Advanced Treatments for Autism and Strategies for NonResponders

Dan Rossignol, MD FAAFP
International Child Development Resource Center 321-259-7111 Autism One Conference 2009 May 21, 2009

Autism Spectrum
ADHD Asperger Syndrome PDD-NOS Autism

Psychologically / Behaviorally defined Stereotypical behaviors Social interaction


Underlying pathophysiology ???


Inflammation: GI, Brain

Oxidative Stress / Mito Dysfunction

Impaired Glutathione / Sulphation

Autism: Regression
        Seizures (language regression) Inflammation [Connolly, 1999] Maternal antibodies [Braunschweig, 2008] Familial autoimmune problems Oxidative stress [Chauhan, 2004] Fatty acid deficiencies [Bu, 2006] GI problems [Valicenti-McDermott, 2008] Mitochondrial dysfunction [Poling, 2006]

     Existing / ongoing toxicity Brain inflammation / hypoperfusion Uncontrolled Oxidative stress Mitochondrial dysfunction Subclinical seizure activity

Detoxification “Detox”
 Removal of toxic substances from the body  Major function of the liver, kidneys, and gastrointestinal system  In people with kidney failure, dialysis is a form of detoxification  Impairments in detox can occur in some individuals  e.g., Acetaldehyde dehydrogenase: facial flushing with ethanol



Acetic acid

Genetic Finding in Autism
MTHFR, Adenosine Deaminase GST M1-null ALAD PON-1 HLA-DR4 MTF1, SCL11A3 metal transporters

Clinical Result
Decreased production of glutathione Increased susceptibility to mercury and xenobiotic toxicity; increased body burden of mercury Increased susceptibility to lead toxicity; increased body burden of lead Increased susceptibility to pesticide toxicity Increased allergy and intolerance to heavy metals Might lead to impaired efflux of heavy metals

The adjusted odds ratios (AORs) were elevated by 50% in the top quartile of chlorinated solvents and heavy metals [95% confidence intervals (CIs), 1.1–2.1], but not for aromatic solvents. The individual compounds that contributed most to these associations included mercury, cadmium, nickel, trichloroethylene, and vinyl chloride.
Windham et al., 2006 Environ Health Perspect 114:1438-44

Multivariate a posteriori models comparing children of mothers living within 500 m of field sites with the highest nonzero quartile of organochlorine poundage to those with mothers not living near field sites suggested an odds ratio for ASD of 6.1 (95% confidence interval, 2.4-15.3).
Roberts et al, 2007 Environ Health Perspect 115:1482-9

Sources of toxins: Prenatal
 Mom (good history needed):
– – – – – – – – – Dietary (seafood consumption) Thimerosal containing vaccines; Rhogam Amalgams Smoking Alcohol use Lead stored in bone Mercury and other metals stored in tissues Occupational exposures (dentist, etc…) Psychological stress during pregnancy (hurricanes)

Sources of toxins: Postnatal
 Child:
– – – – – – – Thimerosal (flu) / aluminum from vaccines Environmental / atmospheric Dietary sources (arsenic, seafood) Water ? Household Amalgams Unusual: weighted vests, old bathtubs, lead weights – Phenols, food dyes, propionic acid

Evaluation for Toxins
 Unprovoked blood and urinary heavy metal samples reflect recent exposure  Hair tests reflect metals as long as hair has been there  Chelator challenge  Urinary fractionated porphyrins  Markers of autoimmunity  Plasma sulphate / cysteine  Urinary pesticide levels  Propionic acid

The atypical molecule precoproporphyrin, a specific indicator of heavy metal toxicity, was also elevated in autistic disorder (p < 0.001) but not significantly in Asperger's. A subgroup with autistic disorder was treated with oral dimercaptosuccinic acid (DMSA) with a view to heavy metal removal. Following DMSA there was a significant (p = 0.002) drop in urinary porphyrin excretion. These data implicate environmental toxicity in childhood autistic disorder.
Nataf et al., 2006 Toxicol Appl Pharmacol 214(2):99-108

Nataf et al., 2006 Toxicol Appl Pharmacol 214(2):99-108

This case involves a 4 1/2-year-old boy diagnosed with autism, attention deficit hyperactivity disorder (ADHD), and an elevated blood-lead level of 42 mcg/dl. The child was treated for the elevated blood-lead with the chelating agent succimer. The parents reported a decrease in repetitive behaviors while on succimer with a regression to previous symptoms when medication was discontinued. Also seen was a decrease of hyperactive behavior while being treated with succimer.
Eppright et al., 1996 Mo Med 93(3):136-8

Toxic Metal Treatment (off-label use)
 CaNa2 EDTA: FDA approved for lead toxicity, very poor absorption orally. Usually IV or suppository. Good for lead, ok for aluminum, poor for mercury.  DMSA: FDA approved for lead intoxication. Used orally or suppository. Good for mercury and lead, poor for aluminum.  DMPS: Not licensed in the US, but can be legally imported and compounded. Typically used IV or suppository. Good for mercury, fairly poor for lead.  D-penicillamine: FDA approved for Wilson’s disease and rheumatoid arthritis. Used orally. Good chelator of mercury. Crosses blood-brain barrier.  OTC products: Typically lack efficacy studies.

Typically Used Doses
 CaEDTA: 10-50 mg/kg  DMPS: 2-3 mg/kg (2 mg IV, 3 mg supp.)  DMSA
– Oral: 10 mg/kg tid x 3 days / 11 days off – Suppository: 10-20 mg/kg, 2-3 x per week

 D-penicillamine: 5-15 mg/kg/day oral

Other IV Therapies
    Glutathione: 200-1200 mg N-Acetylcysteine: 200-600 mg Vitamin C: 2,000-4,000 mg Other vitamins/minerals

Brown et al., 2006 Pediatrics 118(2):e534-6

Possible Side-Effects of Chelators
Depressed white blood cell (WBC) count Elevated liver function tests (LFTs) Depletion of vitamins and minerals Dysbiosis Behavioral changes (stimming, hyperactive, irritability)  Allergic reaction / rash  Anaphylaxis  Use only under physician supervision     

Laboratory monitoring
 Initially, and generally every 2-3 months (unless problem identified):
– – – – – – – – Complete blood count (CBC) CMP (liver enzymes, renal function) Mineral stores (red blood cell elements) Iron storage Cysteine / sulphate Thyroid function Provoked urine toxic metals GI testing as indicated (OAT, stool culture)

4 yo boy with autism
      Had regression and lost words Now speaks 20-30 words Stimming: mild Social interaction: poor Hyperactivity: moderate GI: loose BM

Previous UTM after oral DMSA

 CMP, TSH, ferritin, testosterone, lactic acid, ammonia normal  CBC shows mild anemia  Cysteine 0.44 (ref 0.61-1.16)  Sulfate 3.9 (ref 3.0-5.9)

UTM after DMSA suppository (20 mg/kg)

Immune Dysregulation
Deficiencies or dysfunctions: ineffective or defective immune response(s)  2 Hypersensitivity: over-reaction to innocuous foreign substances  3 Autoimmunity: inappropriate reaction to self, loss of self-recognition  4 Inflammation: damage to normal tissue (“bystander effect”) from over-reaction by immune system  1

Immune System Evaluation
 A child with autism who has recurrent infections deserves an immune evaluation for immunodeficiency.  A child with autism who has eczema, chronic nasal symptoms, asthma, significant GI symptoms, or recurrent respiratory infections deserves an allergy evaluation for IgE inhalant and food allergies.

Boris et al., 2004 J Nutr Environ Med 14(1):47-54

Autism and Neuroinflammation

Over 4X

Over 4X

Vargas et al., 2005 Ann Neurol 57(1):67-81

Autism and Neuroinflammation

Perivascular macrophages and microglia
Vargas et al., 2005 Ann Neurol 57(1):67-81



Connolly et al., 1999 J Pediatr 134:607-13

Messahel et al., 1998 Neurosci Letters 241:17-20

in vivo vasoconstriction

Ming et al., 2005 Prostaglandins Leukot Essent Fatty Acids 73(5):379-84

Other tests
 C-reactive protein / Sed rate  Platelet count  GI: fecal calprotectin / lactoferrin  Inflammatory comorbidities:
– Eczema – Asthma – Allergies

Propionic acid (PPA) is a short chain fatty acid, a metabolic end-product of enteric bacteria in the gut, and a common food preservative. Recent evidence indicates that PPA can cause behavioral abnormalities and a neuroinflammatory response in rats. These findings suggest that PPA can change both brain and behavior in the laboratory rat in a manner that is consistent with symptoms of human ASD.

Shultz et al., 2008 Neuropharmacology 54(6):901-11

The authors describe a child whose language and behavior regressed at 22 months and in whom pervasive developmental disorder was later diagnosed. At 6 years, he displayed a profound receptive-expressive aphasia accompanied by behavioral disturbances characterized by hyperactivity, impaired social interactions, tantrums, gestural stereotypies, and echolalia. Corticosteroid treatment resulted in amelioration of language abilities and behavior.
Stefanatos et al., 1995 J Am Acad Child Adolesc Psychiatry 34(8):1107-11

Previously developmentally normal, he had symptoms of autism with rapid regression in developmental milestones coincident with the onset of lymphoproliferation and autoimmune hemolytic anemia. Low-dose steroid therapy induced early and complete remission in the ALPS phenotype. There was subjective improvement, followed by objective improvement in speech and developmental milestones. We propose that autism may be part of the autoimmune disease spectrum of ALPS in this child.
Shenoy et al., 2000 J Pediatr 136(5):682-7

A prospective study was done with 44 children with language regression and abnormal Digitrace 24 EEG epileptiform activity in sleep. All the patients were treated with a form of Depakote or Depakene for 8 to 12 weeks and were reassessed with a 24-hour EEG before the addition of weekly bolus high-dose prednisone or methylprednisolone (10 mg/kg/wk). Results of poststeroid add-on treatment were available for 25 cases. Of these patients, EEG showed further improvement in 60% (n = 15), with no improvement seen in 40% (n = 10). Clinical speech data showed the combination of Depakote/Depakene and pulse dose steroid treatment yielding improvement in 82% (n=36). Side effects were unremarkable with no cushingoid complications even after 18 months of therapy.
Chez et al., 1998 Annals Neurology 44(3):539

A total of 25 children (average age 7.9 +/- 0.7 year old) were enrolled. Safety was assessed by measurements of metabolic profiles and blood pressure. There were no adverse effects noted and behavioral measurements revealed a significant decrease in 4 out of 5 subcategories (irritability, lethargy, stereotypy, and hyperactivity). Improved behaviors were inversely correlated with patient age, indicating stronger effects on the younger patients.
Boris et al., 2007 J Neuroinflammation 4:3

Children with autism have a significantly reduced level of plasma IgG (5.39+/-0.29 mg/mL) compared to the TD (7.72+/-0.28 mg/mL; P<0.001) and DD children (8.23+/-0.49 mg/mL; P<0.001). Children with autism also had a reduced level of plasma IgM (0.670.06mg/mL) compared to TD (0.79+/-0.05 mg/mL; P<0.05). Ig levels were negatively correlated with ABC scores for all children (IgG: r=-0.334, P<0.0001; IgM: r=-0.167, P=0.0285).
Heuer et al., 2008 Autism Res 1(5):275-283

Gupta et al., 1996 J Autism Dev Disord 26(4):439-52

In documented autistic children, 400mg/kg IVIG was administered each month for 6 months. Baseline and monthly Aberrant Behavior Checklists were completed on each child in order to measure the child’s response to IVIG. The participants’ overall aberrant behaviors decreased substantially soon after receiving their first dose of IVIG. Further analysis of the total scores revealed decreases in hyperactivity, inappropriate speech, irritability, lethargy and stereotypy. However, 22 of the 26 children regressed to their pre-IVIG status within 2–4 months of discontinuing the IVIG.
Boris et al., 2006 J Nut Environ Med 15(4):1-8

 Naltrexone increased T-helper cells and decreased T-suppressor cells in children with autism.

Scifo et al., 1996 Ann Ist Super Sanita 32(3):351-9

Bradstreet et al., 2007 Med Hypotheses 68(5):979-87

Anti-inflammatories: Typical doses
 Prednisone: 1-2 mg/kg/day tapered unless using high-dose protocol  Spironolactone: 2-3 mg/kg/day target  Actos: 15-60 mg/day  Singulair: 4-10 mg/day  Minocycline: 50-100 mg bid  IVIG: 400-800 mg/kg once a month

Wilson et al., 2006 Brain Res 1098:126-8

5 yo girl with autism
 On supplements including antioxidants, MB12, GFCF diet  Urinary neopterin is very elevated  Mildly elevated platelet count  Porphyrins mildly elevated  History of eczema

 Singulair  Spironolactone 2-3 mg/kg/day trial for 2-3 months  HBOT

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus:  Presence of obsessive-compulsive disorder and/or a tic disorder  Pediatric onset of symptoms  Episodic course of symptom severity  Association with group A Beta-hemolytic streptococcal infection (a positive throat culture for Strep or history of Scarlet Fever)  Association with neurological abnormalities (motoric hyperactivity, or adventitious movements, such as choreiform movements)

Twenty-three subjects with PANDAS were enrolled in a double blind, randomized controlled trial. Antibiotic prophylaxis with penicillin or azithromycin was administered for 12 months. Penicillin and azithromycin prophylaxis were found to be effective in decreasing streptococcal infections and neuropsychiatric symptom exacerbations among children in the PANDAS subgroup.

Penicillin VK 250 mg twice a day or Zithromax 500 mg once a week
Snider et al., 2005 Biol Psychiatry 57(7):788-92

In children, exacerbations of tics and obsessive symptoms may occur after infection with group A beta-haemolytic streptococci. Children with severe, infection-triggered exacerbations of obsessive-compulsive disorder (OCD) or tic disorders, were randomly assigned treatment with plasma exchange (five single-volume exchanges over 2 weeks), IVIG (1 g/kg daily on 2 consecutive days), or placebo (saline solution given in the same manner as IVIG). Plasma exchange and IVIG were both effective in lessening of symptom severity for children with infection-triggered OCD and tic disorders.
Perlmutter et al., 1999 Lancet 354(9185):1153-8

6 yo girl with autism
     Obsessive and compulsive Extensive self-stimulatory behavior Episodic course to some degree Unusual movements Never had strep throat as far as parent recall

 Antibiotic prophylaxis:
– Zithromax 500 mg once a week – PCN 250 mg bid

 IVIG 1 gm/kg/day x 2 days  May need serotonin modulator

Oxidative Stress Free Radical


8 electrons

1 electron ejected

7 electrons



8 electrons

Folic Acid


Methyl Folate

Methionine Cycle



Oral B12 inactive MB12 active Transsulfuration Pathway Folate Cycle

Cysteine Glutathione Free Radicals


Toxic Metals

Plasma methionine and the ratio of S-adenosylmethionine (SAM) to S-adenosylhomocysteine (SAH), an indicator of methylation capacity, were significantly decreased in the autistic children relative to age-matched controls. Plasma levels of cysteine, glutathione, and the ratio of reduced to oxidized glutathione, an indication of antioxidant capacity and redox homeostasis, were significantly decreased. We propose that an increased vulnerability to oxidative stress (endogenous or environmental) may contribute to the development and clinical manifestations of autism.
James et al., 2006 Am J Med Genetics Part B 141B:947-56

Based on reports of abnormal methionine and glutathione metabolism in autistic children, it was of interest to examine the same metabolic profile in the parents. The results indicated that parents share similar metabolic deficits in methylation capacity and glutathione-dependent antioxidant/detoxification capacity observed in many autistic children.
James et al., 2008 J Autism Dev Disord 38(10):1966-75

in vivo vasoconstriction

Ming et al., 2005 Prostaglandins Leukot Essent Fatty Acids 73(5):379-84

Testing: Oxidative Stress
    Urinary 8-OHDG Urinary 8-OHG Urinary Isoprostanes Cysteine

Doses: Antioxidants
         

Vitamin C: 100 mg/kg/day CoEnzyme Q 10: 5-10 mg/kg/day Acetyl-L-Carnitine: 50-100 mg/kg/day L-Carnosine: 200-400 mg twice a day Pycnogenol: 1 mg/kg/day (often higher) MB12 injections: 75 mcg/kg every 1-3 days Folinic acid 400 mcg twice a day Omega-3’s: DHA and EPA ~800 mg/day each Zinc 20-150 mg/day Melatonin: 1-6 mg 30 mins before bedtime


ATP production in the mitochondria through the electron transport chain (ETC) from aerobic metabolism creates about 13fold more ATP from glucose than produced from anaerobic metabolism An electrochemical gradient is produced across the inner membrane Mitochondria are primary source of ROS by electron leak from the electron transport chain; 1-2% of oxygen normally produces free radicals

Jain et al., 1990 Proc Natl Acad Sci USA 88:1913-17

Fernandez-Checa et al., 1998 BioFactors 8:7-11

Atkuri et al., 2009 Proc Natl Acad Sci U S A., in press

Mitochondrial Disease (MD)
• Primary mitochondrial disease typically refers to genetic defects leading to mitochondria dysfunction (MtD) • Secondary mitochondrial disease (dysfunction) refers to impaired functioning of mitochondria • Organs with highest aerobic demand are most affected (CNS, heart, and skeletal muscle), but any organ can be affected including GI and endocrine

Symptoms / Signs of MtD
• “Any symptom in any organ at any age” [Munnich, 1996] • Developmental delay • Hypotonia (low muscle tone) • Constipation / GI dysmotility • Slow cognitive processing speed • Fatigue [Weissman, 2008] • Seizures • Oxidative stress

Labs: MtD (blood)
• Basic chemistry (CO2, anion gap) • • • • • Liver enzymes (AST, ALT) Ammonia Creatine kinase Lactic acid and pyruvate Plasma amino acids: alanine (compared to lysine), glycine, proline, sacrosine, tyrosine • Fasting plasma acylcarnitine analysis

Chances of Mito Dysfunction in ASD?
• Epidemiological studies: 4-7% mito disease, 20% mito dysfunction • If you suspect mito dysfunction, and especially if lactic acid is elevated, 4565% chance of mitochondrial defect upon muscle biopsy

Treatments: MtD
• • • • • • • • • CoEnzyme Q10: 5-10 mg/kg/day Idebenone: 45-360 mg/day Acetyl-L-Carnitine: 50-100 mg/kg/day L-Carnitine (Carnitor) Thiamine (B1): 15 mg/kg/day Pyridoxine: 5-15 mg/kg/day Riboflavin (B2): 15 mg/kg/day Pantothenic acid: 15 mg/kg/day Vitamin E: 15 IU/kg/day

Treatments: MtD, con’t
• • • • • • • • • Vitamin C: 25 mg/kg/day Alpha-lipoic acid: 15 mg/kg/day Vitamin K3: 5-80 mg/day Folate: 1-10 mg/day Creatine monohydrate: 5-10 g/day B12, selenium, succinate, Ginkgo biloba D-ribose Antioxidants Chelation / HBOT

Case # 2: 4 yo boy with autism
• • • • • • • Multiple regressions with illnesses Chronic constipation Seizures Speech: has 10 words Stimming: moderate Social interaction: poor No family history of mitochondrial disease

Case #2 con’t
• • • • • • • Pregnancy/birth history unremarkable Parents saw regression with vaccines Gets 10 hours of ABA/week No meds, takes MVI and fatty acids Diet: large protein intake No recent labs PE significantly for moderate hypotonia

Initial labs: Case #2
• • • • • CBC, CMP, TSH, lead, ferritin normal Ammonia 62 (ref 11-32) Lactic acid 2.6 (ref 0.4-2.0) Cysteine 0.43 (ref 0.61-1.16) Plasma amino acids (alanine to lysine ratio = 4.3, ref < 2.5)

Mitochondrial biogenesis
• When energy needs of a cell are high, mitochondria divide • Increased ROS triggers mtDNA proliferation; nDNA can also trigger increased mitochondrial division • If mitochondrion cannot maintain ATP production, then undergoes apoptosis • Cells normally remove old mitochondria (autophagy) and synthesize new mitochondria (biogenesis)

Gutsaeva et al., 2006 Neuroscience 137:493-504

CONCLUSION: Children with autism who received hyperbaric treatment at 1.3 atm and 24% oxygen for 40 hourly sessions had significant improvements in overall functioning, receptive language, social interaction, eye contact, and sensory/cognitive awareness compared to children who received slightly pressurized room air.
Rossignol et al., 2009 BMC Pediatr 9:21

 Need high index of suspicion  Look for absence seizures  Think of subclinical seizures in children who are slow to respond to standard treatments  Consider 24-hour hour EEG or SPECT scan  Lamotrigine (Lamictal): also blocks glutamate, is a mood stabilizer  Gabapentin (Neurontin): may help with selfstimulatory behavior

This retrospective review of 24-hour ambulatory digital EEG data collected from 889 ASD patients presenting between 1996 and 2005 shows that 540 of 889 (60.7%) subjects had abnormal EEG epileptiform activity in sleep with no difference based on clinical regression. The most frequent sites of epileptiform abnormalities were localized over the right temporal region. Of 176 patients treated with valproic acid, 80 normalized on EEG and 30 more showed EEG improvement compared with the first EEG (average of 10.1 months to repeat EEG).
Chez et al., 2006 Epilepsy Behav 8(1):267-71

Results suggested that the regressed group had higher incidence of circadian rhythm disorders than non-regressed children. The regressed group showed higher Children's Sleep Habits Questionnaire Bedtime Resistance, Sleep Onset Delay, Sleep Duration and Night-Wakings scores. Epilepsy and frequent epileptiform EEG abnormalities were more frequent in regressed children. This study is an initial step in better understanding sleep problems in regressed children with autism, further studies are necessary to better investigate these aspects.
Giannotti et al., 2008 J Autism Dev Disord, in press

12 yo girl with autism
 Almost complete lack of speech, which did not progress while other symptoms were improving over time  Staring spells  Improved speech was observed with the addition of lamotrigine after SPECT scan performed

6 yo boy with autism
 Slow to progress with standard biomed  However, did respond to antiinflammatories  Severe refractory self-stimulatory behavior  SPECT performed due to slow progress  Improvement in speech and almost complete cessation of stimming with Gabapentin

Proceedings of the 11th International Congress on Hyperbaric Medicine

Acute nicotine treatment has been found to reduce symptoms of attention deficit/hyperactivity disorder in adults. Acute and chronic nicotine treatment significantly attenuated the rise in hit reaction time standard error over session blocks on the Conners Continuous Performance Test. Acute nicotine significantly reduced severity of clinical symptoms on the Clinical Global Impressions scale. Nicotine caused a significant decrease in self-report of depressive mood as measured by the Profile of Mood States test.
Levin et al., 2001 Exp Clin Psychopharmacol 9(1):83-90

Forty-three patients (35 males, 8 females, average age 6.8 yrs., range 2.1-10.3 yrs), with diagnoses of Autistic Spectrum Disorders enrolled in a randomized six-week, double blind, placebocontrolled trial of donepezil hydrochloride, with an additional six weeks of open-label treatment. Expressive and receptive speech gains, as well as decreases in severity of overall autistic behavior, were documented after 6-weeks for the treatment group. These improvements were statistically significant when compared to placebo, and were clinically meaningful as assessed over time.
Chez et al., 2003 Journal of Pediatric Neurology 1(2):83-88

When parent and teacher scores were combined, mean scores were slightly lower during treatment with galantamine than during treatment with placebo for irritability classified by ratings of the aberrant behaviour checklist (galantamine 11.5 (7.6) v placebo 15.1 (5.4), P=0.039), hyperactivity (17.2 (12.8) v 21.7 (15.4), P=0.038), inadequate eye contact (placebo 7.6 (3.2) v 8.4 (5.2), P=0.049), and inappropriate speech 4.7 (3.1) v 6.2 (2.4), P=0.045).
Niederhofer et al., 2002 BMJ 325:1422

Open-label add-on therapy was offered to 151 patients with prior diagnoses of autism or Pervasive Developmental Disorder Not Otherwise Specified over a 21-month period. Results showed significant improvements in open-label use for language function, social behavior, and self-stimulatory behaviors, although self-stimulatory behaviors comparatively improved to a lesser degree.
Chez et al., 2007 J Child Neurol 22(5):574-9

METHODS: Oxytocin and placebo challenges were administered to 15 adult subjects diagnosed with autism or Asperger's disorder, and comprehension of affective speech (happy, indifferent, angry, and sad) in neutral content sentences was tested. RESULTS: All subjects showed improvements in affective speech comprehension from pre- to post-infusion.

Hollander et al., 2007 Biol Psychiatry 61(4):498-503

Clinical Pearls
 Loss of speech (regression): oxidative stress / brain inflammation (autoantibodies)  Low muscle tone / constipation: mitochondrial dysfunction  Improvement with motrin / rarely sick: immune activation / inflammation  Immediate response to chelation: oxidative stress  OCD / self-stimulatory behavior: low serotonin, PANDAS, Clostridia  Toe-walking: think tryptophan depletion  Don’t forget iron deficiency and hypothyroidism