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Pediatric Neuropsychiatry

For appointments with our Pediatric Neuropsychiatrists: (727) 767-8230 or 1-800-456-4543


The Rothman Center of USF Health is the Southeast’s Foremost Center for Diagnosis and Evidence-based Treatments.

The USF Health team provides safe and effective treatments for a range of common conditions that include a focus on the whole person as well as the family unit.

The Rothman center conducts clinical trials and research studies that directly impact the advancement of patient care.  

USF Health providers at the Rothman Center offer clinical care and support for individuals with;

  • Obsessive-Compulsive Disorder (OCD)
  • Tourette Syndrome
  • Other Tic Disorders
  • Trichotillomania
  • Body Dysmorphic Disorder
  • Anxiety Disorders
  • Learning Disabilities
  • Autism Spectrum Disorders
  • PANDAS
  • Attention Deficit Hyperactivity Disorder

Treatment Options

Cognitive behavioral therapy
-- Exposure and response prevention
-- Cognitive therapy – managing anxious thinking
-- Family support for treating OCD/anxiety and parent training

Habit reversal training/Comprehensive Behavioral Intervention for Tics (CBIT)
-- Becoming aware of urges that precede tics, picking and pulling
-- Replacing hair pulling, skin picking with a competing response; managing tics so they do not cause impairment
-- Manage distress and anxiety that may contribute to hairpulling, skin picking

Medication management
-- Minimizing side effects
-- Maximizing drug effectiveness

Neurocognitive testing
-- Intelligence testing
-- Other aspects of daily living and emotional function

What if I'm From Out of Town?

We also provide treatment in an intensive (daily) format so that treatment can be completed in 3-4 weeks. We will help you make accommodations at a nearby extended stay facility. The Ronald McDonald House is one option for low-cost accommodations while receiving treatment


Fax: 727-767-7786, Email: rothmanctr@health.usf.edu
Fax: 727-767-7786, Email: rothmanctr@health.usf.edu

Clinical Services


What is PANS/PANDAS?
Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is associated with the sudden onset of obsessive-compulsive disorder (OCD) symptoms, anxiety, tics, personality changes, sensory sensitivities, and/or restrictive eating habits. The symptoms associated with OCD include the presence of unwanted thoughts, impulses, or images (obsessions) that cause anxiety followed by behaviors done to reduce the anxiety (compulsions). The symptoms associated with PANS often cause sudden and significant impairment in daily life and functioning. The occurrence of the dramatic shift in symptoms is often the result of infectious diseases, non-infectious health problems, or environmental factors. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal (PANDAS) follows the same trajectory and symptoms as PANS but is specifically associated with streptococcus.

What are the causes of this condition?
Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is the result infectious diseases, environmental factors, or non-infectious health problems leading to an inappropriate immune response resulting in inflammation of the brain. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal (PANDAS) is specifically triggered by Group A Streptococcus.

PANS/PANDAS Symptoms
PANS/PANDAS symptoms often include unwanted thoughts, images, or impulses (obsessions) along with personal rituals to reduce the anxiety caused by the obsessions (compulsions). Additional symptoms of PANS/PANDAS can include food refusal, emotional instability and/or depression, irritability, developmental regression, worsening of school performance, sensory or motor abnormalities, and somatic symptoms such as sleep problems urinary control issues.

Obsessions

- Recurring thoughts, images, or impulses, that cause distress and anxiety

- Recognition that the thoughts are unreasonable

Compulsions

- Activities repeated to reduce anxiety over an obsessive thought

- The acts, though intended to help, are either excessively done or not related to the source of anxiety

Emotional instability and/or depression
New onset food restriction/refusal/avoidance
Irritability
Developmental regression
Worsening of school performance
Sensory or motor abnormalities
Somatic symptoms such as sleep problems, urinary frequency and urinary control issues 

 
PANS/PANDAS Treatment
An initial evaluation is conducted under the supervision of Dr. Justyna Wojas or Dr. Tanya Murphy, an international expert in PANS/PANDAS, and includes a comprehensive assessment of the presenting concerns, developmental history, nutritional history, medical history, history of illness course, and level of psychosocial functioning in order to obtain a proper diagnosis and medication evaluation. This evaluation will assess what neuropsychiatric disorders are currently evident and identify other disorders that need to be ruled out. Recommendations are made at the conclusion of the evaluation for services that, in the opinion of the team, would be most beneficial to address the identified problems. In addition, laboratory testing is frequently used to help identify any underlying medical basis of symptoms. Treatment is tailored to the child's history and clinical presentation.

The first line of treatment for PANS/PANDAS is to treat any infection or inflammation that may be present, which may include antibiotics. In addition, Cognitive Behavioral Therapy (CBT) with Exposure Response Prevention (ERP) is often recommended, which is offered in weekly or intensive (daily) versions. Other options include medication management.

Children should be monitored for acute changes and behavior and screen for potential infectious trigger. Treatment of the precipitating infection may help reduce symptom severity.

The purpose of a medication evaluation is to determine whether a child could benefit from a trial of medication that would help to alleviate some or all of the symptoms known to be interfering with his/her optimal functioning. We offer evidence-based medication management for a variety of childhood psychiatric disorders, including obsessive-compulsive disorder (OCD), pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), autism spectrum disorders, tic disorders, trichotillomania, and other childhood neurodevelopmental disorders.

The initial appointment will involve a comprehensive assessment of the presenting concerns, developmental history, nutritional history, medical history, detailed history on illness course, and level of psychosocial functioning for proper diagnosis and medication evaluation.
Cognitive Behavior Therapy (or CBT) is a form of psychological treatment that has been shown to be very effective with a wide variety of psychiatric and psychological problems, especially OCD and anxiety. Treatment consists of two main parts, exposure and response prevention (ERP) and cognitive therapy. In ERP, patients are gradually exposed to anxiety-provoking triggers/situations while refraining from engaging in anxiety-reducing rituals. Extended and repeated exposure to feared stimuli/situations results in better ability to tolerate/cope with anxiety and patients learn that their fears are not as difficult as initially perceived. In addition we use cognitive techniques that teach patients to identify and correct anxiety-provoking cognitions that often motivate compulsive behaviors (including avoidance). As anxious thoughts are replaced with more objective and realistic cognitions, the need to engage in ritualistic behavior tends to decrease. Treatment is generally family focused, but is individual (not group-based).

Cognitive-behavior therapy can be delivered in either a weekly or intensive (daily) format. Intensive CBT generally involves 60-minute therapy sessions held daily for approximately 2 to 4 weeks and is particularly suitable for severe cases or for those who do not have access to local CBT providers.

Problems we generally treat: OCD, Anxiety (generalized, social phobia, separation, phobias, panic), selective mutism, school refusal, BDD

For behavioral treatment of Tourette/tics, hairpulling/Trichotillomania, and skin picking, please click HERE for our Habit Reversal Therapy (HRT)/Comprehensive Behavioral Intervention for Tics (CBIT) link

CBT for obsessive-compulsive disorder (OCD)
Studies with CBT for obsessive-compulsive disorder (OCD) show a very high success rate in both adults and children. In fact, about 80-85% of adults and children with OCD make substantial improvements following a course of CBT. For example, clinical research studies reported that up to 86% of people who completed CBT were significantly improved. In children, the results are quite similar. In fact, a recent study completed by our program found that about 85% of children were rated as significantly improved after CBT. The findings in these studies of CBT, as well as other outcome studies, suggest that benefits are maintained after treatment is concluded.

CBT for OCD is based primarily on two principles: exposure and response prevention and cognitive therapy. Exposure is an essential practice in CBT for OCD that most simply may be described as having the patient face his or her fear. This is an anxiety-provoking activity for patients at first. In fact, some clinicians are uncomfortable with intentionally increasing patient's anxiety, which may contribute to the scarcity of therapists who are able to conduct CBT. In the clinical setting it has been demonstrated that exposure results in a habituation of anxiety, that is, through repeatedly confronting their fears, OCD patients experience a decrease in anxiety. This is similar to "getting back on the horse after you've fallen off".

Response prevention, also called ritual prevention, follows exposure and involves the patient with OCD refraining from engaging in repetitive compulsive activities that consume time and interfere with his or her functioning. Often these repetitive rituals or compulsive activities function to ease anxiety. Again, numerous studies have shown that through response prevention patients may decrease and eventually eliminate these time consuming and interfering compulsive rituals that they engage in so often.

Finally, cognitive exercises such as restructuring teach the patient to challenge anxious thought processes and the necessity of performing compulsive behaviors are included. This is similar to talking back to worried thoughts.

Having helpful family support can be an important asset in treatment. This is why we tend to include parents of children in our sessions. Similarly, our approach is to teach the person to be his or her own therapist. With this attitude, we are able to teach people all about OCD and what is the best manner of dealing with their symptoms. We believe that this helps reduce symptom return and improves overall treatment outcome.

Intensive CBT for obsessive-compulsive disorder (OCD)
Our intensive cognitive-behavior therapy (CBT) program is particularly well-suited for patients who lack access to trained CBT providers and for patients with severe or treatment-refractory obsessive-compulsive disorder (OCD). Generally speaking, the treatment received in the intensive program is the same treatment that patients undergoing standard weekly CBT receive, with the major exception being that treatment is condensed into a 2 to 4 week time frame.

Packaging CBT into this more succinct and focused manner has many potential benefits, including increased access to evidence-based care, enhanced patient motivation, and rapid symptom relief. In fact, our own data indicate that the intensive program is as effective as weekly CBT in both youth and adults with OCD. The vast majority of patients who participated in a trial of our intensive CBT program had positive treatment responses. Specifically, 90% percent of youth and 88% of adults who completed our intensive CBT program were considered treatment responders, with the majority of these patients maintaining their gains 3-months after treatment.

Similar to standard weekly treatment, intensive CBT for OCD is based primarily on two principles: exposure and response prevention and cognitive therapy. Exposure is an essential practice in CBT for OCD that most simply may be described as having the patient face his or her fear. This is an anxiety provoking activity for patients at first. In the clinical setting it has been demonstrated that exposure results in a habituation of anxiety; that is, through repeatedly confronting their fears, OCD patients experience a decrease in anxiety. Response prevention, also called ritual prevention, follows exposure and involves refraining from engaging in compulsive activities that often function to ease anxiety temporarily at the expense of interfering with life. Again, numerous studies have shown through response prevention patients may decrease and eventually eliminate these time-consuming and interfering compulsive rituals that they engage in.

Cognitive exercises such as thought restructuring teach the patient to challenge anxious thought processes and the necessity of performing compulsive behaviors are included. Finally, family involvement is often central to the success of CBT. Family members may accommodate the patient's symptoms by facilitating avoidance, assisting with ritualistic behaviors, or inadvertently facilitating the development of the disorder by participating in rituals (e.g., providing reassurance, allowing compulsive avoidance of feared stimuli, and tolerating delays associated with ritual completion). Given this, our intensive CBT program often includes the patient's spouse, parents, and other significant others in the treatment process.

Findings from randomized, controlled trials comparing CBT, pharmacological treatment, and placebo/waitlist conditions have established strong support for the efficacy of CBT, pharmacological treatment, and their combination. In light of the existing data, we also offer expert pharmacological interventions for OCD and, when it is clinically appropriate, patients undergoing intensive CBT may be seen concurrently by Dr. Tanya Murphy, an expert psychiatrist in OCD and tic disorders.

CBT for Anxiety Disorders: Separation Anxiety, Social Phobia, Panic/Agoraphobia, Generalized Anxiety, Selective Mutism, School Refusal, and Phobias
We offer evidence-based cognitive behavioral therapy with exposure and response prevention for youth and adults. Our treatment team has expertise in assessing and treating broad range of anxiety, as well as the problems that may accompany anxiety (e.g., depression, school refusal, academic problems, peer problems/teasing, and acting out). Treatment focuses on exposure (behavioral) and cognitive therapy. Exposure therapy involves facing fears – gradually challenging overestimations of fear and risk via practice. Cognitive techniques are used to challenge and correct anxious thinking. Treatment is generally family based – working to teach the family to help the patient to learn new skills and collaboratively manage fears and worries. Weekly and more frequent options are available.

CBT for body dysmorphic disorder
Body Dysmorphic Disorder (BDD) is characterized by preoccupation with an imagined or slight physical defect in appearance that causes significant distress or impairment in functioning. Frequent targets of concern include the hair, nose, and skin, though BDD patients may also become negatively fixated on other areas of the body or face and most patients engage in repetitive and time-consuming behaviors (e.g., mirror gazing, excessive grooming, skin picking) to reduce their distress. Left untreated, BDD tends to be a chronic and disabling condition that negatively impacts quality of life. In our clinic, we offer both once or twice weekly CBT or intensive CBT for people with BDD. We also offer expert pharmacological interventions for BDD and, when clinically appropriate, a combination of medication management and CBT.
Tics refer to involuntary, repetitive movements of the body or detectable vocalizations that are not typical behaviors for the context in which they occur. Tic disorders represent a class of interrelated conditions, which include the presence of isolated or co-occurring motor and vocal tics (e.g., Tourette's Syndrome). Individuals with tic disorder are at risk for experiencing social, emotional, and behavioral impairment in a variety of domains.

One of the most effective non-pharmacological treatments for tic disorders is Habit Reversal Training (HRT). Habit Reversal Training involves several components aimed at increasing tic awareness, developing competing responses to tics, and building and sustaining motivation and compliance. Awareness training is based on the premise that increased awareness of tic behaviors facilitates better self-control. A competing response is a response physically incompatible with the targeted tic. When the ability to reliably detect tic urges has been demonstrated, the person uses a competitive response at each occurrence of the urge and holds the response until the urge passes. The use of anxiety management techniques for tic control can also be implemented. It is based on the observation that increases in anxiety lead to concomitant increases in tic frequency, intensity, and duration. Deep breathing, progressive muscle relaxation, and imagery are the most frequently used anxiety management techniques for tic disorders.

Habit Reversal Training was first tested in the 1970s but two recent, large clinical trials (sponsored by the Tourette Association of America and the National Institutes of Health), one in adults and one in youth, found strong support for Habit Reversal Training as part of CBIT – or the Comprehensive Behavioral Intervention for Tics.

CBIT is a behavioral treatment that teaches patients a set of skills to manage tics and urges-to-tic. It also helps families learn to understand how the environment (setting, emotions, activities) impact tics – and more important, how to make small changes to help the patient better manage tics and the negative impacts of tics. CBIT has three main parts – training tic and tic urge awareness, HRT/competing response training, and functional interventions that help make day-to-day changes to decrease the impact of tics. The treatment trials that tested CBITS lasted 10 weeks – with 8 psychotherapy sessions; most patients showed improvement with no negative side effects. Most showed lasting improvement.

We also offer expert pharmacological interventions for tic disorders and, when clinically appropriate, a combination of medication management and Habit Reversal Training. Often, we will provide other forms of psychotherapy, such as cognitive-behavioral therapy, to help youth with tics deal with feelings of distress related to having tics. Many youth with tics struggle with anxiety, OCD, anger management, school problems, and ADHD – we offer individualized, family-based treatment to supplement CBIT for individuals who struggle with these and other problems in addition to tics/Tourette.

Habit Reversal Training
Habit Reversal Training is a multi-stage process. First, the individual is made aware the behaviors in question (e.g., hair-pulling or a particular tic) and any premonitory urges (i.e., a preceding urge to perform the behavior). Second, the individual is taught to replace the presenting behavior with a competing behavior. Third, relaxation training is utilized to diminish the presenting behavior as well as the competing replacement behavior.

Habit Reversal Training for Trichotillomania and Skin Picking
Trichotillomania is a disorder characterized by the chronic compulsion of pulling out one's own hair, and it is associated with noticeable hair loss, distress, and impairment. Individuals suffering from trichotillomania often feel a compulsion to engage in a ritual associated with their hair-pulling (e.g., a need to bite the hair or root, tactile stimulation of lips or face with the hair shaft, a need to pull the hair in a particular way, searching for hairs that do not feel right or look right). Trichotillomania is a chronic and often disabling illness with a lifetime prevalence of 0.6-2.5%.

One leading approach in the treatment of trichotillomania and skin picking, Habit Reversal Training (HRT), is a form of psychotherapy with proven efficacy. Habit Reversal Training involves several components: awareness training, development of competing responses to hair pulling/skin picking, and building and sustaining motivation and compliance. Awareness training is based on the premise that increased awareness of hair pulling/skin picking incidents facilitates better self-control. The goal of awareness training is to identify each hair-pulling/skin picking incident and any preceding sensations. At the heart of HRT is competing response training. The therapist and patient choose a competing response to hair pulling or picking (i.e., a behavior that is incompatible with hair pulling or skin picking), and the therapist demonstrates the competing response and its proper implementation. The patient then practices the competing response, contingent upon hair-pulling or skin picking warning signs or a simulated hair-pulling/skin picking, while receiving the therapist's feedback.

In addition, having helpful family/social support can be an important asset in treatment and this is why we tend to include parents (or a support person) of patients in our sessions. The therapist will teach the support person about trichotillomania and train him or her to help the patient with the treatment implementation. For example, the support person may learn to praise correct implementation of a competing response and to prompt the correct use of a competing response.Habit Reversal Training for Tic Disorders

Habit Reversal Training for Tic Disorders
Tics refer to involuntary, repetitive movements of the body or detectable vocalizations that are not typical behaviors for the context in which they occur. Tic disorders represent a class of interrelated conditions, which include the presence of isolated or co-occurring motor and vocal tics (e.g., Tourette's Syndrome). Individuals with tic disorder are at risk for experiencing social, emotional, and behavioral impairment in a variety of domains.

One of the most effective non-pharmacological treatments for tic disorders is Habit Reversal Training. Habit Reversal Training involves several components aimed at increasing tic awareness, developing competing responses to tics, and building and sustaining motivation and compliance. Awareness training is based on the premise that increased awareness of tic behaviors facilitates better self-control. A competing response is a response physically incompatible with the targeted tic. When the ability to reliably detect tic urges has been demonstrated, the person uses a competitive response at each occurrence of the urge and holds the response until the urge passes. The use of anxiety management techniques for tic control can also be implemented. It is based on the observation that increases in anxiety lead to concomitant increases in tic frequency, intensity, and duration. Deep breathing, progressive muscle relaxation, and imagery are the most frequently used anxiety management techniques for tic disorders.

We also offer expert pharmacological interventions for tic disorders and, when clinically appropriate, a combination of medication management and Habit Reversal Training. Often, we will provide other forms of psychotherapy, such as cognitive-behavioral therapy, to help youth with tics deal with feelings of distress related to having tics.
The psychoeducational testing clinic generally serves youth ages 6-17. Prior to testing, patients are scheduled for a clinical interview with our psychology team to review the reason for testing and determine (1) if our clinic is the best option to provide testing and (2) determining an individualized plan for testing. Testing visits are generally 2-3 hours over one or more separate follow-up visits. Assessments usually include a review of records, intellectual (IQ) and achievement testing, as well as an assessment of behavioral/emotional functioning. Attention, memory, and executive functioning abilities can also be examined. A separate visit with parents will be scheduled approximately 3 weeks later to discuss results of the evaluation. Some insurances cover testing, but certain diagnoses are not covered. Please check with your insurance company and our financial specialist prior to scheduling.