Co- Director, Director of Psychiatric Services
Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) Clinic

Clinical Focus

  • Psychiatry
  • Psychiatry, Child and Adolescent
  • Pediatric Acute-Onset Neuropsychiatric Syndrome

Professional Education

  • Fellowship:Stanford University School of Medicine Registrar (1989) CA
  • Residency:Stanford University School of Medicine Registrar (1987) CA
  • Board Certification: Psychiatry, American Board of Psychiatry and Neurology (1990)
  • Board Certification: Child and Adolescent Psychiatry, American Board of Psychiatry and Neurology (1990)
  • Residency:University of Wisconsin School of Medicine (1986) WI
  • Board Certification: Internal Medicine, American Board of Internal Medicine (1984)
  • Residency:University of TX Hlth Science Ctr (1984) TX
  • Medical Education:Duke University School of Medicine (1981) NC

Research & Scholarship

Current Research and Scholarly Interests

Pediatric Acute-Onset Neuropsychiatric Disorder


2017-18 Courses


All Publications

  • Multidisciplinary clinic dedicated to treating youth with pediatric acute-onset neuropsychiatric syndrome: presenting characteristics of the first 47 consecutive patients. Journal of child and adolescent psychopharmacology Frankovich, J., Thienemann, M., Pearlstein, J., Crable, A., Brown, K., Chang, K. 2015; 25 (1): 38-47


    Abrupt, dramatic onset obsessive-compulsive disorder (OCD) and/or eating restriction with at least two coinciding symptoms (anxiety, mood dysregulation, irritability/aggression/oppositionality, behavioral regression, cognitive deterioration, sensory or motor abnormalities, or somatic symptoms) defines pediatric acute-onset neuropsychiatric syndrome (PANS). Descriptions of clinical data in such youth are limited.We reviewed charts of 53 consecutive patients evaluated in our PANS Clinic; 47 met PANS symptom criteria but not all met the requirement for "acute onset." Patients meeting full criteria for PANS were compared with patients who had a subacute/insidious onset of symptoms.Nineteen of 47 (40%) patients in the study had acute onset of symptoms. In these patients, autoimmune/inflammatory diseases and psychiatric disorders were common in first-degree family members (71% and 78%, respectively). Most acute-onset patients had a relapsing/remitting course (84%), prominent sleep disturbances (84%), urinary issues (58%), sensory amplification (66%), gastrointestinal symptoms (42%), and generalized pain (68%). Inflammatory back pain (21%) and other arthritis conditions (28%) were also common. Suicidal and homicidal thoughts and gestures were common (44% and 17%, respectively) as were violent outbursts (61%). Group A streptococcus (GAS) was the most commonly identified infection at onset (21%) and during flares (74%). Rates of the abovementioned characteristics did not differ between the acute-onset group and the subacute/insidious-onset groups. Low levels of immunoglobulins were more common in the subacute/insidious-onset group (75%) compared with the acute-onset group (22%), but this was not statistically significant (p=0.06).In our PANS clinic, 40% of patients had acute onset of symptoms. However, those with and without acute onset of symptoms had similar symptom presentation, rates of inflammatory conditions, somatic symptoms, and violent thoughts and behaviors. GAS infections were the most commonly identified infection at onset and at symptom flares. Because of the wide variety of medical and psychiatric symptoms, youth with PANS may require a multidisciplinary team for adequate care management.

    View details for DOI 10.1089/cap.2014.0081

    View details for PubMedID 25695943

  • Clinical Evaluation of Youth with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): Recommendations from the 2013 PANS Consensus Conference. Journal of child and adolescent psychopharmacology Chang, K., Frankovich, J., Cooperstock, M., Cunningham, M. W., Latimer, M. E., Murphy, T. K., Pasternack, M., Thienemann, M., Williams, K., Walter, J., Swedo, S. E. 2015; 25 (1): 3-13


    On May 23 and 24, 2013, the First PANS Consensus Conference was convened at Stanford University, calling together a geographically diverse group of clinicians and researchers from complementary fields of pediatrics: General and developmental pediatrics, infectious diseases, immunology, rheumatology, neurology, and child psychiatry. Participants were academicians with clinical and research interests in pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS) in youth, and the larger category of pediatric acute-onset neuropsychiatric syndrome (PANS). The goals were to clarify the diagnostic boundaries of PANS, to develop systematic strategies for evaluation of suspected PANS cases, and to set forth the most urgently needed studies in this field. Presented here is a consensus statement proposing recommendations for the diagnostic evaluation of youth presenting with PANS.

    View details for DOI 10.1089/cap.2014.0084

    View details for PubMedID 25325534

    View details for PubMedCentralID PMC4340805

  • Five youth with pediatric acute-onset neuropsychiatric syndrome of differing etiologies. Journal of child and adolescent psychopharmacology Frankovich, J., Thienemann, M., Rana, S., Chang, K. 2015; 25 (1): 31-37


    Pediatric acute-onset neuropsychiatric syndrome (PANS) is diagnosed by the abrupt onset of new obsessive compulsive disorder (OCD) or food-restricting symptoms, and at least two of a variety of other neuropsychiatric symptoms. Detailed clinical presentation of youth with this condition has not yet been provided in the literature.We review the clinical charts of five youth meeting criteria for PANS in our PANS Clinic. These five patients were selected for differing underlying causes thought to be driving an inflammatory response that appeared to impact psychiatric symptoms.Five youth with varying potential etiologies impacting neuropsychiatric symptoms were identified. These youth were from 8 to 18 years old at the onset of their PANS illness, and had bacterial, autoimmune, and unknown etiologies. Treatment directed at presumed etiologies ranged from antibiotics to intravenous gamma globulin (IVIG) to other immunomodulatory regimens, and appeared to improve the psychiatric illness.Youth with PANS may present in differing ways, with psychiatric and physical symptoms overlapping with inflammatory or infectious diseases, pain syndromes, and other psychiatric diagnoses. Patients' psychiatric symptoms may respond to treatments targeting the underlying cause of physical illness. Faced with a pediatric patient demonstrating the abrupt onset or exacerbation of psychiatric and physical symptoms, clinicians should consider PANS in their differential diagnosis.

    View details for DOI 10.1089/cap.2014.0056

    View details for PubMedID 25695942

  • Activation During Observed Parent-Child Interactions with Anxious Youths: A Pilot Study JOURNAL OF PSYCHOPATHOLOGY AND BEHAVIORAL ASSESSMENT Gonzalez, A., Moore, P. S., Garcia, A. M., Thienemann, M., Huffman, L. 2011; 33 (2): 159-170


    Parent-child interaction paradigms are often used to observe dysfunctional family processes; however, the influence of such tasks on a participant's level of activation remain unclear. The aim of this pilot project is to explore the stimulus value of interaction paradigms that have been commonly used in child anxiety research. Twenty-nine parent-child dyads with clinically anxious (nā€‰=ā€‰16) and non-anxious (nā€‰=ā€‰13) youths engaged in a series of tasks (threat and non-threat) used in previous studies of parenting and youth anxiety. Heart rate (HR) data, as an indicator of physiological activation, were collected across tasks, and participants rated the perceived representativeness of their interactions in the laboratory to their usual behavior at home. Significant HR changes were observed for both parent and child. Change in child HR from baseline to non-threat task was smaller than change in HR from baseline to threat tasks. Change in parent HR from baseline to ambiguous situations tasks was smaller than changes from baseline to other threat tasks. Differences in HR change between anxious and non-anxious children were explored. Participants rated laboratory interactions as similar to those experienced in the home. Results suggest that presumably emotionally-charged discussion tasks may produce increased activation compared to tasks that were designed to be more neutral. Implications for future research and limitations are discussed.

    View details for DOI 10.1007/s10862-011-9216-y

    View details for Web of Science ID 000291169600002

  • Learning evidence-based practices for anxious children JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY Thienemann, M., Hamilton, J. D. 2007; 46 (10): 1367-1374

    View details for DOI 10.1097/chi.0b013e3181354811

    View details for Web of Science ID 000249802900015

    View details for PubMedID 17885579

  • Teaching evidence-based psychotherapies CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA Thienemann, M., Joshi, S. V. 2007; 16 (1): 183-?


    Currently our field is actively involved in developing new ways to characterize and treat children and adolescents with psychiatric disorders and in evaluating the effects of our therapies. We also are beginning to examine the effectiveness of our teaching methods. This article presents evidence for, ideas about, and a philosophy to guide individuals who are privileged to train child psychiatrists in psychotherapies. Specifically, it discusses the issues of the evidence base for diagnosis and for nonspecific and specific active elements of child psychotherapy. Evidence for methods of training is presented. The article addressed the need for supervising psychiatrists to keep abreast of developments in teaching methods so that we can best train competent, curious, and compassionate child psychiatrists.

    View details for DOI 10.1016/j.chc.2006.09.004

    View details for Web of Science ID 000243016300012

    View details for PubMedID 17141124

  • A parent-only group intervention for children with anxiety disorders: Pilot study JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY Thienemann, M., Moore, P., Tompkins, K. 2006; 45 (1): 37-46


    Working to optimize treatment outcome and use resources efficiently, investigators conducted the first test of an existing parent-only group cognitive-behavioral therapy protocol to treat 24 children 7 to 16 years old with primary anxiety disorder diagnoses.Over the course of 7 months, the authors evaluated a manual-based therapy protocol that teaches parents skills to work with their children as lay therapists in the context of their ongoing interactions and daily life. This was an uncontrolled pilot study, examining within-subject outcomes via measures from multiple informants, aimed at generating estimates of effect size.Children demonstrated significant improvement on parent- and clinician-rated measures of anxiety. Twenty-five percent of primary anxiety diagnoses fully remitted, and the average number of anxiety diagnoses dropped from 3.4 to 1.5. The intervention had a large effect on anxiety disorder severity and impairment, parental attitudes, targeted anxious behavior problems, and clinician-rated impairment. Children with anxiety-disordered parents reported more improvement than children whose parents were not anxious. The intervention was acceptable to families.The results of this pilot study suggest that parents acting as lay cognitive-behavioral therapists for their anxious children may be effectively and acceptably trained in a group format.

    View details for DOI 10.1097/01.chi.0000186404.90217.02

    View details for Web of Science ID 000234221200005

    View details for PubMedID 16327579

  • Group Cognitive-behavior Therapy with family involvement for middle-school-age children with obsessive-compulsive disorder: A pilot study CHILD PSYCHIATRY & HUMAN DEVELOPMENT Jacqueline, M., Margo, T. 2005; 36 (1): 113-127


    Middle-school-aged children with obsessive-compulsive disorder (OCD) are poised in development between the dependency of elementary-school-aged children and growing independence of adolescence. OCD patients of this age group may differ from older ones in the quality of symptoms and level of insight. We report the results of a naturalistic, pilot study of group Cognitive-behavior Therapy (CBT) for school-aged children with OCD with parents involved. The authors predicted symptom improvement and format acceptability.Over a 1.5 year period, 14 children with OCD aged 8-14 years and their parents received 14-week group CBT based on March and Mulle's OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual in three consecutive sessions of four to six families. Age of onset averaged 8.7 years, 36% had undergone at least one medication trial, and 36% had previous CBT experience.OCD symptoms measured by the Children's Yale-Brown Obsessive Compulsive Scale improved significantly, both statistically and clinically (25%) from moderate-severe to mild-moderate. Mean Clinical Global Impression of Impairment (NIMH-CGI) Impairment ratings fell from clinical to sub-clinical and CGI Improvement ratings were "much improved". Children's self-reported depression decreased significantly from pre- to post-group. Parent ratings of the negative impact of OCD symptoms on the Children's OCD Impact Scale and of behavior problems on the Child Behavior Checklist each improved significantly.This pilot study, which included a non-selected clinical sample, demonstrates that a manual-based treatment protocol may be effectively adapted for group treatment of different developmental levels and be exported for clinical use. Clinical improvement justifies further investigation in a controlled study.

    View details for DOI 10.1007/s10578-005-3496-y

    View details for Web of Science ID 000203010200006

    View details for PubMedID 16049647

  • Introducing a structured interview into a clinical setting JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY Thienemann, M. 2004; 43 (8): 1057-1060
  • Manual-driven group cognitive-behavioral therapy for adolescents with obsessive-compulsive disorder: A pilot study JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY Thienemann, M., Martin, J., Cregger, B., Thompson, H. B., Dyer-Friedman, J. 2001; 40 (11): 1254-1260


    Concerns about isolation, compromised development, partial pharmacotherapy response, therapist scarcity, and inadequate cognitive-behavioral therapy (CBT) adherence led the authors to adapt a CBT protocol to a group format for adolescents with obsessive-compulsive disorder (OCD). A naturalistic, open trial of group CBT for adolescent OCD is described. The authors predicted symptom improvement and format acceptability.Over a 1 -year period, 18 adolescents aged 13 to 17 years with OCD received 14-week group CBT based on March and Mulle's OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual in four consecutive sessions of five to nine patients. Eighty-three percent had undergone at least one medication trial, and 78% had previous CBT experience.OCD symptoms measured by the Children's Yale-Brown Obsessive Compulsive Scale improved significantly, both statistically and clinically. Adolescents consistently shared information and designed exposure interventions for themselves and others during sessions. Repeated self-report measures confirmed adolescents' satisfaction with therapy.This pilot study demonstrates that a manual-based treatment protocol may be exported for clinical use, adaptable for the end-user's needs, and palatable to adolescent patients. Clinical improvement and patient satisfaction justify further investigation in a controlled study.

    View details for Web of Science ID 000171752900004

    View details for PubMedID 11699798

  • Cognitive-behavioral group therapy for social phobia in female adolescents: Results of a pilot study JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY Hayward, C., Varady, S., Albano, A. M., Thienemann, M., Henderson, L., Schatzberg, A. F. 2000; 39 (6): 721-726


    To examine the efficacy of cognitive-behavioral group therapy for adolescents (CBGT-A) in females with social phobia and the effect of this treatment on the risk for major depression.Female adolescents with social phobia (N = 35) were randomly assigned to treatment (n = 12) or no treatment (n = 23) groups. Assessments were conducted at baseline, after treatment, and at a 1-year follow-up.Eleven subjects completed treatment. Sixteen weeks of treatment produced a significant improvement in interference and reduction in symptoms of social anxiety. There was a significant reduction in the number of subjects meeting DSM-IV criteria for social phobia in the CBGT-A versus the untreated group; however, at the 1-year follow-up there were no significant differences by treatment condition. There was also suggestive evidence that treatment of social phobia lowers the risk for relapse of major depression among those with a history of major depression. Combining social phobia and major depression as the outcome produced more robust treatment effects in the 1-year follow-up.This pilot study provides evidence for a moderate short-term effect of CBGT-A for treating female adolescents suffering from social phobia and indicates that treatment of social phobia may result in a reduction of major depression.

    View details for Web of Science ID 000087331200010

    View details for PubMedID 10846306

  • Defense style and family environment CHILD PSYCHIATRY & HUMAN DEVELOPMENT Thienemann, M., Shaw, R. J., Steiner, H. 1998; 28 (3): 189-198


    Prospective observations of the defense styles of normal individuals suggest that the quality of the childhood family environment may influence the maturity of defense styles used in adulthood. In this study, 106 female adolescent psychiatric patients completed the Defense Style Questionnaire, and the Family Environment Scale (FES). Positive family characteristics such as cohesion and expressiveness, as measured by the FES, were correlated with the report of Mature Defenses. Negative family characteristics such as conflict were correlated with the report of Immature Defenses. Similar although weaker correlations were found after controlling for the effects of depression and defensiveness on the self-report measures.

    View details for Web of Science ID 000072516800005

    View details for PubMedID 9540242

  • Quality of life for patients with obsessive-compulsive disorder AMERICAN JOURNAL OF PSYCHIATRY Koran, L. M., Thienemann, M. L., Davenport, R. 1996; 153 (6): 783-788


    The health-related quality of life of patients with obsessive-compulsive disorder was compared to published norms for the general U.S. population and for patients with either depressive disorders or diabetes.Sixty medication-free outpatients with moderate to severe obsessive-compulsive disorder were evaluated by using the Structured Clinical Interview for DSM-III-R and the Yale-Brown Obsessive Compulsive Scale. Health-related quality of life was measured with the self-rated Medical Outcomes Study 36-Item Short-Form Health Survey.The instrumental role performance and social functioning of the patients with obsessive-compulsive disorder were worse than those of the general population and of diabetes patients. The more severe the obsessive-compulsive disorder, the lower were the patients' social functioning scores, even after depression ratings were controlled for; scores on instrumental role performance did not correlate with severity of obsessive-compulsive disorder. The ratings of the obsessive-compulsive disorder patients on physical health domains resembled those of the general population and exceeded those of the diabetes patients. The general health and physical health ratings of the obsessive-compulsive disorder patients exceeded those of the depressed patients. In mental health domains, after adjustment for differences in gender distribution, quality of life ratings were similar for the patients with obsessive-compulsive disorder and those with depressive disorders.Moderate to severe obsessive-compulsive disorder is associated with impaired social functioning and impaired instrumental role performance, but only impairment in social functioning is linearly related to severity of obsessive-compulsive disorder.

    View details for Web of Science ID A1996UN63200008

    View details for PubMedID 8633690



    The authors examined 21 outpatients with obsessive-compulsive disorder for five neurological soft signs and abnormalities on two neuropsychological tests before and after 10 to 12 weeks of treatment with serotonin reuptake inhibitors. Patients showed a mean of 1.8 soft signs. Prevalences were finger-to-finger, 10%; adventitious movements, 29%; mirror movements, 33%; impaired cube drawing, 33%; and agraphesthesia, 76%. The Stroop Color and Word Test was abnormal in 10% and the Controlled Oral Word Association Test was abnormal in 14% of patients. Neither the presence of specific soft signs, the number of signs present, nor a combination of signs and test abnormalities predicted a poorer response to pharmacological treatment. Some baseline soft signs and abnormalities disappeared at endpoint in medication responders and nonresponders; no clear pattern of change emerged.

    View details for Web of Science ID A1995QV77600012

    View details for PubMedID 7626966



    We designed this study to replicate previous findings which suggest a relationship between the qualities found in family environments and specific eating disorders through the examination of subjects' reports of family environments. We also attempted to refine previous findings of such relationships by adding an additional psychiatric contrast group. Subjects included patients with the following diagnoses: (1) Anorexia nervosa, restrictor type; (2) anorexia nervosa with bulimic features; (3) normal weight bulimia; and, as a psychiatric control population (4) major depression. In contrast to previous findings, subjects in each diagnostic group do not differ statistically either from each other or from a normative population with regard to reported family environments. However, when we grouped subjects by self-reported level of depression, those with a high level of depression described family environments that are significantly different, independent of the severity of illnesses or diagnoses. We discuss the use of self-report instruments in measuring such complex phenomena as family environment.

    View details for Web of Science ID A1993LJ73800005

    View details for PubMedID 8339098

  • Defense style and adaptation in adolescents with depressions and eating disorders. Acta paedopsychiatrica Smith, C., Thienemann, M., Steiner, H. 1992; 55 (3): 185-186


    Maturity of defense style has been associated with the level of adaptive functioning, but few studies have assessed defense style using self-report questionnaires which can provide ratings with great reliability and objectivity. We compared self-perception of defense style (using Bond's Defense Style Questionnaire) with ratings of adaptation assessed retrospectively by two independent raters (using the DSM III-R Global Assessment of Functioning scale) in a population of 100 adolescent girls diagnosed as having either an eating disorder or depression. There was significant correlation between maturity of defense style and level of adaptation, with greater maturity of defense style being associated with higher levels of adaptive functioning. This effect was independent of diagnosis within this population.

    View details for PubMedID 1414355

  • Psychometric measures in clarifying diagnosis in malnourished adolescents. Acta paedopsychiatrica Thienemann, M., Steiner, H. 1992; 55 (4): 207-210


    Three cases of adolescent females suffering from unexplained weight loss are presented. Differential diagnoses included psychiatric and medical illnesses. We describe how psychometric measures were used in each case to clarify diagnosis.

    View details for PubMedID 1492549



    We investigated vitreous replacement by long-lasting gas in the management of severe Staphylococcus aureus endophthalmitis in 19 rabbits randomized for vitrectomy (9 animals) and for vitrectomy followed by replacement of the vitreous by a 20% perfluoropropane-80% air mixture (10 animals). Both groups received systemic antibiotics and achieved comparable intraocular antibiotic levels. Clinically and histopathologically, gas-filled eyes demonstrated less inflammation than did eyes without gas (P less than 0.01). Replacement of vitreous by gas offers an effective adjunct to vitrectomy by eliminating a culture medium, preventing vitreous abscess formation, enabling fundus visualization, and delaying the onset of retinal detachment.

    View details for Web of Science ID A1991GF69600014

    View details for PubMedID 1937081