)-401.6(studies)-401.4(suggest)]TJ
T*
[(behavioral)-316.5(therapies)-311.9(are)-315.8(still)-312(highly)-308.6(effective)-315.7(in)-312.9(treating)-312.8(the)-308.5(OCD)]TJ
0 -1.2266 TD
[(symptoms)-332(of)-324.1(children)-327.7(with)-325.5(PANS/PANDAS)-329(\(Storch)-329.3(et)-327.9(al.)-324.5(2006\).)]TJ
0 -1.2203 TD
[(Treatment)-219.2(with)-218(CBT/ERP)-221.6(should)-217.3(be)-216.4(initiated)-216.6(as)-217.6(soon)-214.2(as)-217.6(possible)-217.6(to)]TJ
T*
[(maximize)-233.4(benets.)-223.1(During)-228.3(the)-226.3(acute)-230.1(phase)-224.9(of)-229.3(illness,)-225(the)-226.3(child)-223(may)]TJ
0 -1.2266 TD
[(not)-280.8(be)-273.3(ready)-276.9(to)-274.9(fully)-280.1(participate)-275.9(in)-274.9(CBT)-279.7(because)-279.3(of)-273.5(overwhelming)]TJ
0 -1.2203 TD
[(OCD)-401.9(or)-400(anxiety,)-404.4(sensory)-396(sensitivities,)-408.5(emotional)-401.7(lability,)-400.9(and/or)]TJ
28.0042 74.5598 TD
[(cognitive)-322.3(impairments.)-328.8(However,)-329.7(it)-323.2(is)-326.7(helpful)-325.8(when)-326.2(parents)-325.4(learn)]TJ
0 -1.2203 TD
[(strategies)-348.2(to)-344.5()54.8(hold)-345.6(the)-346.4(line)52.6()-343.6(and)-342.4(prevent)-349.5(symptoms)-344.7(from)-348.2(further)]TJ
0 -1.2266 TD
[(worsening)-268.4(through)-268.8(their)-263.5(inadvertent)-269.5(accommodation)-271.3(to)-268.6(the)-270.5(childs)]TJ
0 -1.2203 TD
[(irrational)-400.6(fears)-400.8(\()-84.3(March)-397.7(et)-403.8(al.)-394.1(1998;)-399.9(Lebowitz)-404.1(et)-397.5(al.)-400.4(2011,)-399.3(2014;)]TJ
T*
[(Motluck)-355.5(2013;)-362(Sukhodolsky)-352.5(et)-359.5(al.)-356.1(2013\).)-357.2(Understanding)-361.4(and)-361.4(ap-)]TJ
0 -1.2266 TD
[(plying)-378.2(CBT)-387.2(and)-380.3(ERP)-387.3(strategies)-386.1(will)-380.1(decrease)-391.3(distress)-385.8(and)-380.3(inter-)]TJ
0 -1.2203 TD
[(ference)-226.4(from)-221.8(symptoms)-218.2(in)-224.3(the)-220(short)-220.4(term)-225.6(and)-222.3(can)-218.3(provide)-226.9(tools)-215.5(that)]TJ
T*
[(can)-281.6(be)-279.7(used)-279.9(life-long)-280.9(to)-281.3(manage)-286.1(OCD,)-278.3(anxiety,)-284.3(and)-279.2(life)-283(stressors.)]TJ
1.1128 -1.2266 TD
-.015 Tc
[(P)5.9(s)-15(y)10.1(c)2(hoact)-15(i)9.6(v)4.5(e)-371(m).9(e)-15(d)15.2(ic)-15(a)12.8(tions)-369.8(can)-368.6(a)-15(l)11.2(s)3.3(o)-368.6(be)-371(q)4.5(u)-1.9(ite)-371(h)4.5(e)-15(l)11.2(p)-1.9(ful)-366.3(i).4(n)-368.6(t).4(he)-364.7(ma)-15(n)8.8(-)]TJ
-1.1128 -1.2203 TD
-.0151 Tc
[(agem)-15.1(e)11.5(n)-2(t)-360.1(o)-2(f)-365(P)-.6(ANS/PAN)-15.1(D)10.9(A)1.1(S)-367.3(s)3.2(ymptoms)3.2(.)-365.8(Althoug)4.4(h)-362.4(c)-15.1(o)8.8(n)4.4(tr)-15.1(o)14.9(l).3(l)-15.1(e)11.1(d)-362.4(t).3(r)-15.1(i)10.9(als)]TJ
T*
0 Tc
[(h)19.5(a)0(v)23.8(e)-261.2(n)19.5(o)13.1(t)-262.8(b)19.5(ee)27.8(n)-258.7(d)13.1(o)13.1(n)19.5(e,)-245.1(cl)26.2(i)15.4(n)13.1(i)15.4(c)17(al)-245.7(ex)23.9(p)19.5(e)0(r)27.6(i)15.4(en)30.2(ce)-250.5(s)18.3(u)13.1(g)13.1(g)19.5(es)29(t)15.4(s)-266.3(t)15.4(h)19.5(at)-245.7(an)30.2(x)13.1(i)15.4(et)26.2(y)13.1(,)-255.8(O)16.2(C)0(D)24.6(,)]TJ
T*
-.0152 Tc
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0 Tc
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[(Howeve)-15.5(r)12.1(,)-271.3(t)-15.5(h)13.1(e)-276.7(P)-1(AN)-15.5(S)15.2(/)-15.5(P)8.2(ANDA)-15.5(S)-263(c)1.5(li)-15.5(n)13.1(i)-.1(c)-15.5(a)12.3(l)-278.3(p)4(r)-15.5(e)12.1(s)-15.5(e)13.5(nta)-15.5(t)10.7(ions)-275.4(a)-15.5(r)12.1(e)-276.7(o)4(f)-15.5(t)10.5(en)-274.2(more)]TJ
T*
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[(complex,)-296.4(w)-15.3(i)10(th)-299.3(multiple)-295.4(s)-15.3(y)9.8(mptom)-302.9(t).1(ar)-15.3(g)14.7(e)-15.3(t)10.9(s)-300.5(pr)-15.3(e)12.3(s)-15.3(e)13.7(n)-2.2(ting)-299.3(s)3(imulta)-15.3(n)8.6(e)1.7(ous)-15.3(l)12.1(y.)]TJ
0 -1.2266 TD
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0 -1.2203 TD
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[(d)19.5(i)0(s)27.4(c)0(e)27.8(r)16.9(n)-208.2(r)0(e)27.6(s)0(p)31.4(o)13.1(n)13.1(s)18.3(es)-192.3(to)-192.7(p)13.1(h)13.1(a)17(rm)26.5(a)17(c)0(o)30.2(l)0(o)28.6(g)13.1(i)15.4(c)-210.6(i)15.4(n)19.5(te)26.2(r)16.9(v)13.1(e)17(n)13.1(t)15.4(i)15.4(o)13.1(n)13.1(s)-209.4(t)15.4(h)19.5(at)-195.1(r)16.9(e)0(q)23.9(u)19.5(i)15.4(r)0(e)-193.7(d)13.1(a)17(y)13.1(s)-209.4(o)13.1(r)]TJ
T*
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0 -1.2266 TD
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[(pe)-15.6(n)8.2(d)3.9(e)-15.6(n)14.6(t)-493.3(r)1.3(e)-15.6(l)10.6(apse)-15.6(s)-479.8(a)1.4(nd)-489.3(re)-15.6(m)11(itta)-15.6(n)14.6(c)-15.6(e)12.2(s)-490.5(of)-485.6(PA)-15.6(N)10.4(S)-1.1(/PAND)-15.6(A)10.4(S)-487.9(s)-15.6(y)15.8(m)-15.6(p)13.5(toms)-15.6(.)]TJ
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T*
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T*
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T*
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0 -1.2203 TD
[(P)14.5(A)16.2(N)16.2(S)14.6(/)15.4(P)14.6(AN)26(D)16.2(A)16.2(S)14.6(,)-262.2(a)0(s)-249.2(t)15.4(h)13.1(e)17(y)-265.1(m)15.9(a)17(y)-265.1(a)17(d)13.1(d)13.1(r)16.9(e)17(s)0(s)-248(t)0(h)28.6(e)-261.2(ch)23.9(i)15.4(l)15.4(d)13.1()16.9(s)-259.9(an)30.2(x)13.1(i)15.4(et)26.2(y)19.5(,)-262.2(ag)23.8(i)15.4(t)15.4(a)17(t)15.4(i)15.4(o)13.1(n)13.1(,)]TJ
T*
-.016 Tc
[(aggres)-16(s)7.9(i)-.6(on,)-398.3(i)-.6(ns)-16(o)9.1(m)-.1(nia,)-398.3(and)-394.9(o)-2.9(the)-16(r)-380.5(s)-16(y)9.1(mptom)-16(s)11.9(.)-398.3(C)-1.3(linicia)-16(n)14.2(s)-396.1(a)-16(n)7.9(d)-394.9(p)3.5(a)-16(r)11.6(e)-16(n)14.2(ts)]TJ
0 -1.2266 TD
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[(s)3.3(hou)4.5(l)-15(d)-340.5(be)-358.4(aw)-15(a)11.9(r)1.9(e)-358.4(t).4(hat)-360(p)4.5(e)-15(d)15.2(ia)-15(t)11.1(r)1.9(ic)-358.4(patie)-15(n)8.8(t).4(s)-350.8(m)-15(a)11.6(y)-355.9(exper)-15(i)11(ence)-358.4(s)-15(e)14(ver)-15(e)-341.5(dis)-15(-)]TJ
0 -1.2203 TD
[(inh)4.5(i).4(bition)-299(w)1.2(hen)-299(t).4(re)-15(a)12.8(t).4(e)-15(d)-288.3(with)-299(benzodiaz)-15(e)12.8(p)-1.9(ines)-15(,)-284.2(a)2(lthoug)4.5(h)-299(t).4(he)-295.1(me)-15(d)8.8(i).4(ca)-15(-)]TJ
T*
-.0154 Tc
[(tions)-281.7(a)-15.4(r)12.2(e)-282.9(o)4.1(t)-15.4(h)13.2(e)-15.4(r)12.2(wis)-15.4(e)-270.9(wel)-15.4(l)-269.1(toler)-15.4(a)12.2(te)-15.4(d)-269.8(i)0(n)-280.5(y)4.1(outh)-280.5(w).8(ith)-280.5(PA)-15.4(N)10.6(S)-.8(/PAND)-15.4(A)10.6(S.)]TJ
/F4 1 Tf
0 -2.447 TD
0 Tc
[(Management)-335.8(of)-330.2(Specic)-335.8(PANS/PANDAS)-340.9(Symptoms)]TJ
/F10 1 Tf
0 -1.8336 TD
[(Obsessive)-333.8(compulsive)-334.3(\(OCD\))-335.4(symptoms)]TJ
/F6 1 Tf
1.1128 -1.8336 TD
[(In)-248.2(general,)-260(management)-256.1(of)-248.2(obsessions)-259.2(and)-247.6(compulsions)-257.6(follows)]TJ
-1.1128 -1.2203 TD
[(the)-371.7(usual)-371.9(standard)-375.5(of)-374.7(care)-374.6(for)-370.5(pediatric)-377.9(OCD)-370.3(\(Geller)-378.4(and)-374(March)]TJ
0 -1.2266 TD
[(2012\).)-496.3(Evidence-based)-499.7(therapies)-501.6(include)-502.6(CBT,)-497.6(parent)-495.4(manage-)]TJ
0 -1.2203 TD
[(ment)-362.1(training,)-363.9(and)-361.4(medications.)-369.3(A)-363.2(small)-366.8(study)-363.2(of)-362(intensive)-361.5(CBT)]TJ
T*
[(with)-319.2(family)-323.5(involvement)-318.6(found)-322.6(that)-318.3(OCD)-319.7(symptoms)-319.4(improved)-324.8(in)]TJ
0 -1.2267 TD
[(PANDAS)-311(patients)-311.4(during)-307.2(the)-308.5(current)-307.8(episode)-310.1(and)-310.8(benets)-308.7(carried)]TJ
0 -1.2203 TD
[(over)-439.3(to)-439.3(subsequent)-442.6(ares)-441.1(\(Storch)-443.1(et)-441.7(al.)-444.7(2006\).)-439.4(Applying)-437.4(parent)]TJ
T*
[(management)-294.1(techniques)-289.8(\(PMT\),)-289.3(which)-291.8(include)-287.7(encouraging)-293(fami-)]TJ
T*
[(lies)-490.2(to)-489.9(not)-489.4(participate)-490.9(in)-489.9(behaviors)-488.8(accommodating)-492.7(the)-491.8(childs)]TJ
0 -1.2266 TD
[(avoidance)-489.8(and)-487.8(rituals,)-492(positively)-489(reinforcing)-495.9(desired)-489.8(behaviors,)]TJ
0 -1.2203 TD
[(setting)-454.9(clear)-454(limits,)-457.1(expectations,)-456.3(and)-449.9(consequences,)-460.5(and)-449.9(estab-)]TJ
T*
[(lishing)-370.2(reward)-377.2(systems,)-373.4(will)-373.8(likely)-372(improve)-369.6(symptoms)-376.3(and)-367.7(child)]TJ
0 -1.2266 TD
[(compliance.)-297.5(PMT)-294.8(are)-296.8(particularly)-300.9(useful)-291.8(when)-300.9(PANS)-292.7(patients)-298.7(are)]TJ
0 -1.2203 TD
[(not)-230.2(ready)-232.6(or)-229.2(willing)-237.3(to)-230.7(use)-229.8(CBT)-235.4(themselves)-237.6(\(Lebowitz)-229.2(et)-233.1(al.)-236(2014\).)]TJ
1.1128 -1.2203 TD
[(Selective)-275.2(serotonin)-281.7(reuptake)-275.5(inhibitors)-280.6(\(SSRI\))-278.7(are)-277.9(the)-276.9(preferred)]TJ
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[(medication)-454.2(for)-459(treatment)-457.3(of)-450.6(OCD)-458.8(in)-452(PANS,)-453.7(based)-458.8(on)-454.3(multiple)]TJ
0 -1.2203 TD
[(placebo-controlled)-290.2(clinical)-297.6(trials)-287.2(\(Geller)-296.2(2003;)-286.1(Grados)-291.1(and)-291.8(Riddle)]TJ
T*
[(2001;)-235.5(Pediatric)-243.7(OCD)-243.8(Treatment)-244.5(Study)-240.4(Team)-240.2(2004,)-241.2(2011\))-240.4(\(Gabbay)]TJ
T*
[(and)-355(Coffey)-357.2(2003;)-355.7(Coffey)-350.9(and)-355(Wieland)-359.1(2007\).)-357.2(Fluoxetine,)-355(sertra-)]TJ
0 -1.2266 TD
[(line,)-340.2(uvoxamine,)-344.1(and)-336.1(clomipramine)-345.6(are)-341.1(Food)-344.4(and)-336.1(Drug)-345.4(Admin-)]TJ
0 -1.2203 TD
[(istration)-283.5(\(FDA\))-286.2(approved)-288.1(for)-282(treating)-287.5(pediatric)-289.4(OCD)-281.7(and)-285.5(have)-287.4(the)]TJ
T*
[(most)-518.9(evidence)-528.3(to)-521.5(support)-522.9(their)-522.8(use)-520.6(\(ibid\).)-519.1(Clinical)-527.6(experience)]TJ
0 -1.2266 TD
[(suggests)-227.4(both)-229.7(that)-229.8(SSRIs)-233(may)-225.8(be)-229.1(helpful)-230.9(and)-228.6(that)-229.8(using)-230.4(a)-229.6(low)-227.2(dose)]TJ
0 -1.2203 TD
[(and)-374(slow)-373.3(titration)-381.1(minimizes)-374.8(the)-371.7(risk)-378.9(of)-374.7(side)-372.4(effects.)-377.6(Upward)-381.7(ti-)]TJ
T*
[(trations)-381.1(should)-381.7(be)-380.8(adjusted)-383.2(no)-378.4(faster)-379.1(than)-383.9(2-week)-380.9(intervals.)-385.9(Fre-)]TJ
0 -1.2266 TD
[(quent)-193.7(monitoring)-190.4(is)-193.9(recommended)-197.3(to)-192.7(ensure)-189.1(that)-198.2(side)-189(effects)-197.6(are)-195.7(not)]TJ
0 -1.2203 TD
[(becoming)-343.6(troublesome.)-346.5(In)-343.1(one,)-345.3(14)-340.5(of)-343.1(38)-340.5(children)-346.7(with)-344.5(PANDAS)]TJ
/F4 1 Tf
-28.0042 77.228 TD
[(PANS)-336.6(CONSENSUS)-341.1(GUIDELINES)-334.1(PSYCHIATRIC/BEHAVIORAL)-24269.3(3)]TJ
ET
endstream
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BT
/F6 1 Tf
8.9663 0 0 8.9663 62.022 725.7825 Tm
0 0 0 rg
0 Tc
0 Tw
[(experienced)-519.2(behavioral)-512.5(activation)-518(when)-509.6(treated)-520.3(with)-508.9(an)-513.6(SSRI;)]TJ
0 -1.2203 TD
[(symptoms)-471.1(included)-464.2(hyperactivity,)-471.4(mania,)-474.4(disinhibited)-466.8(behavior,)]TJ
0 -1.2266 TD
[(worsening)-426.5(OCD)-427.2(behavior,)-427.8(aggression,)-429.2(irritability,)-431.2(agitation,)-430.4(and)]TJ
0 -1.2203 TD
[(suicidality)-406.5(\()-84.3(Murphy)-405(et)-403.8(al.)-406.7(2006\).)-401.4(In)-400(one)-405.6(boy)-403.2(with)-407.7(PANS,)-403.1(when)]TJ
T*
[(5)-170.2(mg/day)-215.7(of)-216.6(uoxetine)-222(was)-220.4(discontinued,)-217.5(suicidal)-222.8(behaviors)-216.9(ceased)]TJ
0 -1.2266 TD
[(and)-298.1(he)-298.6(was)-296.3(able)-297.8(to)-300.2(tolerate)-296.2(2)-170.2(mg/day)-297.9(of)-298.8(uoxetine)-297.9(when)-294.6(the)-295.8(med-)]TJ
0 -1.2203 TD
[(ication)-335.9(was)-334.2(reintroduced)-330.8(\()-84.3(Murphy)-329.2(et)-334.3(al.)-330.8(2006\).)-331.9(SSRI)-337.7(side)-328.1(effects)]TJ
T*
[(can)-224.7(match)-224.9(symptoms)-224.5(one)-222.3(is)-219.2(trying)-222.7(to)-224.3(relieve,)-226.1(so)-221.5(careful)-221.7(attention)-225.2(to)]TJ
0 -1.2266 TD
[(the)-207.3(relationship)-208.5(of)-204(medication)-207.7(dose)-204(and)-203.3(timing)-202.4(of)-204(symptom)-204.9(change,)]TJ
0 -1.2203 TD
[(along)-415(with)-414.1(monitoring)-411.7(the)-416(course)-410.4(of)-412.6(underlying)-412.9(PANS)-412.8(itself,)-416.6(is)]TJ
T*
[(necessary)-282.1(to)-281.3(optimize)-282.1(SSRI)-280.7(treatment.)]TJ
1.1128 -1.2203 TD
[(Antipsychotic)-246.7(medications,)-242.9(such)-241.9(as)-249.2(risperidone)-241.5(\(0.1251)-166.5(mg\))-244.9(or)]TJ
-1.1128 -1.2266 TD
[(aripiprazole)-451(\(0.52.0)-169.9(mg\),)-443.9(should)-444.9(be)-450.4(reserved)-452.3(for)-446.3(incapacitating)]TJ
0 -1.2203 TD
[(OCD.)-253(An)-248.9(electrocardiogram)-250.9(\(EKG\))-249.5(should)-248.9(be)-248(obtained)-249.2(before)-253.7(and)]TJ
T*
[(during)-212.4(treatment)-217.1(with)-211.7(antipsychotics)-214.9(to)-211.7(monitor)-213.1(the)-207.3(QTc)-219(interval)]TJ
0 -1.2266 TD
[(excessive)-233(prolongation)-232.5(\(QTc)]TJ
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11.7733 0 TD
(>)Tj
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[(450)-232.5(mseconds\))-230.3(is)-231.9(a)-229.5(contraindication)]TJ
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[(to)-281.3(use)-280.3(of)-279.8(antipsychotic)-283.7(medications.)]TJ
/F10 1 Tf
0 -2.447 TD
[(Restriction)-334.4(of)-336.7(food)-332.9(or)-335.3(uid)-334.1(intake)]TJ
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[(The)-329.6(sudden)-323.1(onset)-334(of)-324.1(reduced)-328.9(and)-329.7(restricted)-330.6(food)-329.4(intake)-326.1(fullls)]TJ
-1.1128 -1.2203 TD
[(the)-346.4(rst)-345.9(criterion)-352.8(for)-345.2(PANS,)-346.2(even)-350.6(in)-344.5(the)-346.4(absence)-348.9(of)-349.4(more)-341.7(typical)]TJ
T*
[(OCD)-231.2(symptoms)-224.5(\(Swedo)-231.6(et)-226.8(al.)-223.4(2012;)-229.2(Toufexis)-227.4(et)-226.8(al.)-229.7(2015\).)-224.4(Medical)]TJ
0 -1.2267 TD
[(evaluation)-235.7(should)-236.2(be)-235.4(done)-234.4(to)-237(rule)-234.7(out)-236.5(other)-234.2(medical)-236.7(disorders)-237.3(\(e.g.,)]TJ
0 -1.2203 TD
[(eosinophilic)-313.4(esophagitis,)-320.3(structural)-315.6(or)-311.4(neurological)-319.6(causes)-310.2(of)-317.8(dys-)]TJ
T*
[(phagia,)-388.2(and)-380.3(nausea\))-387(and)-386.7(assess)-386(for)-383.1(medical)-388.5(instability)-382.8(related)-387.5(to)]TJ
T*
[(restricted)-463.4(intake)-465.2(of)-463.2(food)-462.2(and/or)-461.4(uids.)-459.5(For)-461.3(those)-460.4(with)-464.6(severely)]TJ
0 -1.2266 TD
[(limited)-233.6(oral)-228.4(intake,)-234.2(assessment)-229.7(should)-236.2(include)-230.8(checking)-228.7(orthostatic)]TJ
0 -1.2203 TD
[(vital)-587.4(signs,)-588.6(EKG,)-583.3(and)-589(electrolytes,)-589.3(including)-585.5(phosphorus)-588.1(and)]TJ
T*
[(magnesium)-347.8(and)-348.7(monitoring)-348.4(for)-345.2(refeeding)-347.2(syndrome.)-350.2(Hospitaliza-)]TJ
0 -1.2266 TD
[(tion)-309.6(may)-308(be)-311.3(required)-313.7(for)-307.2(children)-308.8(who)-311.7(are)-309.5(medically)-309.3(unstable)-313.7(be-)]TJ
0 -1.2203 TD
[(cause)-277.9(of)-273.5(restricted)-280.1(intake)-275.5(of)-279.8(food)-272.5(and/or)-278(uids)-273.2(\(Chang)-278.7(et)-277.3(al.)-273.9(2015;)]TJ
T*
[(Golden)-285(et)-277.3(al.)-280.3(2015\).)]TJ
1.1128 -1.2267 TD
[(In)-349.4(treating)-350.7(children)-353(with)-350.8(intake)-351.4(disturbances)-355.9(related)-349.6(to)-350.8(PANS,)]TJ
-1.1128 -1.2203 TD
[(the)-308.5(focus)-307.3(should)-305.8(be)-311.3(on)-308.8(maintaining)-309.9(adequate)-307(nutrition)-311.5(and)-304.5(hydra-)]TJ
T*
[(tion)-353.8(while)-346.4(treating)-357(underlying)-349.6(brain)-354.4(inammation.)-348.9(Feeding)-351.8(tubes)]TJ
0 -1.2266 TD
[(may)-187.8(be)-178.5(necessary,)-190.2(at)-182.5(least)-188.7(during)-180.7(the)-188.3(acute)-185.9(phases)-187.6(of)-178.7(the)-188.3(illness.)-187.1(The)]TJ
0 -1.2203 TD
[(severity)-309.9(and)-310.8(duration)-306.3(of)-311.4(the)-308.5(eating)-307.1(disturbances)-311.6(can)-306.9(vary.)-309.5(For)-309.5(ex-)]TJ
T*
[(ample,)-329(in)-325.5(four)-332(reported)-326.3(cases)-329.7(of)-330.4(infection-triggered)-334.4(anorexia)-326.1(ner-)]TJ
T*
[(vosa,)-383.9(treatment)-381.5(with)-382.4(antibiotics)-387.5(improved)-381.7(symptoms)-376.3(remarkably)]TJ
0 -1.2266 TD
[(\(Sokol)-280.5(2000\).)-281.3(However,)-285.4(many)-282.2(PANS)-286.4(patients)-286.1(experience)-285.7(ongoing)]TJ
0 -1.2203 TD
[(eating)-262.9(abnormalities)-264.6(and)-260.2(require)-257.2(interventions)-265(used)-260.9(in)-262.3(other)-259.5(eating)]TJ
T*
[(disorder)-325.1(treatments)-325.3(to)-319.2(directly)-325.4(target)-328.7(other)-322.7(factors)-321.7(contributing)-325.1(to)]TJ
0 -1.2267 TD
[(the)-283.2(eating)-281.8(restrictions)-281.9(\(Lock)-280.6(2015\).)]TJ
1.1128 -1.2203 TD
[(For)-417(patients)-425.2(with)-420.4(high)-419.4(anxiety)-420.5(and)-424.6(compulsive)-423.7(behaviors,)-422.2(an)]TJ
-1.1128 -1.2203 TD
[(exposure)-434.7(and)-437.2(response)-435.9(prevention)-434.2(approach)-435.9(may)-434.4(prove)-432.5(helpful.)]TJ
0 -1.2267 TD
[(This)-382.4(involves)-387.1(gradual)-387.4(exposure)-384.1(to)-382.4(foods)-387(or)-381(situations)-389(that)-381.6(cause)]TJ
0 -1.2203 TD
[(anxiety)-395.2(or)-393.6(fear,)-390.4(within)-391.8(a)-393.9(support)-390.1(framework)-394.5(that)-394.2(encourages)-394.3(in-)]TJ
T*
[(cremental)-373.5(progress)-366.5(toward)-369.8(expanding)-364.9(diet)-368.9(and)-367.7(increasing)-368.3(intake.)]TJ
T*
[(Occupational)-310(therapy)-305.2(interventions)-309.2(that)-305.7(include)-306.6(targeting)-306(posture,)]TJ
0 -1.2266 TD
[(breathing,)-361.8(and)-355(relaxation)-358.5(may)-358.6(be)-361.8(helpful)-357.4(adjuncts,)-360.8(especially)-359.5(for)]TJ
0 -1.2203 TD
[(patients)-241.8(who)-235.8(fear)-235.7(of)-235.6(choking)-237(or)-235.6(vomiting.)-235.9(When)-236.3(the)-238.9(problems)-237.5(with)]TJ
T*
[(eating)-326.1(involve)-323.2(obsessions)-322.5(or)-324.1(compulsions,)-323.7(a)-318.1(psychopharmacolog-)]TJ
0 -1.2266 TD
[(ical)-270.2(approach)-271.5(similar)-265(to)-268.6(that)-267.7(used)-273.5(for)-263(OCD)-269.1(may)-270(help.)-266.6(However,)-272.8(in)]TJ
0 -1.2203 TD
[(cases)-228.5(of)-229.3(signicant)-233.1(malnutrition,)-228.1(medication)-226.6(may)-232.1(not)-223.9(help)-232.1(until)-224.6(the)]TJ
T*
[(child)-412.7(has)-406.8(restored)-416(weight,)-405.8(and)-411.9(malnourished)-412.7(patients)-412.5(may)-409.2(be)-406.1(at)]TJ
0 -1.2267 TD
[(increased)-285(risk)-277.7(of)-279.8(adverse)-285.8(side)-283.9(effects.)]TJ
/F10 1 Tf
0 -2.4406 TD
(Tics)Tj
/F6 1 Tf
1.1128 -1.8336 TD
[(Based)-558.4(on)-555.4(preliminary)-557.7(studies,)-562.4(as)-552.7(many)-560.4(as)-559(70%)-550.7(of)-558(PANS/)]TJ
-1.1128 -1.2266 TD
[(PANDAS)-190.8(patients)-184.9(either)-189.6(present)-186.3(with)-186.4(or)-185(develop)-182.5(tics)-186.7(\()-84.3(Murphy)-183.7(et)-188.8(al.)]TJ
0 -1.2203 TD
[(2015;)-330.4(Swedo)-330.7(et)-334.3(al.)-330.8(2015\).)-325.6(PANS)-330.6(patients)-336.6(with)-331.9(tics)-325.8(have)-331.7(been)-331.7(re-)]TJ
27.9978 74.5598 TD
[(ported)-366.5(to)-357.1(be)-361.8(more)-360.7(severely)-358.9(affected)-362.8(at)-359.5(home)-364.4(and)-355(at)-359.5(school,)-361.7(with)]TJ
0 -1.2203 TD
[(poorer)-422(school)-415.7(performance,)-416.9(handwriting,)-416.3(visual-spatial)-423.8(memory,)]TJ
0 -1.2266 TD
[(and)-298.1(self-esteem)-301.7(\()-84.3(Murphy)-291.2(et)-296.3(al.)-299.2(2015\).)-293.9(Some)-293.4(PANS/PANDAS)-297.3(pa-)]TJ
0 -1.2203 TD
[(tients)-312(tics)-306.9(rst)-307.9(present)-312.7(with)-306.6(complex)-306.1(motor)-304.9(and)-310.8(vocal)-309.9(tics,)-303.5(rather)]TJ
T*
[(than)-402.8(presenting)-403.8(with)-401.4(a)-406.6(progression)-400.7(from)-398.8(simple)-404.3(tics)-401.7(to)-401.4(complex)]TJ
0 -1.2266 TD
[(motor)-248(and)-241.2(phonic)-243.8(tics)-243.6(that)-242.5(is)-244.5(typical)-241.1(of)-241.9(Tourette)-245.3(syndrome)-246.1(\(Tucker)]TJ
0 -1.2203 TD
[(et)-283.7(al.)-280.3(1996\).)]TJ
1.1128 -1.2203 TD
[(In)-311.4(most)-316.6(cases,)-313.6(tics)-313.2(are)-315.8(not)-312.4(considered)-313.7(a)-311.8(treatment)-318.2(target)-316.1(unless)]TJ
-1.1128 -1.2266 TD
[(they)-314.3(cause)-315.8(pain,)-310.9(signicant)-315.3(interference)-319.3(in)-312.9(function,)-309.2(or)-311.4(create)-316.9(un-)]TJ
0 -1.2203 TD
[(resolvable)-406.2(embarrassment)-414(or)-400(teasing.)-405.6(Comprehensive)-409(behavioral)]TJ
T*
[(intervention)-428.7(for)-421.1(tics)-427(\(CBIT\),)-421.7(habit)-425.3(reversal)-424.8(training)-424.2(\(HRT\),)-424.5(and)]TJ
T*
[(cautious)-307.3(monitored)-309.4(pharmacotherapy)-308.4(are)-303.1(the)-308.5(treatments)-306.3(of)-305.1(choice)]TJ
0 -1.2266 TD
[(\(Piacentini)-227.8(et)-220.4(al.)-223.4(2010;)-222.9(Murphy)-221.7(et)-220.4(al.)-223.4(2013\).)-218.1(In)-222.9(HRT,)-224.3(children)-220.2(learn)]TJ
0 -1.2203 TD
[(to)-395.1(be)-387.1(aware)-390.1(of)-393.6(their)-390(tics)-389.1(and)-386.7(their)-390(antecedent)-394.6(premonitory)-393.2(urge.)]TJ
T*
[(They)-341.7(help)-333.3(design)-339.8(a)-337()54.8(competing)-336.6(response,)52.3()-337.2(which)-342.4(is)-333(a)-337(motor)-336.5(be-)]TJ
0 -1.2266 TD
[(havior)-233.7(that)-223.5(makes)-234.7(doing)-222.9(the)-232.6(tic)-224(impossible.)-233.4(When)-230(children)-226.6(practice)]TJ
0 -1.2203 TD
[(this,)-301(resisting)-299.6(or)-292.5(suppressing)-298.1(the)-302.2(tic,)-296.4(as)-293.5(in)-300.2(response)-296.8(prevention)-301.5(for)]TJ
T*
[(OCD,)-392.2(they)-390.2(stop)-382.6(reinforcing)-388.4(the)-390.7(urge)-388.8(and)-386.7(the)-390.7(urge)-382.4(frequency)-393.8(di-)]TJ
0 -1.2266 TD
[(minishes.)-495.9(Examples)-490(of)-488.5(competing)-492.6(responses)-487.2(include)-490(staring)-491.4(or)]TJ
0 -1.2203 TD
[(looking)-409.3(up)-410(to)-407.7(extinguish)-409.1(a)-406.6(blinking)-406.5(tic)-413.7(and)-405.6(slow,)-407.8(rhythmic)-411(dia-)]TJ
T*
[(phragmatic)-218.9(breathing)-213.4(for)-212.4(vocal)-215.1(tics.)-214.9(Relaxation)-215.2(training,)-212.1(analyzing,)]TJ
T*
[(and)-203.3(addressing)-205(situations)-199.4(that)-198.2(worsen)-202.6(tics)-205.7(and)-197(family)-203.4(reinforcement)]TJ
0 -1.2266 TD
[(of)-400(applying)-404.9(HRT)-398.4(strategies)-405.1(comprise)-398(other)-398.6(elements)-401.8(of)-400(CBITC.)]TJ
0 -1.2203 TD
[(Exposure)-375.2(with)-363.5(Response)-374.8(Prevention)-369.6(may)-364.9(also)-372.4(be)-368.2(effective)-372.6(inter-)]TJ
T*
[(vention)-285.2(for)-282(severe)-280(tics)-281.6(\(Wile)-284.4(and)-279.2(Pringsheim)-283.4(2013\).)]TJ
1.1128 -1.2266 TD
[(Many)-342.6(clinicians)-348.4(consider)-350.2(the)-340.1(alpha-2)-349.5(adrenergic)-342.8(agonists,)-347(clo-)]TJ
-1.1128 -1.2203 TD
[(nidine,)-446.7(and)-449.9(guanfacine)-447.7(to)-439.3(be)-450.4(the)-441.3(rst-line)-451.3(pharmacologic)-447.5(inter-)]TJ
T*
[(vention)-196.7(for)-187.1(tics.)-196(However,)-190.6(a)-191.6(recent)-194.3(meta-analysis)-194.6(has)-191.8(suggested)-190.2(that)]TJ
0 -1.2266 TD
[(alpha-2)-305.2(agonists)-299.8(may)-301.7(have)-300.1(minimal)-296.3(benet)-301.7(in)-300.2(tic)-299.8(patients)-305(without)]TJ
0 -1.2203 TD
[(ADHD)-207.3(\(Weisman)-210.2(et)-207.8(al.)-204.4(2013\).)-205.4(Antipsychotics)-203.1(may)-206.8(be)-203.8(indicated)-210.9(for)]TJ
T*
[(severe)-368.5(tics,)-360.4(although)-360.6(their)-364.7(use)-362.5(should)-362.7(be)-361.8(restricted)-362.3(for)-364.1(as)-363(short)-359.5(a)]TJ
0 -1.2266 TD
[(duration)-515(as)-514.8(necessary.)-512.7(Haloperidol,)-513.5(pimozide,)-514.9(and)-513.1(aripiprazole)]TJ
0 -1.2203 TD
[(have)-224.2(FDA)-218.7(approval)-222.5(for)-218.7(the)-220(treatment)-223.4(of)-216.6(Tourette)-226.4(Syndrome.)-221.1(Of)-219.9(the)]TJ
T*
[(atypical)-369.5(antipsychotics,)-369.6(risperidone)-361.7(also)-366.1(has)-368.9(evidence)-363.9(supporting)]TJ
T*
[(its)-191.1(use)-191.8(for)-193.4(the)-188.3(treatment)-191.8(of)-191.3(tics,)-189.7(but)-192.2(does)-185(not)-192.2(have)-192.6(an)-191.1(FDA)-187.1(indication)]TJ
0 -1.2266 TD
[(\(Budman)-212.2(2014\).)-205.4(In)-204(addition,)-209.5(a)-210.6(recent)-207(meta-analysis)-213.6(of)-204(the)-207.3(available)]TJ
0 -1.2203 TD
[(scientic)-204.4(literature)-207(found)-202.5(no)-201.4(signicant)-201.5(difference)-206.3(in)-199.1(the)-201(efcacy)-203.4(of)]TJ
T*
[(four)-351(antipsychotic)-353.3(agents)-348.6(evaluated)-348.4(\(risperidone,)-354(pimozide,)-350.5(halo-)]TJ
0 -1.2266 TD
[(peridol,)-480.5(and)-475.2(ziprasidone\))-477.4(\(Weisman)-482.1(et)-479.7(al.)-476.3(2013\).)-471(As)-477.7(described)]TJ
0 -1.2203 TD
[(above,)-340.4(an)-336.6(EKG)-340.1(should)-337.4(be)-336.6(obtained)-337.8(before,)-338.8(and)-336.1(during,)-335.4(treatment)]TJ
T*
[(with)-281.3(antipsychotic)-283.7(medications)-284.2(to)-281.3(rule)-279(out)-280.8(a)-280.1(prolonged)-282.9(QTc.)]TJ
/F10 1 Tf
0 -3.0603 TD
[(Irritability)-339.9(and)-335.7(aggression)]TJ
/F6 1 Tf
1.1128 -1.8336 TD
[(Irritability,)-423.4(aggression,)-416.5(and)-418.3(unprovoked)-417.5(violent)-415.7(behaviors)-419.2(are)]TJ
-1.1128 -1.2203 TD
[(among)-288(the)-283.2(most)-285(troubling)-288.5(symptoms)-281.4(of)-286.2(PANS.)-289.3(Parents)-286(frequently)]TJ
T*
[(report)-451.3(mood)-450.5(lability)-454.9(and)-449.9(impulsive)-451.1(aggression)-451.6(in)-452(children)-447.8(with)]TJ
0 -1.2266 TD
[(PANS/PANDS.)-316.4(Sensory)-311.2(sensitivities,)-313.6(irritability,)-311(fatigue,)-312.2(anxiety,)]TJ
0 -1.2203 TD
[(and)-317.1(cognitive)-309.7(changes)-314.8(may)-314.3(cause)-309.5(the)-314.8(child)-311.5(to)-312.9(adapt)-309.9(poorly)-313.5(to)-306.5(en-)]TJ
T*
[(vironmental)-403.4(changes,)-400(making)-399.1(them)-400(vulnerable)-398.7(to)-401.4(aggressive)-397.1(be-)]TJ
0 -1.2266 TD
[(haviors.)-363.8(The)-354.9(episodes)-361.4(may)-358.6(last)-357.5(for)-357.8(4560)-351.6(minutes)-359.5(or)-355.7(longer,)-356.8(but)]TJ
0 -1.2203 TD
[(within)-221.1(a)-223.2(few)-221.8(minutes)-220.4(of)-222.9(the)-220(rage)-220.5(subsiding,)-217.6(the)-220(child)-223(is)-219.2()54.8(back)49.8()-217.1(and)]TJ
T*
[(expresses)-350.5(remorse)-346.5(for)-345.2(his)-345.2(tantrum,)-344.9(often)-348(not)-344(knowing)-345.3(or)-343.1(remem-)]TJ
T*
[(bering)-284.3(why)-280(they)-282.7(behaved)-282(as)-280.8(they)-282.7(did.)]TJ
1.1128 -1.2266 TD
[(Environmental)-522.3(interventions)-517.9(may)-510.3(decrease)-524.1(the)-517.1(frequency)-513.9(of)]TJ
-1.1128 -1.2203 TD
[(aggressive)-669(behavior.)-668.1(Modulating)-661.6(stimulation,)-663.4(minimizing)-665.6(de-)]TJ
T*
[(mands,)-513.4(and)-506.8(promoting)-509.3(adequate)-509.3(nutrition)-513.8(and)-506.8(sleep)-513.4(may)-504(each)]TJ
0 -1.2266 TD
[(help.)-291.9(In)-292.5(the)-289.5(moment,)-291.7(distraction)-291.2(may)-295.3(be)-292.3(one)-285.5(of)-292.5(the)-289.5(most)-291.3(effective)]TJ
0 -1.2203 TD
[(tools,)-281.6(for)-282(example,)-286.2(the)-283.2(use)-280.3(of)-279.8(favorite)-286.1(toys)-281.5(\(that)-276.2(are)-284.2(unlikely)-282.5(to)-281.3(be)]TJ
T*
[(used)-355.7(as)-350.4(weapons\),)-352.4(singing,)-350.2(dancing,)-349.8(television,)-348.9(food,)-351.3(crying,)-350.5(and)]TJ
0 -1.2266 TD
[(acting)-357.7(silly)-358.6(may)-352.2(re-engage)-358.2(the)-352.7(childs)-358.6()54.8(cortex)50.5()-349.9(and)-355(truncate)-361.8(the)]TJ
0 -1.2203 TD
[(episode.)-256.1(Designing)-250.8(a)-254.8(home)-250.6(plan)-257.4(for)-250.3(calling)-253.7(for)-250.3(help)-251.1(and)-253.9(remaining)]TJ
/F4 1 Tf
-27.9978 77.2217 TD
(4)Tj
44.4501 0 TD
[(THIENEMANN)-336.8(ET)-338.7(AL.)]TJ
ET
endstream
endobj
77 0 obj
<>stream
/GS1 gs
BT
/F6 1 Tf
8.9663 0 0 8.9663 59.7543 725.7825 Tm
0 0 0 rg
0 Tc
0 Tw
[(nonpunitive)-255.7(with)-256(the)-257.9(child)-254.6(is)-250.8(important.)-259.4(Although)-254(calling)-253.7(911)-251.5(may)]TJ
0 -1.2203 TD
[(seem)-228.9(like)-223.5(an)-222.7(extreme)-222.6(solution)-224.3(to)-218(a)-223.2(childs)-225.8(behavior,)-225.5(it)-222(is)-219.2(sometimes)]TJ
0 -1.2266 TD
[(necessary)-332.7(in)-325.5(order)-327.7(for)-326.2(the)-327.4(parents)-331.7(to)-325.5(protect)-328.2(themselves)-332.5(and)-323.4(their)]TJ
0 -1.2203 TD
[(children)-390.9(from)-392.5(harm,)-388.9(to)-388.7(reassure)-396.6(children)-390.9(that)-387.9(their)-390(behavior)-393.3(can)]TJ
T*
[(be)-311.3(contained,)-311(and)-304.5(to)-306.5(not)-312.4(undermine)-307.8(established)-307.2(behavior)-311.1(plans.)-305.3(If)]TJ
0 -1.2266 TD
[(rages)-372.9(are)-366.4(frequent,)-367.2(it)-367.5(may)-364.9(be)-368.2(worthwhile)-366.6(to)-369.8(educate)-370.7(local)-364.5(police)]TJ
0 -1.2203 TD
[(ofcers)-328.9(about)-326.5(the)-321.1(nature)-324.7(of)-324.1(the)-327.4(illness,)-319.9(as,)-328(understandably,)-325(police)]TJ
T*
[(might)-281(misinterpret)-284.2(rageful)-282.5(episodes)-285.5(as)-280.8(acting-out)-280.2(behavior.)]TJ
1.1128 -1.2266 TD
[(For)-353.8(irritability)-352.4(related)-355.9(to)-357.1(anxiety,)-353.8(benzodiazepines)-357.8(may)-352.2(be)-355.5(the)]TJ
-1.1128 -1.2203 TD
[(safest)-333.4(and)-323.4(most)-329.3(effective)-328.3(psychotropic)-327(with)-325.5(which)-329.8(to)-325.5(begin)-326.5(treat-)]TJ
T*
[(ment.)-428.2(Antipsychotic)-423.7(medications)-423.3(or)-418.9(mood)-425.2(stabilizers)-427.6(have)-420.2(been)]TJ
T*
[(shown)-299.2(to)-300.2(reduce)-297.8(the)-295.8(frequency)-298.9(and)-298.1(intensity)-299.8(of)-298.8(aggressive)-295.9(behav-)]TJ
0 -1.2266 TD
[(iors.)-204.8(Despite)-203.6(their)-200.3(associated)-204.9(adverse)-203.6(effects,)-206.9(they)-200.5(may)-200.5(be)-203.8(indicated)]TJ
0 -1.2203 TD
[(for)-319.9(children)-321.4(whose)-320.6(aggressive)-327.5(behavior)-317.4(risks)-322.7(harming)-319(themselves)]TJ
T*
[(or)-191.3(others.)-193.6(The)-196.8(medications)-189.4(may)-194.2(be)-191.1(prescribed)-196.1(on)-188.7(an)-191.1(as-needed)-198.8(basis)]TJ
0 -1.2266 TD
[(\(if)-355.5(possible)-356.7(to)-350.8(administer)-354.5(then\))-354.4(or)-349.4(on)-353.1(a)-356(regular)-352.1(schedule.)-359.2(Risper-)]TJ
0 -1.2203 TD
[(idone)-237.9(and)-241.2(aripiprazole)-242.4(are)-239.9(FDA)-237.7(approved)-237.5(for)-244(treating)-236.9(irritability)-238.6(in)]TJ
T*
[(autistic)-283.8(children.)]TJ
1.1128 -1.2266 TD
[(For)-322.2(patients)-324(with)-319.2(aggression)-325.1(secondary)-322.8(to)-325.5(encephalitis,)-321.2(helpful)]TJ
-1.1128 -1.2203 TD
[(interventions)-283.9(have)-281.1(included)-280.9(the)-283.2(following:)]TJ
/F11 1 Tf
7.9702 0 0 7.9702 69.7323 502.4125 Tm
()Tj
/F6 1 Tf
8.9663 0 0 8.9663 78.1795 501.1085 Tm
[(Diphenhydramine)-346.2(in)-344.5(doses)-343.8(from)-341.9(12.5)-342.9(to)-344.5(50)-163.4(mg.)-346.9(Side)-344.5(effects)]TJ
T*
[(include)-426.8(paradoxical)-425.9(excitation)-423.1(or)-425.3(confusion.)-426.1(May)-425.3(be)-418.8(given)]TJ
T*
[(orally,)-335.5(intramuscularly)-335.8(\(IM\),)-338.3(or)-330.4(IV.)]TJ
/F11 1 Tf
7.9702 0 0 7.9702 69.7323 469.5306 Tm
()Tj
/F6 1 Tf
8.9663 0 0 8.9663 78.1795 468.2267 Tm
[(Benzodiazepines:)-404(Lorazepam)-403.2(at)-391.2(doses)-400.7(beginning)-398.1(at)-397.5(0.5)-166.3(mg.)]TJ
T*
[(Also)-480.8(can)-477.6(cause)-473.9(agitation)-478.1(and)-475.2(disinhibition.)-477.1(May)-475.9(be)-475.7(given)]TJ
T*
[(orally,)-335.5(IM,)-334(or)-336.7(IV.)]TJ
/F11 1 Tf
7.9702 0 0 7.9702 69.7323 436.6487 Tm
()Tj
/F6 1 Tf
8.9663 0 0 8.9663 78.1795 435.3448 Tm
[(Antipsychotics:)-213(Risperidone,)-214.9(aripiprazole,)-213.7(or)-204(haloperidol)-210.1(may)]TJ
T*
[(be)-260.7(helpful)-262.6(for)-263(children)-264.5(with)-262.3(aggression)-261.9(and)-260.2(rage.)-261.3(Haloperidol)]TJ
T*
[(is)-333(started)-335.7(at)-334.2(0.025)-165.4(mg/kg/day)-332.1(in)-331.8(divided)-329.5(doses)-331.1(going)-336.7(up)-327.8(to)-331.8(a)]TJ
0 -1.2266 TD
[(maximum)-203.3(of)-204(0.05)-165.8(mg/kg/day)-205.6(in)-205.4(divided)-203.1(doses)-204.7(\(compared)-201.3(with)]TJ
0 -1.2203 TD
[(the)-276.9(typical)-279(starting)-273.6(dose)-273.5(of)-273.5(0.5)-166.3(mg)-274.4(for)-275.6(larger)-276.7(children)-277.1(and)-272.8(ad-)]TJ
T*
[(olescents\).)-220.6(May)-223(be)-216.4(given)-219(orally,)-221.7(IM,)-213.9(or)-222.9(IV.)-216.5(When)-217.4(given)-219(orally)]TJ
T*
[(or)-317.8(IM,)-321.4(it)-316.9(should)-318.4(be)-317.6(given)-320.1(with)-319.2(diphenhydramine.)-320.5(Due)-320.4(to)-319.2(the)]TJ
0 -1.2266 TD
[(risk)-252.5(of)-254.5(drug)-253.6(effects)-254.5(and)-253.9(drugdrug)-253.7(interactions,)-258.1(an)-248(EKG)-257.9(must)]TJ
0 -1.2203 TD
[(be)-273.3(checked)-271.8(for)-269.3(QTc)-276(prolongation)-270.5(when)-269.3(using)-268.3(antipsychotics.)]TJ
/F10 1 Tf
-2.0549 -3.6673 TD
(Anxiety)Tj
/F6 1 Tf
1.1128 -1.8336 TD
[(Separation)-346.7(anxiety)-344.6(frequently)-348.3(interferes)-348.2(with)-344.5(PANS)-343.3(childrens)]TJ
-1.1128 -1.2203 TD
[(comfort)-334.2(and)-323.4(family)-329.8(function,)-334.5(restricting)-331.8(both)-324.5(the)-327.4(childs)-333.3(and)-329.7(par-)]TJ
0 -1.2266 TD
[(ents)-248.1(activity.)-253.9(Fortunately,)-249.6(with)-243.3(treatment)-248.7(of)-248.2(the)-251.6(underlying)-242.1(causes)]TJ
0 -1.2203 TD
[(of)-355.7(PANS,)-352.5(the)-359.1(suffering)-352.5(and)-355(burden)-356.2(may)-352.2(be)-355.5(short-lived.)-353.5(If)-358.3(symp-)]TJ
T*
[(toms)-392.5(are)-391.7(resolving,)-392.2(accommodating)-391.5(the)-390.7(anxiety)-388.8(for)-389.4(a)-393.9(short)-391.1(time)]TJ
T*
[(may)-276.4(be)-273.3(tolerable.)-279.7(As)-275.4(soon)-271.1(as)-274.5(possible,)-277.4(the)-276.9(child)-273.6(should)-274.2(go)-270.9(back)-274.8(to)]TJ
0 -1.2266 TD
[(his)-282(bedroom)-277(and)-279.2(classroom.)-281.5(When)-280.6(separation)-279.8(anxiety)-281.3(persists,)-281.2(the)]TJ
0 -1.2203 TD
[(parent)-217.2(may)-213.1(become)-216.5(exhausted)-210.4(and)-215.9(require)-213(respite,)-218.5(so)-208.9(efforts)-214.3(should)]TJ
T*
[(be)-191.1(made)-189.8(to)-186.4(integrate)-194.6(other)-190(attachment)-191.1(gures)-185.2(into)-189.5(care.)-194.2(Parents)-184.9(may)]TJ
0 -1.2267 TD
[(also)-271.2(benet)-263.8(from)-266(behavioral)-265.9(interventions)-271.3(for)-263(caregivers,)-271(if)-264.9(family)]TJ
0 -1.2203 TD
[(accommodation)-359.9(is)-352(part)-354.9(of)-355.7(the)-352.7(clinical)-360.9(picture)-353.5(\()-122.2(Jones)-356.4(et)-353.2(al.)-356.1(2015;)]TJ
T*
[(Norman)-287.1(et)-277.3(al.)-280.3(2015\).)]TJ
1.1128 -1.2266 TD
[(CBT)-286(is)-282.4(helpful)-281.5(for)-282(both)-280.3(generalized)-289.2(and)-285.5(separation)-286.1(anxiety)-281.3(and)]TJ
-1.1128 -1.2203 TD
[(may)-314.3(involve)-316.9(the)-314.8(cognitive)-316(skills)-308.7(of)-317.8(reappraisal)-315.9(and)-310.8(problem)-319(solv-)]TJ
T*
[(ing.)-264.7(Children)-260.5(learn)-268.3(to)-262.3(assess)-265.9(the)-257.9(probability)-268.7(and)-260.2(the)-264.2(likely)-264.5(severity)]TJ
0 -1.2266 TD
[(of)-406.3(feared)-414.2(events)-405.5(and)-411.9(generate)-410.7(backup)-406.6(plans)-403.5(should)-406.9(the)-409.6(problem)]TJ
0 -1.2203 TD
[(arise.)-240.7(For)-240(example,)-235.6(a)-242.2(child)-235.6(might)-236.8(work)-237.9(through)-237.2(the)-238.9(probability)-237(that)]TJ
T*
[(no)-188.7(one)-184.3(would)-181.9(pick)-181.5(him)-189.5(up)-182.4(from)-183.8(school,)-184.7(articulate)-187.9(realistic)-187.1(outcomes)]TJ
T*
[(of)-222.9(being)-212.7(left)-219.8(at)-220.4(school,)-216.3(and)-222.3(list)-213.6(possible)-223.9(actions)-219.3(the)-213.6(child)-223(might)-217.8(take)]TJ
0 -1.2266 TD
[(if)-334.4(left.)-336.5(The)-335.9(child)-336.8(might)-331.6(role-play)-336.2(those)-334(actions)-339.4(and,)-332.7(with)-331.9(parents,)]TJ
0 -1.2203 TD
[(and)-424.6(design)-422(a)-425.6(gradual)-419(exposure)-428.4(plan)-421.8(with)-420.4(rewards)-428.4(for)-421.1(following)]TJ
T*
[(through.)-315.9(Notifying)-310.8(the)-314.8(school)-314.5(of)-311.5(the)-314.8(issue)-316.2(and)-310.8(identifying)-312.9()54.8(safe)52.3()]TJ
0 -1.2267 TD
[(individuals)-286.2(and)-279.2(ways)-283.2(to)-274.9(access)-287.3(them)-279.9(may)-282.7(aid)-276.9(in)-281.2(this)-285.5(endeavor.)]TJ
29.117 74.5598 TD
[(Should)-221(pharmacotherapy)-232.5(be)-222.7(necessary,)-228.1(benzodiazepines)-231.4(may)-225.8(be)]TJ
-1.1128 -1.2203 TD
[(used)-437.9(temporarily.)-434.2(Antihistamines,)-441.2(gabapentin,)-443.3(or)-431.6(clonidine)-442.5(may)]TJ
0 -1.2266 TD
[(help;)-336.8(dosages)-332.6(for)-338.9(these)-336.4(have)-338(not)-331.3(been)-338(empirically)-340.2(established,)-335.4(so)]TJ
0 -1.2203 TD
[(the)-422.3(recommendation)-431.5(is)-427.9(to)-426.7(begin)-421.3(with)-426.7(small)-430(doses)-426(and)-424.6(titrate)-431.1(to)]TJ
T*
[(effects)-374.7(and)-374(side)-378.7(effects.)-377.6(Administration)-374.1(of)-374.7(SSRIs)-378.4(should)-375.3(follow)]TJ
0 -1.2266 TD
[(guidelines)-278.8(outlined)-282.5(in)-281.3(the)-283.2(section)-282.5(above)-280.6(on)-277.2(OCD.)]TJ
/F10 1 Tf
0 -3.054 TD
[(ADHD)-335.1(symptoms)]TJ
/F6 1 Tf
1.1128 -1.8336 TD
.0218 Tc
[(Some)-492.3(ADHD)-493.2(symptoms)-491.1(se)-5.4(en)-489.9(in)-489.9(PANS/PANDAS)-494.8(may)-489.9(b)3.3(e)]TJ
-1.1128 -1.2203 TD
0 Tc
[(manifestations)-341.2(of)-343.1(underlying)-343.3(ADHD.)-343(PANS/PANDAS)-341.6(childrens)]TJ
0 -1.2267 TD
[(hyperactivity)-481.2(may)-478.7(reect)-483.8(anxiety,)-480.3(complex)-483.2(tic)-483.2(sequences,)-484.8(rest-)]TJ
0 -1.2203 TD
[(lessness)-433.3(exacerbated)-439.4(by)-429(cognitive)-436.1(and)-430.9(physical)-433.8(fatigue,)-438.6(sensory)]TJ
T*
[(overload,)-314(pain)-308(or)-311.4(urge)-312.9(to)-312.9(urinate,)-312.2(or)-311.5(agitated)-312.6(catatonia)-314.5(\(Elia)-313.9(et)-309(al.)]TJ
T*
[(2005\).)-458.3(Inattention)-460.8(may)-466.1(reect)-458.5(sleep)-462.9(deprivation,)-466(mood)-456.8(lability,)]TJ
0 -1.2266 TD
[(intrusive)-361.6(thoughts)-359.4(of)-355.7(OCD,)-360.5(or)-362(the)-359.1(cognitive)-360.3()54.8(fog)57.9()-362.5(some)-359.3(PANS/)]TJ
0 -1.2203 TD
[(PANDAS)-254(patients)-260.8(describe.)-260.7(Academic)-256.9(frustrations)-259.1(may)-257.4(contribute)]TJ
T*
[(to)-281.3(impulsivity)-278.7(and)-279.2(disruptive)-285.3(behaviors.)]TJ
1.1128 -1.2266 TD
.0233 Tc
[(If)-446.7(the)-446.5(t).8(reatment)-448.1(team)-447.6(cons)3.6(iders)-451.6(s)3.6(ymp)4.8(t).8(oms)-451.6(c)2.4(on)4.8(sis)3.6(t).8(ent)-448.1(w)1.5(ith)]TJ
-1.1128 -1.2203 TD
0 Tc
[(ADHD,)-216.5(management)-224.5(of)-216.6(ADHD)-219.9(symptoms)-218.2(in)-218(the)-220(context)-224.4(of)-216.6(PANS/)]TJ
T*
.01 Tc
[(P)10(A)-9.9(NDAS)-304.2(is)-313.2(b)10(a)-4.1(sed)-305.7(o)-2.1(n)-305.7(o)-2.2(u)10(r)-314.1(un)10(d)-8(e)1.8(rstan)10(d)-8(in)10(g)-317.8(o)10(f)-314.1(ADHD)-309(ma)-4.6(n)10(a)-4.1(gement)]TJ
0 -1.2266 TD
0 Tc
[(i)-9.9(n)-492.7(ge)-20.4(ne)-14.1(r)-14.8(a)-8.2(l)-9.9(.)-489.8(T)-12(y)0(p)-18(i)-9.9(c)-8.3(a)-8.3(l)-496.7(c)-8.3(l)-9.9(a)-8.3(s)-13.3(s)-7(r)-8.4(o)-12.2(o)0(m)-502.1(a)-8.3(c)-8.3(c)-14.6(om)-15.2(m)-9.4(o)-12.2(da)-14.1(t)-9.9(i)-9.9(o)-12.2(ns)-12.9(,)-496.1(p)-12.2(os)-12.9(s)-13.3(i)-9.9(bl)-15.7(y)-492.7(w)-9.1(i)-9.8(t)-9.9(h)]TJ
0 -1.2203 TD
[(ph)-18(a)-8.3(r)-8.4(m)-9.4(a)-8.3(c)-14.6(o)0(t)-15.7(h)0(e)-20.4(r)-8.4(a)-8.3(p)-12.2(y,)-331.2(m)-9.4(a)-8.3(y)-322(h)-12.2(e)-8.3(l)-9.9(p)-322(t)-9.9(he)-336.6(c)-8.2(h)0(i)-15.7(l)-9.9(d)-322(t)-9.9(o)-12.2(l)-9.9(e)-8.3(r)-8.4(a)-8.2(t)-9.9(e)-324.4(t)-9.9(he)-336.6(c)-8.2(l)-9.9(a)-8.2(s)-7(s)-13.3(r)-8.4(oo)-18(m)-319.2(a)-14.6(nd)]TJ
T*
.0101 Tc
[(h)10.1(e)-10.3(l)10.1(p)-422.9(th)10.1(e)-427.6(c)1.8(lassroo)10.1(m)-422.4(tolerate)-415.5(the)-415.5(c)-4.5(h)10.1(i)-5.6(ld)10.1(.)-422.3(U)1(seful)-417.1(c)1.9(han)10.1(g)-7.9(es)-420.6(h)10.1(a)-4(ve)-415.5(in-)]TJ
0 -1.2266 TD
.0092 Tc
[(clu)9.2(d)-8.8(ed)-407.6(p)9.2(r)-5.1(e)-5.4(f).8(erential)-405.3(s)2.2(ea)-5.4(t)9.2(i)-4.2(ng)-401.3(\()-5.6(fro)9.2(n)-8.8(t)-405.3(an)9.2(d)-413.5(s)2.2(ide\),)-404.7(p)-3(ermissi)9.2(o)-6.5(n)-401.3(t)-.7(o)-407.6(t)-.7(ak)9.2(e)]TJ
0 -1.2203 TD
0 Tc
[(br)-14.3(e)-14.6(a)-8.3(ks)-493.4(w)-9.1(i)-9.9(t)-9.9(h)-12.2(ou)-18(t)-484.1(i)-9.9(nt)-15.7(e)-8.3(r)-14.8(r)-8.4(u)0(p)-18(t)-9.9(in)-15.7(g)-486.4(t)-9.9(he)-494.6(c)-8.3(l)-9.9(a)-8.3(s)-13.3(s)-487.6(a)-8.3(nd)-492.2(w)-15.5(i)0(t)-13.4(h)-12.2(ou)-18(t)-484.1(i)-9.8(n)-12.2(t)0(e)-18.1(r)-8.4(r)-8.4(u)0(p)-18(t)-9.9(i)-9.9(o)0(n)]TJ
T*
.0106 Tc
[(\(e.g.,)-251.6(to)-248.2(do)-248.2(sh)10.6(am)-258(errand)10.6(s)-261.5(f)2.2(o)10.6(r)-262.9(th)10.6(e)-256.4(t).7(eacher\),)-251.6(extend)10.6(ed)-254.5(time)-250.6(f)2.2(or)-250.8(test)10.6(s)-6.3(,)]TJ
T*
0 Tc
[(a)-8.3(n)-12.2(d)-322(r)-8.4(e)-8.3(s)-7(o)-12.2(u)0(r)-14.3(c)-14.6(e)-324.4(a)-8.3(s)-7(s)-13.3(is)-16.9(t)-9.9(a)-8.3(nc)-20.4(e)-318.1(f)-14.8(or)-330.4(m)-9.4(a)-8.3(t)-9.9(h)-322(a)-8.3(n)-12.2(d)-322(e)-8.3(x)-12.2(e)-8.3(c)-8.2(u)-12.2(ti)-13.4(v)-12.2(e)-324.4(f)-8.4(u)0(n)-18(c)-8.3(t)-9.9(i)-9.9(o)0(n)-327.8(s)-13.3(up)-18(po)-18(r)-8.4(t)]TJ
0 -1.2266 TD
.0095 Tc
[(and)-274.5(t)-.4(ra)-5.1(i)9.5(n)-6.2(in)9.5(g)-8.5(.)]TJ
1.1128 -1.2203 TD
0 Tc
[(Stimulants)-541.7(\(methylphenidate)-548.9(and)-544.7(amphetamine)-544.2(compounds\),)]TJ
-1.1128 -1.2203 TD
[(the)-384.3(rst-line)-381.8(medication)-391(for)-383.1(idiopathic)-382.8(ADHD,)-387.2(may)-383.9(be)-387.1(tolerated)]TJ
0 -1.2266 TD
[(and)-336.1(helpful.)-341.4(Methylphenidate)-347.9(may)-339.6(be)-342.9(preferable)-339.1(to)-344.5(amphetamine)]TJ
0 -1.2203 TD
[(preparations)-325.7(as)-331.4(they)-320.6(may)-327(have)-331.7(a)-324.4(smaller)-326.6(risk)-328.3(of)-324.1(exacerbating)-333(tics)]TJ
T*
[(or)-469.5(compulsive)-474.3(behaviors)-476.2(in)-470.9(children)-473.1(with)-471(non-PANS/PANDAS)]TJ
0 -1.2266 TD
[(ADHD)-352.7(\(Borcherding)-357(1990;)-355.7(Castellanos)-356.2(1997;)-349.3(Pringsheim)-359.2(2011\).)]TJ
0 -1.2203 TD
[(Some)-204.9(have)-211.5(suggested)-202.8(that)-210.8(amphetamine)-209.1(formulations)-208.2(pose)-210.3(a)-204.3(higher)]TJ
T*
[(risk)-385.2(for)-383.1(neurotoxicity,)-380.5(so)-385.9(methylphenidate)-388.7(preparations)-382.6(are)-385.3(pref-)]TJ
T*
[(erable)-453.6(\(Berman)-451.2(et)-454.4(al.)-451(2009\).)-452(Atomoxetine,)-451.2(a)-450.9(second)-452(line)-451.1(treat-)]TJ
0 -1.2266 TD
[(ment)-311.5(for)-307.2(ADHD)-314.8(symptoms,)-309.7(appears)-311.1(to)-312.9(possess)-313.6(anti-inammatory)]TJ
0 -1.2203 TD
[(properties)-355.8(through)-351(modulation)-348.3(of)-355.7(noradrenaline)-358(signaling,)-349.3(and)-355(in)]TJ
T*
[(so)-423.8(reduces)-431.3(the)-428.6(expression)-432.6(of)-425.3(proinammatory)-434.2(cytokines,)-429.9(down-)]TJ
0 -1.2266 TD
[(regulates)-337.2(cell)-339.7(adhesion)-334.9(molecules)-338.1(important)-338.7(in)-338.2(leukocyte)-333.4(inltra-)]TJ
0 -1.2203 TD
[(tion,)-457.9(and)-456.2(strengthens)-461.4(the)-460.2(bloodbrain)-456.6(barrier)-462.2(\(OSullivan)-458.8(et)-454.4(al.)]TJ
T*
[(2010\).)-281.3(Alpha-2)-280.8(adrenergic)-285.9(agonists,)-277.4(guanfacine,)-286.2(and)-279.2(clonidine)-284.4(are)]TJ
0 -1.2266 TD
[(less)-348.3(helpful)-351.1(for)-351.5(ADHD)-346.4(symptoms,)-353.9(but)-344(may)-352.2(be)-349.2(the)-346.4()54.8(treatment)-352(of)]TJ
0 -1.2203 TD
[(choice)52.8()-476.3(for)-478(PANS/PANDAS)-480.7(hyperactivity)-481.2(and)-475.2(impulsivity)-481(be-)]TJ
T*
[(cause)-372.7(they)-364.9(may)-371.2(also)-372.4(produce)-364.4(improvements)-372(in)-369.8(tics,)-373(anxiety,)-366.5(and)]TJ
0 -1.2266 TD
[(sleep)-279.5(disruptions.)]TJ
/F10 1 Tf
0 -3.054 TD
[(Sleep)-330.6(disturbances)]TJ
/F6 1 Tf
1.1128 -1.8336 TD
[(Disordered)-279.2(sleep)-279.5(in)-274.9(PANS/PANDAS)-284.7(may)-276.4(be)-279.6(a)-273.8(function)-281(of)-279.8(sep-)]TJ
-1.1128 -1.2203 TD
[(aration)-353.5(anxiety,)-360.1(OCD)-357.6(bedtime)-354.4(rituals,)-359.2(enuresis,)-354.3(nightmares,)-359.7(tem-)]TJ
T*
[(perature)-240.2(dysregulation,)-238.6(sleep)-235.2(apnea)-238.8(\(sometimes)-235(with)-237(large)-243(tonsils\),)]TJ
0 -1.2266 TD
[(or)-317.8(rapid)-316.4(eye)-319.5(movement)-321.8(\(REM\))-317.8(Sleep)-321.1(Behavioral)-321.2(Disorder.)-318.7(In)-317.8(the)]TJ
0 -1.2203 TD
[(latter)-471.8(condition,)-468.3(muscle)-472.2(tone)-472.4(is)-465.8(maintained)-473.2(during)-471.6(REM)-471.7(sleep,)]TJ
T*
[(permitting)-279(movement)-283.9(during)-281.9(dreams.)-284(REM)-282(Sleep)-276.9(Behavioral)-283.3(Dis-)]TJ
0 -1.2266 TD
[(order,)-381.2(associated)-388.2(with)-382.4(neuroinammation)-380.2(in)-382.4(other)-386(disorders,)-379.3(has)]TJ
0 -1.2203 TD
[(been)-205.2(observed)-207.1(in)-205.4(12)-201.4(of)-204(15)-207.7(children)-207.6(with)-205.4(PANS/PANDAS)-208.8(studied)-204.2(at)]TJ
T*
[(NIMH)-204(\(Gaughan)-209.2(et)-207.8(al.)-210.7(2016\).)-205.4(REM)-206.1(Sleep)-207.3(Behavioral)-213.7(Disorder)-208.2(also)]TJ
0 -1.2266 TD
[(may)-396.5(occur)-403.3(as)-401(an)-399.8(adverse)-406(effect)-405.6(of)-400(SSRI)-400.9(treatment)-400.4(\(Lloyd)-401.9(et)-397.5(al.)]TJ
0 -1.2203 TD
(2012\).)Tj
/F4 1 Tf
-28.0042 77.228 TD
[(PANS)-336.6(CONSENSUS)-341.1(GUIDELINES)-334.1(PSYCHIATRIC/BEHAVIORAL)-24269.3(5)]TJ
ET
endstream
endobj
82 0 obj
<>stream
/GS1 gs
BT
/F6 1 Tf
8.9663 0 0 8.9663 72 725.7825 Tm
0 0 0 rg
0 Tc
0 Tw
[(Employing)-569.7(good)-573.4(sleep)-570.3(hygiene)-574.5(improves)-572.6(the)-567.7(likelihood)-576.4(of)]TJ
-1.1128 -1.2203 TD
[(sleeping)-332.6(well,)-337.2(even)-331.7(for)-332.5(children)-334(with)-331.9(PANS/PANDAS.)-331.9(The)-335.9(prin-)]TJ
0 -1.2266 TD
[(ciples)-283(of)-279.8(sleep)-279.5(hygiene)-283.6(include)-281.3(the)-283.2(following:)]TJ
/F11 1 Tf
7.9702 0 0 7.9702 72 688.7053 Tm
()Tj
/F6 1 Tf
8.9663 0 0 8.9663 80.4472 687.4014 Tm
[(Scheduling)-379.6(regular)-383.7(times)-379.5(to)-376.1(go)-378.4(to)-382.4(bed)-380.3(and)-380.3(get)-378(up)-378.4(\(even)-378.1(on)]TJ
0 -1.2203 TD
[(weekends\))-338.7(and)-329.7(to)-338.2(set)-334.9(circadian)-332.1(and)-336.1(sleep-wake)-338.4(rhythms)]TJ
/F11 1 Tf
7.9702 0 0 7.9702 72 666.8219 Tm
()Tj
/F6 1 Tf
8.9663 0 0 8.9663 80.4472 665.5179 Tm
[(Healthy)-246.7(sleep)-247.9(habits)-249(\(e.g.,)-246.3(having)-250.1(a)-248.5(consistent,)-244.9(short,)-248.6(pleasant)]TJ
0 -1.2266 TD
[(bedtime)-335.5(routine\),)]TJ
/F11 1 Tf
7.9702 0 0 7.9702 72 644.8817 Tm
()Tj
/F6 1 Tf
8.9663 0 0 8.9663 80.4472 643.5778 Tm
[(Comfortable)-337.1(sleep)-330.1(environment)-336.1(\(e.g.,)-334.8(cool,)-329.9(dark,)-334.8(and)-329.7(quiet\),)]TJ
/F11 1 Tf
7.9702 0 0 7.9702 72 633.94 Tm
()Tj
/F6 1 Tf
8.9663 0 0 8.9663 80.4472 632.636 Tm
[(Avoid)-504.4(caffeine)-501.9(in)-502.6(the)-504.5(evening)-504.9(and)-506.8()61.1(wind)-507(down)53.4()-501.6(toward)]TJ
0 -1.2203 TD
[(bedtime,)-477.5(restricting)-477.2(exercise,)-478.1(high-energy)-476.6(play,)-475.3(and)-475.2(heavy)]TJ
0 -1.2266 TD
[(meals)-333.6(\()-84.3(Moore)-338.4(2010\))]TJ
/F11 1 Tf
7.9702 0 0 7.9702 72 601.0581 Tm
()Tj
/F6 1 Tf
8.9663 0 0 8.9663 80.4472 599.7542 Tm
[(Restrict)-388.2(evening)-378.5(use)-387.8(of)-381(electronic)-386.2(games)-380.2(and)-386.7(toys)-382.6(and)-380.3(turn)]TJ
0 -1.2203 TD
[(off)-256.7(televisions)-251.9(for)-256.7(at)-258.4(least)-251.9(an)-254.4(hour)-253.6(before)-260(bedtime,)-256.2(as)-255.5(the)-251.6(blue)]TJ
0 -1.2266 TD
[(light)-319.4(of)-317.8(electronic)-329.3(screens)-318.6(can)-325.8(delay)-316.2(sleep)-323.7(onset)-321.3(and)-317.1(shorten)]TJ
0 -1.2203 TD
[(sleep)-336.4(duration)-331.6(\(Hale)-334.8(and)-336.1(Guan)-332.6(2015\))]TJ
-.9421 -1.8336 TD
[(If)-326.7(behavioral)-329.2(interventions)-328.2(fail)-333.6(to)-325.5(improve)-325.3(sleep,)-333(diphenhydra-)]TJ
-1.1128 -1.2203 TD
[(mine,)-390.3(melatonin,)-392(cyproheptadine,)-389.5(clonidine,)-388.5(trazodone,)-391.8(or)-387.3(zolpi-)]TJ
0 -1.2266 TD
[(dem)-270(may)-270(be)-273.3(useful;)-270.1(each)-277.2(has)-267.7(anecdotal)-272.6(report)-274.3(of)-273.5(benet)-270.1(in)-268.6(PANS.)]TJ
0 -1.2203 TD
[(However,)-317(controlled)-318.1(studies)-312.9(are)-315.8(lacking,)-315.9(and)-317.1(none)-316.6(of)-311.5(these)-317.4(medi-)]TJ
T*
[(cations)-206.7(is)-200.2(approved)-199.5(by)-201.4(the)-201(FDA)-199.7(for)-206.1(use)-198.1(in)-199.1(children.)-204.2(A)-205.1(low)-201.9(dose)-197.7(may)]TJ
T*
[(be)-279.6(adequate)-288(and)-279.2(desirable)-280.3(to)-281.3(minimize)-285.6(side)-277.6(effects.)]TJ
/F10 1 Tf
0 -2.447 TD
(Depression)Tj
/F6 1 Tf
1.1128 -1.8336 TD
[(Dysphoria)-464.4(and)-468.8(depressive)-466.6(symptoms)-464.8(are)-467.5(common)-468.1(in)-464.6(PANS/)]TJ
-1.1128 -1.2203 TD
[(PANDAS,)-358.1(particularly)-357.8(during)-351.5(later)-354.5(stages)-356.1(of)-355.7(the)-352.7(illness)-354.9(\(Franko-)]TJ
0 -1.2266 TD
[(vich)-270(et)-271(al.)-273.9(2015;)-267.1(Murphy)-272.3(et)-264.7(al.)-273.9(2015;)-267.1(Swedo)-273.7(et)-271(al.)-267.6(2015\).)-268.6(For)-271.6(mild)]TJ
0 -1.2203 TD
[(mood)-393.6(symptoms,)-385.5(supportive)-395.1(interventions,)-394.3(such)-387.4(as)-394.6(individual)-393(or)]TJ
T*
[(family)-431(therapy,)-428.3(may)-421.8(be)-431.4(sufcient.)-424.8(However,)-430.9(children)-428.9(with)-426.7(full-)]TJ
0 -1.2266 TD
[(blown)-321(depression,)-315.4(suicidal)-324(ideation,)-319.4(or)-317.8(self-injurious)-319(behavior)-317.4(re-)]TJ
0 -1.2203 TD
[(quire)-386(more)-379.7(intensive)-386.7(treatment.)-384.4(Psychotherapy)-386.7(or)-387.3(psychotherapy)]TJ
T*
[(combined)-210.8(with)-211.7(an)-210.1(SSRI)-204.9(is)-212.9(the)-207.3(standard)-211.1(of)-210.3(care)-210.2(for)-212.4(youth)-203.9(with)-211.7(major)]TJ
0 -1.2267 TD
[(depressive)-295.9(episodes)-291.9(\(Hopkins)-298.1(et)-290(al.)-292.9(2015\).)-293.9(Elements)-298(of)-292.5(evidenced)]TJ
0 -1.2203 TD
[(psychotherapies)-375.8(for)-376.8(depression)-375.7(seem)-374.3(particularly)-376.8(useful)-374(for)-370.5(chil-)]TJ
T*
[(dren)-414.1(with)-414.1(PANS.)-415.7(In)-412.6(Interpersonal)-416.3(Therapy)-414.8(for)-414.7(Adolescents,)-416.9(the)]TJ
0 -1.2266 TD
[(therapist,)-246.8(family,)-244.2(and)-241.2(school)-238.6(recognize)-245.8(that)-242.5(the)-245.2(child)-242(is)-244.5()54.8(sick)53.3()-242.4(and)]TJ
0 -1.2203 TD
[(unable)-284.1(to)-274.9(function)-281(at)-283.7(usual)-283.4(capacity)-279.4(\()-84.3(Mufson)-279.8(et)-283.7(al.)-280.3(2004\).)-281.3(In)-279.8(CBT)]TJ
T*
[(for)-218.7(depression,)-220.5(planning)-221.5(pleasant)-221.2(\(and)-218(for)-218.7(PANS)-216.8(patients,)-219.4(probably)]TJ
T*
[(low-key\))-282.9(experiences)-286.4(comprises)-278.5(part)-285.3(of)-279.8(the)-276.9(behavioral)-284.9(element.)]TJ
1.1128 -1.2266 TD
[(When)-527.2(depressive)-523.5(symptoms)-528(are)-524.4(sustained)-523(and/or)-524.6(impairing,)]TJ
-1.1128 -1.2203 TD
[(clinical)-304(experience)-298.4(suggests)-297(treatment)-305.6(with)-293.9(an)-298.6(SSRI)-299.7(or)-298.8(bupropion)]TJ
T*
[(may)-396.5(be)-399.8(helpful.)-398.3(The)-399.1(medications)-398(are)-404.3(started)-398.9(at)-397.5(a)-393.9(low)-397.9(dose,)-402.9(and)]TJ
0 -1.2267 TD
[(parents)-420.2(are)-410.6(advised)-417.6(to)-414(watch)-420.7(for)-414.7(emergent)-418.2(adverse)-412.3(effects,)-421.8(p)-18.5(a)-27.2(r)-21.1(-)]TJ
0 -1.2203 TD
.0229 Tc
[(ticularly)-324.4(w)-5.2(o)4.4(rsening)-330.7(m).9(ood,)-327.8(irrita)]TJ
13.6448 0 TD
.0225 Tc
[(bility,)-328.2(a)-4.7(gitation,)]TJ
7.1828 0 TD
.0224 Tc
(hyperactivity,)Tj
-20.8277 -1.2203 TD
.0222 Tc
[(suicidal)-436.6(thoughts,)-436(or)-435.2(sleepless)]TJ
13.139 0 TD
.0229 Tc
[(ness.)-435.3(L)4.6(ikewise,)-435.3(when)-431.9(a)-434.3(c)2(hilds)]TJ
-13.139 -1.2267 TD
0 Tc
[(symptoms)-287.8(are)-296.8(consistent)-292.6(with)-287.6(bipolar)-287.9(mood)-292.4(disorder,)-290.1(medications)]TJ
0 -1.2203 TD
[(for)-446.3(this)-443.6(indication,)-442.6(given)-440.3(with)-445.7(the)-441.3(same)-443.9(caution,)-448.7(could)-440.3(provide)]TJ
T*
[(benet.)-184.5(In)-185(families)-191(with)-186.4(a)-185.3(history)-185.5(of)-185(bipolar)-180.4(disorder,)-188.9(antidepressant)]TJ
T*
[(medications)-436(must)-430.4(be)-431.4(used)-425.3(with)-433(extreme)-431.3(caution)-433.1(because)-431.1(of)-431.6(the)]TJ
0 -1.2266 TD
[(increased)-285(risk)-277.7(of)-279.8(precipitating)-289.2(mania.)]TJ
/F10 1 Tf
0 -2.447 TD
(Psychosis)Tj
/F6 1 Tf
1.1128 -1.8273 TD
[(At)-271.9(least)-277.2(25%)-272.5(of)-273.5(children)-277.1(with)-275(PANS/PANDAS)-272(report)-274.3(auditory,)]TJ
-1.1128 -1.2266 TD
[(olfactory,)-440.2(or)-444.2(visual)-438.7(hallucinations)-445.3(\(distinct)-441.5(from)-436.7(OCD)-446.1(intrusive)]TJ
0 -1.2203 TD
[(images,)-392.9(Frankovich)-397.2(et)-391.2(al.)-394.1(2015\))-392.2(If)-389.9(disturbing)-390.4(or)-393.6(impairing,)-392.2(then)]TJ
T*
[(antipsychotic)-296.4(medications)-296.9(may)-295.3(be)-292.3(warranted,)-302.8(despite)-295.2(their)-295.2(associ-)]TJ
0 -1.2266 TD
[(ated)-209.2(adverse)-210(effects.)-213.2(These)-212(are)-208.3(used)-210.3(typically)-206.2(for)-212.4(a)-204.3(short)-214(duration)-205.2(to)]TJ
0 -1.2203 TD
[(manage)-355.6(acute)-350.3(psychosis)-353.4(and)-348.7(agitation.)-354.6(Medication)-350.2(choice)-356.1(should)]TJ
T*
[(consider)-369.1(minimizing)-368.4(adverse)-368(effects)-368.3(and)-361.4(being)-370.7(aware)-364.8(of)-368.4(interac-)]TJ
0 -1.2266 TD
[(tions)-455.7(with)-452(other)-455.5(medications.)-457.9(For)-448.6(chronic)-457(psychotic)-452.3(symptoms,)]TJ
0 -1.2203 TD
[(diagnosis)-381.5(and)-380.3(ongoing)-380(treatment)-387.8(need)-375.9(to)-382.4(be)-380.8(reassessed.)-388.1(In)-374.7(other)]TJ
27.9978 74.5598 TD
[(encephalitides,)-423.8(the)-416(following)-411.9(have)-420.2(been)-413.9(reported)-414.8(helpful:)-417.8(\(Kup-)]TJ
0 -1.2203 TD
[(puswamy)-285.2(et)-277.3(al.)-286.6(2014\))]TJ
/F11 1 Tf
7.9702 0 0 7.9702 323.0361 699.7037 Tm
()Tj
/F6 1 Tf
8.9663 0 0 8.9663 331.4834 698.3998 Tm
[(Aripiprazole)-338.1(\(lupus,)-336.6(anti-NMDAR\))]TJ
/F11 1 Tf
7.9702 0 0 7.9702 323.0361 688.7053 Tm
()Tj
/F6 1 Tf
8.9663 0 0 8.9663 331.4834 687.4014 Tm
[(Risperidone)-338.5(\(Wilsons,)-338.5(Hashimotos,)-336(anti-NMDAR\))]TJ
/F11 1 Tf
7.9702 0 0 7.9702 323.0361 677.7636 Tm
()Tj
/F6 1 Tf
8.9663 0 0 8.9663 331.4834 676.4597 Tm
[(Olanzapine)-338.6(\(anti-NMDAR\))]TJ
/F11 1 Tf
7.9702 0 0 7.9702 323.0361 666.8219 Tm
()Tj
/F6 1 Tf
8.9663 0 0 8.9663 331.4834 665.5179 Tm
[(Haloperidol)-339.9(\(anti-NMDAR\))]TJ
/F11 1 Tf
7.9702 0 0 7.9702 323.0361 655.8235 Tm
()Tj
/F6 1 Tf
8.9663 0 0 8.9663 331.4834 654.5195 Tm
(Quetiapine)Tj
/F10 1 Tf
-2.055 -2.4217 TD
(Pain)Tj
/F6 1 Tf
1.1128 -1.8336 TD
[(While)-224.9(not)-217.5(often)-221.6(volunteered)-221.2(as)-223.9(a)-216.9(complaint,)-221.3(upon)-219.3(questioning,)-221.9(it)]TJ
-1.1128 -1.2266 TD
[(has)-343.6(been)-338(found)-341.6(that)-343.6(pain)-339.6(is)-339.3(a)-337(common)-341.7(comorbidity)-344(in)-338.2(PANS)-336.9(pa-)]TJ
0 -1.2203 TD
[(tients)-341.5(\(Frankovich)-336.1(et)-334.2(al.)-337.2(2015\).)-331.9(Musculoskeletal)-344(pain)-333.3(in)-338.2(PANS)-336.9(is)]TJ
T*
[(broadly)-353.4(caused)-353.3(by)-353.1(two)-353.6(factors:)-350.5(inammatory)-357.2(\(arthritis\))-353.5(or)-349.4(a)-356(pain)]TJ
T*
[(amplication)-247.2(syndrome)-239.8(due)-241.2(to)-243.3(pain)-238.4(processing)-242.9(abnormalities.)-242.2(Pain)]TJ
0 -1.2266 TD
[(due)-291.8(to)-293.9(arthritis)-292.4(typically)-288.4(precedes)-294.1(or)-292.5(presents)-288.1(simultaneously)-291.9(with)]TJ
0 -1.2203 TD
[(the)-302.2(PANS)-292.7(symptoms.)-297(Wide-spread)-305.1(pain)-295.3(and)-298.1(other)-297.5(pain)-295.3(amplica-)]TJ
T*
[(tions)-190.2(syndromes)-189.9(more)-190(commonly)-186.6(present)-192.6(during)-187.1(the)-188.3(recovery)-191.9(phase)]TJ
0 -1.2267 TD
[(of)-260.9(PANS.)-264(If)-257.1(the)-264.2(pain)-257.4(disorder)-261.8(is)-263.5(not)-261.8(diagnosed)-258.6(and)-260.2(treated)-267.4(early,)-258.5(it)]TJ
0 -1.2203 TD
[(can)-408(develop)-410.1(into)-404.4(a)-406.6(refractory)-408.8(pain)-409.2(syndrome.)-407.1(When)-407.1(widespread)]TJ
T*
[(pain)-371.2(is)-371(present,)-372.6(patients)-374.6(often)-373.3(report)-369.1(other)-373.3(forms)-367.9(of)-374.7(sensory)-370.7(am-)]TJ
0 -1.2266 TD
[(plication)-450.9(\(increased)-445.2(sensitivity)-443.2(to)-445.6(light,)-442.5(sound,)-437.9(and)-443.6(sometimes)]TJ
0 -1.2203 TD
[(smells\),)-480(abdominal)-479.9(pain,)-475.3(headaches,)-479.7(muscle)-478.5(aches,)-476.8(waking)-474.7(un-)]TJ
T*
[(refreshed,)-293(daytime)-291.2(fatigue,)-286.9()54.8(foggy)-286.8(brain,)51.6()-286.6(and)-285.5(depression.)-290.1(Physi-)]TJ
0 -1.2266 TD
[(cal)-273(examination)-270.4(may)-270.1(reveal)-270.2(areas)-274.2(of)-267.2(tenderness)-270.6(to)-268.6(palpation)-271.7(in)-268.6(the)]TJ
0 -1.2203 TD
[(classic)-260.8(distribution)-252(for)-256.7(bromyalgia.)-255.4(Patients)-253(who)-254.8(report)-255.3(both)-255(pain)]TJ
T*
[(and)-361.4(stiffness)-356.3(upon)-358.5(awakening)-357.9(or)-355.7(after)-359.4(prolonged)-358.7(stationary)-357.2(posi-)]TJ
T*
[(tions)-430.4(should)-425.9(be)-431.4(assessed)-431.7(further)-428.1(for)-427.4(arthritis,)-428.1(enthesitis,)-432.3(and)-430.9(in-)]TJ
0 -1.2266 TD
[(ammatory)-328.9(back)-325.3(pain.)-329.9(Involvement)-323.5(of)-330.4(a)-324.4(pediatric)-327.4(rheumatologist)]TJ
0 -1.2203 TD
[(and/or)-347.5(pain)-345.9(specialist,)-346.2(occupational)-351(therapist,)-348(and)-342.4(physical)-345.3(thera-)]TJ
T*
[(pist)-317.1(is)-320.4(necessary)-320.1(for)-319.9(treating)-319.1(these)-317.4(pain)-314.3(conditions.)-317.2(Alleviation)-320.1(of)]TJ
0 -1.2266 TD
[(pain)-251.1(will)-247.4(secondarily)-247.7(improve)-249.4(emotional)-250(and)-241.2(physical)-250.4(functioning.)]TJ
/F4 1 Tf
0 -2.2004 TD
(Conclusion)Tj
/F6 1 Tf
1.1128 -1.8336 TD
[(The)-203.1(treatment)-198.1(of)-204(PANS/PANDAS)-202.5(is)-200.2(symptom)-198.5(based)-199.6(and)-197(closely)]TJ
-1.1128 -1.2266 TD
[(mirrors)-386.2(that)-381.6(of)-387.3(childhood)-379.1(mental)-386.5(illness)-380.2(of)-387.3(idiopathic)-382.8(etiologies.)]TJ
0 -1.2203 TD
[(Mainstays)-416.2(of)-418.9(treatment)-413.1(include)-414.1(psychoeducational,)-418.3(psychothera-)]TJ
T*
[(peutic,)-316.4(behavioral,)-313.1(family,)-307.4(school-based,)-316.8(and)-310.8(pharmacological)-313.8(in-)]TJ
T*
[(terventions,)-283.8(which)-285.5(reduce)-278.8(suffering)-282.9(and)-285.5(improve)-281(functioning)-277.3(until)]TJ
0 -1.2267 TD
[(the)-529.8(immunologic)-534.7(and)-525.8(infectious)-534.3(processes)-533.8(are)-530.8(addressed.)-529.2(For-)]TJ
0 -1.2203 TD
[(tunately,)-376.3(many)-377(patients)-374.6(with)-369.8(PANS/PANDAS)-379.5(will)-373.8(recover)-375.8(com-)]TJ
T*
[(pletely)-392.9(and)-393(symptomatic)-392.8(treatments)-388.5(can)-389.1(be)-393.5(discontinued.)-388.2(Others)]TJ
0 -1.2266 TD
[(are)-385.3(less)-386.2(fortunate)-386.7(and)-380.3(have)-382.3(ongoing)-386.3(symptoms)-382.6(that)-381.6(require)-383.7(con-)]TJ
0 -1.2203 TD
[(tinuous)-195.5(intervention)-194.7(and)-190.6(accommodation.)-198.4(At)-189.7(present,)-195.5(we)-194.4(are)-195.7(unable)]TJ
T*
[(to)-256(predict)-258.7(the)-257.9(individual)-253.9(differences)-257.6(in)-256(the)-257.9(course)-252.3(and)-260.2(prognosis)-251.2(of)]TJ
0 -1.2266 TD
[(individual)-222.3(PANS/PANDAS)-215.1(cases.)-218.8(Additional)-219.3(research)-214.5(is)-219.2(needed)-213(to)]TJ
0 -1.2203 TD
[(understand)-286(the)-283.2(clinical)-278.7(heterogeneity)-283.5(associated)-287.1(with)-281.3(these)-279.5(cases.)]TJ
/F4 1 Tf
0 -2.3142 TD
[(Clinical)-341.3(Signicance)]TJ
/F6 1 Tf
1.1128 -1.8336 TD
[(Until)-373.3(further)-371.2(research)-372.6(informs)-364.6(clinicians)-373.7(about)-370.7(effective)-372.6(treat-)]TJ
-1.1128 -1.2203 TD
[(ments)-198.4(for)-193.4(behavioral)-190.1(and)-197(psychiatric)-194.8(interventions)-195.4(for)-187.1(children)-194.9(with)]TJ
0 -1.2266 TD
[(PANS)-564.6(and)-557.4(Pediatric)-566.2(Autoimmune)-559.7(Neuropsychiatric)-561.1(Syndrome)]TJ
0 -1.2203 TD
[(Associated)-288(with)-287.6(Streptococcal)-290.9(Infection)-285.6(\(PANDAS\),)-286.5(current)-282.5(liter-)]TJ
T*
[(ature)-344.1(and)-342.4(clinical)-341.9(experience)-348.9(must)-335.6(guide)-345.4(clinicians)-342.1(treating)-344.4(these)]TJ
0 -1.2266 TD
[(children.)-425.5(This)-420.4(article)-423.2(lls)-416.8(the)-422.3(gap)-418.3(between)-422.1(empiric)-426.6(therapy)-419(and)]TJ
0 -1.2203 TD
[(current)-352.1(knowledge)-342.9(by)-346.8(conveying)-345.9(consensus)-345.4(guidelines)-348.3(for)-345.2(symp-)]TJ
T*
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T*
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