Does your child always seem to be in a state of fight or flight response? The nervous system of an adult or child dealing with constant high stress loads will often shift out of balance and primarily operate in sympathetic mode. If you recall, the nervous system is made up of two parts: the sympathetic and parasympathetic. The sympathetic nervous system is our high alert mode, keeping us ready to fight or flee during a stressful situation. The parasympathetic nervous system allows us to “rest and digest,” essentially winding the body down from previous nervous system activity. Healthy nervous systems find a balance between stress mode and relax mode, but children with PANS/PANDAS, ASD, tick-borne illness, or any other chronic illness tend to be stuck in sympathetic nervous system overdrive. Our children are in a unique situation of psychological stress (infections, detoxification impairments, mitochondrial dysfunction, etc.) and perceived stress (social challenges, schoolwork, fears, etc.), because of the inflammation present in their brains. As a result of this chronic and persistent stress, they are likely struggling with nervous system dysregulation and adrenal dysfunction.


The adrenals are small, kidney bean shaped glands that sit on top of our two kidneys. Adrenals have two layers: the cortex and the medulla. The cortex is responsible for secreting hormones such as glucocorticoids (i.e cortisol), androgens (i.e estrogen, progesterone, testosterone, DHEA), and mineralocorticoids (i.e aldosterone). The medulla is the center part of the gland that secretes catecholamines (i.e epinephrine and norepinephrine). Although epinephrine and norepinephrine are more well known for their impact on the fight or flight response, another major player that is often overlooked in children is cortisol.

Cortisol is released to help the body manage stress so that the body can go back into homeostasis (the medical term for “balance”). However, when the body is constantly exposed to stress, both psychological and perceived, cortisol dysregulation occurs, causing the adrenal glands to feel “burnt out.” This process is known as “General Adaptation Syndrome,” and it was first identified by Hans Selye in 1974. He described this syndrome in three different phases.

The first phase, known as “alarm,” is when the body encounters the stressor. The second phase, adaptation, occurs when the body learns to cope with the stressor. However, the body’s resistance and coping mechanisms can only last so long before the third stage sets in. The third phase, exhaustion, begins when prolonged stress has caused the body to deplete its reserves, leading to an abnormal cortisol pattern. When cortisol is dysregulated, it impacts many different physiological processes, the most important of which include sleep-wake patterns, immune function, metabolism, and mitochondrial/energy production.


For healthy individuals, cortisol is highest in the morning, about 30 minutes after waking, getting us ready to take on the day. In a healthy sleep-wake cycle, cortisol levels will then slowly drop throughout the day, until they are the lowest in the evening, preparing us for sleep.  Cortisol has an inverse relationship with melatonin, a hormone that promotes deep sleep. Therefore, when cortisol is high, melatonin is low, and this can cause insomnia or abnormal sleep behaviors, such as night time waking with difficulty falling back asleep and decreased amount and quality of rapid eye movement (REM) sleep. Humans require more REM sleep than any other animal–about 20% of our total sleep–because of our high degree of cognitive intelligence. REM sleep increases our ability to recognize socio-emotional signals (body gestures and eye contact and mass group behavior) and helps emotional navigation as well.


Elevated cortisol levels have been associated with an increase in pro-inflammatory cytokines, which lead to increased inflammation. This is a detriment to our children with immune dysregulation, as it contributes to additional inflammation that they are already burdened with. Cortisol has also been shown to decrease white blood cells and lymphocytes, cells essential to a healthy and robust immune response, and can activate latent viruses. Because of this, cortisol is directly related to a higher risk of chronic immune dysfunction and inflammation issues, so addressing cortisol in our children dealing with chronic illness should be a high priority in all treatment plans.


Cortisol impacts our metabolism by affecting thyroid and blood sugar regulation. It has the ability to decrease thyroid stimulating hormone (TSH), and to impair the conversion of T4 to T3 (active thyroid hormone), instead converting it to reverse T3. Because of this, elevated cortisol has been associated with clinical or subclinical hypothyroidism, often seen in adults and children alike experiencing fatigue, weight gain, dry skin, constipation, cold sensitivity, hair loss, or delayed puberty.

Elevated cortisol levels can lead to blood sugar issues because it bombards insulin receptors, leading them to become insensitive to signaling, also known as “insulin resistance.” This is a precursor for Type 2 Diabetes mellitus, which sets the stage for future metabolic complications, including diabetes, metabolic syndrome, polycystic ovarian syndrome (PCOS), and Cushing’s syndrome. If your child has been diagnosed with any of these conditions, it would be worth investigating cortisol and ruling out adrenal dysfunction.


  • Weight gain
  • Sleep disturbances – can’t fall asleep, can’t stay asleep, don’t feel refreshed after sleep
  • Hyperactivity
  • Anxiety
  • Food cravings – most commonly salt or sugar
  • Dilated pupils
  • Excessive or easy perspiration
  • Sensitivity to bright lights and loud noises
  • Blood sugar issues – hypoglycemia, insulin resistance, irritability if a meal is skipped, early satiety
  • Aggression/Irritability
  • Fatigue
  • Headaches
  • Dizziness/Syncope
  • Irregular Menstrual Cycles
  • Brain Fog
  • Cold/Heat intolerance


  • Scalloped tongue – seen as indentations on the sides of your tongue
  • Stretch marks
  • Dilated Pupils
  • Clamminess


  • Increase water intake – at least ½ body weight in ounces
  • Increase salt intake – up to an additional teaspoon per day
  • Increase exercise
  • Decrease exposure to blue light (a nervous stimulant) by decreasing time spent on electronics or wearing blue light blocking glasses while exposed to electronics
  • Spend more time in nature to upregulate parasympathetic nervous activity
  • Talk to your health care provider about herbal adaptogens, which help to balance sympathetic and parasympathetic activity


Because my practice specializes in the care of children with chronic illness, all of my patients are clinically evaluated for adrenal dysfunction in their initial workup. The majority of cases of adrenal dysfunction can be diagnosed by a simple history taking and basic physical exam. For cases that require further investigation, I will recommend cortisol testing either through blood, urine, or saliva, which can guide a more tailored treatment plan if needed.

If you are interested in becoming a patient of our practice, please visit my website at or call our office directly at (203) 834-2813.


  1. Selye H.  Stress without Distress. New American Library; New York: 1974.
  2. N. Vgontzas, C. Tsigos, E. O. Bixler, et al., “Chronic insomnia and activity of the stress system: a preliminary study,” Journal of Psychosomatic Research, vol. 45, no. 1, pp. 21–31, 1998.
  3. A. N. Vgontzas, E. O. Bixler, H.-M. Lin, et al., “Chronic insomnia is associated with nyctohemeral activation of the hypothalamic-pituitary-adrenal axis: clinical implications,” Journal of Clinical Endocrinology and Metabolism, vol. 86, no. 8, pp. 3787–3794, 2001.
  4. E. Van Cauter, R. Leproult, and L. Plat, “Age-related changes in slow wave sleep and REM sleep and relationship with growth
  5. Carlsson E, Frostell A, Ludvigsson J, Faresjö M Psychological stress in children may alter the immune response.. J Immunol. 2014 Mar 1; 192(5):2071-81.
  6. Morey, Jennifer N et al. “Current Directions in Stress and Human Immune Function” Current opinion in psychology vol. 5 (2015): 13-17.
  7. Walter, Kimberly N et al. “Elevated thyroid stimulating hormone is associated with elevated cortisol in healthy young men and women” Thyroid research vol. 5,1 13. 30 Oct. 2012, doi:10.1186/1756-6614-5-13
  8. Geer, Eliza B et al. “Mechanisms of glucocorticoid-induced insulin resistance: focus on adipose tissue function and lipid metabolism” Endocrinology and metabolism clinics of North America vol. 43,1 (2014): 75-102.