Our children are sitting in therapy offices with inflamed brains. Psychiatrists are prescribing medications for immune-driven symptoms. Parents are being counseled on behavior while their child’s immune system attacks the brain. This is not rare. This is systematic. The mental health system is structurally designed to miss neuroimmune disease, not because clinicians are incompetent, but because the diagnostic framework itself cannot see what it was never built to recognize. Every intake form, every assessment protocol, every treatment algorithm moves a child with brain inflammation directly into psychiatric care without ever asking if the brain itself is diseased. For example, a mother brings her 12-year-old daughter for a psychiatric evaluation. The intake focuses on family stressors, school functioning, trauma history, mood patterns, and behavioral challenges. What the therapist does not ask is equally important. No one asks whether she was recently sick. No one asks about tick exposure, sudden cognitive slowing, episodes where she seems disconnected, or rages that look panicked rather than oppositional. No one asks whether symptoms shift dramatically from one day to the next in ways that do not fit any psychological pattern. Or if there are significant fluctuating changes after she gets sick. This is not due to incompetence. The standard intake form does not include these questions. The diagnostic model does not recognize these clues. The child has a neuroimmune disorder. The intake will not uncover it. Psychiatric treatment starts. Her condition worsens. And because no one is trained to consider brain inflammation, no one identifies the true cause. How the System Misses Neuroimmune Root Causes The mental health system is structurally incapable of recognizing neuroimmune disease. Psychiatrists are trained in psychopharmacology, not immunology. Therapists are trained to observe symptoms from a psychological perspective, not infectious disease. We operate in separate domains. A child with brain inflammation falls through the gaps. Our diagnostic categories describe phenomenology, not causation (Insel, 2013). “Major depressive disorder” tells us about symptoms, nothing about whether those symptoms originate from monoamine deficiency, hypothyroidism, or brain inflammation. We treat the category without investigating the mechanism. Before psychiatric diagnosis, we should rule out five critical neurological root causes (Gertel Kraybill, 2020): underlying infections (including PANS/PANDAS and autoimmune encephalitis) traumatic brain injury medication side effects genetic predisposition environmental factors Yet insurance reimburses therapy and medication management but resists comprehensive medical workups for “behavioral” symptoms (Swedo et al., 2012). The system incentivizes psychiatric treatment rather than medical investigation. What Neuroimmune Reactive Avoidance Reveals Neuroimmune Reactive Avoidance (NRA) is a framework I developed to understand how immune dysregulation produces specific behavioral manifestations often misidentified as psychiatric resistance (Gertel Kraybill, 2025). The avoidance is not psychological; it is a direct neurological consequence of neuroinflammation. When the brain is inflamed, it cannot properly execute motor planning and behavioral initiation. When the prefrontal cortex is compromised by immune attack, it cannot regulate impulse and emotion (Dalmau & Graus, 2018). The child experiences demand as neurologically intolerable because the neural circuits required to respond are actively compromised. This is why cognitive-behavioral interventions fail. We attempt to modify behavior by engaging cognitive processes in a brain that cannot execute those processes. The inflammation must be addressed first. Clinical features distinguishing NRA Parents describe children as “not there,” having vacant eyes, and confused by their own behavior. This is altered consciousness and loss of volitional control, not anxiety or opposition. Symptoms fluctuate with immune activity. A child is functional for three days, incapacitated for two, and then functional again. This correlates with immune flares (Chang et al., 2015; Gertel Kraybill, 2025). Psychiatric conditions don’t fluctuate in this way. The symptom constellation crosses domains: avoidance plus motor tics plus urinary urgency plus handwriting deterioration plus sleep fragmentation plus sudden food restrictions (Gertel Kraybill, 2020). These reflect inflammatory processes affecting multiple brain regions. Most significant is the response to immunological treatment versus psychiatric treatment. When immune dysregulation is addressed, symptoms can improve dramatically (Frankovich et al., 2015). With only psychiatric medications, improvement is minimal or absent. The Sliding Doors: The Moment a Child Is Saved or Lost A 10-year-old develops strict avoidant/restrictive food intake disorder (ARFID) and almost stops eating, repeating, “I want to die.” Door #1: Intake. Depression diagnosis. SSRI prescribed. Activation syndrome. Switch medications. Antipsychotic added. Day 120: Three medications, out of school for four months, parents devastated, marriage fracturing. The child has autoimmune encephalitis. Every day without treatment, inflammation continues. The condition becomes more chronic and resistant to any intervention. Door #2: Day 1: Clinician recognizes acute presentation, asks about recent illness, and refers to a neurologist. Day 7: Elevated inflammatory markers, positive autoantibodies, recent strep. Day 8: Treatment begins. Day 14: Significant improvement, child is eating, and suicidal ideation has resolved. Day 30: Continued improvement with accommodations. The difference is medical treatment of disease versus years of psychiatric intervention for symptoms caused by untreated inflammation. The Mother Who Knew Her son got the flu. Two weeks later, everything collapsed. He could not tolerate anyone speaking, developed tics, washed his hands compulsively, and screamed about things touching him when nothing was there. The pediatrician said it was anxiety. The therapist said it was OCD. The psychiatrist said they should start an SSRI. She kept repeating that it all began after he was sick and that something was wrong with his brain. They kept insisting that children can develop anxiety suddenly and that he needed therapy and medication. She documented every symptom. She found information about PANDAS, brought articles to appointments, and was dismissed. She was told it was controversial and that her son simply had anxiety. Eventually, she found a PANS-informed doctor four hours away and paid out of pocket. Testing showed elevated strep antibodies. Treatment began. Her son improved. She said that she spent six months fighting every professional. Her son’s pediatrician and two others told her she was wrong. But what happens to parents who trust the system? What happens to families without resources? Those children fall apart while everyone believes they are doing the right thing. I Am That Mother My story is different yet grounded in the same core reality. I was dismissed repeatedly by medical providers even though I, as the parent, held the only complete perspective on my child’s symptoms and their timeline (read more here). This should never hinge on whether I am a therapist or a stay-at-home parent. Clinicians must treat parents as the primary source of information, the ones who witness the onset, the pattern, and the suffering, and who hold the deepest authority on their child’s well-being. What Must Change Medical screening before psychiatric diagnosis. For any child with acute-onset neuropsychiatric symptoms, medical rule-outs should be mandatory: inflammatory markers, autoimmune screening, and infection testing. If red flags exist, there should be an immediate neurology referral. Integrated training. Every mental health professional should recognize presentations warranting neuroimmune investigation and know when to refer. Interdisciplinary care. We need clinics where psychiatrists work alongside neurologists and immunologists. These are extremely rare. For Parents and Clinicians Parents: You know something is medically wrong. Your knowing is dismissed as denial. You watch treatment fail while being counseled on consistency. Trust your observations. Document everything. Find clinicians who investigate rather than dismiss. Do not accept a diagnosis until neuroimmune root causes are ruled out. Clinicians: We are failing these children and their families. Learn to recognize these presentations. Develop relationships with neuroimmune specialists. Refer early. Listen when parents insist that something is medically wrong. This Reality Is Unacceptable When a child presents with NRA, we are looking at brain inflammation producing neurological symptoms that manifest behaviorally. Until our diagnostic frameworks, training, insurance systems, and clinical practice align around this reality, children and their families will continue to suffer from well-intentioned treatment of the wrong thing. We know how to identify these conditions. We know how to treat them. We are simply not doing it.
https://www.psychologytoday.com/us/blog/expressive-trauma-integration/202511/is-your-childs-behavior-actually-a-sign-of