650 Treatment Lask et al. [13] stated that ‘there is no one speciﬁc form of treatment for children as ill as these’. Nunn et al. [19], on the other hand, described a very detailed, speciﬁc man- agement approach in the battle against the syndrome. However, no evidence-based treatment is known. We believe that the treatment must involve a compre- hensive multidisciplinary team approach and a structured yet ﬂexible management plan with a clear rationale employed over months to years. Regular multidisciplinary feedback meetings are mandatory in order to minimize splitting. Because PRS is such a severe condition, hospitalization, ideally in a child and adolescent psychiatric unit, is almost always required. Thompson and Nunn [24] described one treated outpatient. It can be argued that this outpatient treatment was successful. Although Thompson and Nunn described symptom-free periods, there were still periodic relapses of short-lived episodes of depressive symptoms or anorexia. In our opinion, inpatient treatment is therefore necessary (see Table 4). Treatment must involve tender loving care. The carers must be very patient and sensitive. It takes a long time for the patients to recover, and pressuring them makes their condition worse. It typically takes a few months of treat- ment before it becomes possible to implement a very gradual rehabilitation programme. Therapeutic enthusiasm in the early stages is almost always counterproductive [11]. The role of the family in the treatment is important yet difﬁcult, since withdrawal of the child from therapy is a major problem. It is important to involve the family in the treatment as it relieves family anxiety and distress. Nev- ertheless, it is vital to create some distance because over- involvement of the family may be counterproductive. Medication appears to play a very limited role in the management of the syndrome, having value in the treat- ment of comorbid disorders only, for example antidepres- sants for comorbid depression. Returning to Kate, treatment consisted of an inpatient multidisciplinary gradual rehabilitation programme, which was characterized by respectful tender loving care and activities just on demand. Parents were involved by means of regular meetings with the family therapist. The treat- ment goals of these sessions were encouragement, comfort and reduction of possible over-involvement. Prognosis and outcome Although the recovery process is painfully slow, most children with PRS fully recover with little residual 123 Eur Child Adolesc Psychiatry (2009) 18:645–651 Table 6 Treatment characteristics of PRS (n = 24)a, 1991-2006 Length of time of therapy in months (mean ± SD) Recovery Complete Partial Not reported Symptom-free periods with relapses Treatment Inpatient Outpatient Not reported 12.8 ± 11.1 (3 not reported) 16 (67%) 6 (25%) 1 (4%) 1 (4%) 22 (92%) 1 (4%) 1 (4%) a Twenty-three patients from the literature search ? 1 patient from the Dutch article [25] pathology [11]. Complete recovery was achieved in 16 (67%) of the 24 cases, while partial recovery was seen in six cases (25%) (see Table 6). However, the condition of some of the partially recovered patients was still improving at the time of publication. In our case report, full recovery with little residual pathology (fatigue) was seen after a period of 4 months of inpatient treatment (1 month at our academic medical psychiatric unit and 3 months at the child psychiatric hospital). This seems a short period of time, because the average duration of therapy is 12.8 months (Table 6). Note, however, that the literature mentions cases of complete recovery after an inpatient treatment of only 2–8 weeks [24]. Concerning Kate, we still have no clue regarding the cause either of her PRS or of her miraculous, spontaneous recovery; but this is also not uncommon. Conclusion In our opinion, PRS, a rare but severe and neglected syn- drome with distinct clinical features and a disabling char- acter, should be incorporated into the DSM and ICD classiﬁcations and the main textbooks on child and ado- lescent psychiatry. We propose an adaptation of the current diagnostic criteria and suggest both PRS in children and the well-known concept of regression in adults to be considered as parts of the refusal–withdrawal–regression spectrum. Acknowledgments We wish to thank Kate and her parents for granting permission to publish their case history; Mrs E.A.F. van Weel, child and adolescent psychiatrist, for initially focusing our attention on PRS; Mr D. Jaspers, professor in English language and literature, and Mr S. Alford, professional reviser, for critically reviewing and correcting our English; and Ms K. Venrooij, medical secretary, for her editorial work.