When it comes to pediatric neuropsychiatric disorders, two conditions that often are unknown to parents and clinicians alike, are Pathological Demand Avoidance (PDA) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) or Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS). In my clinical experience, I often parents and providers don’t learn about these conditions until they do an internet search after unsuccessfully trying to address perplexing behaviors.
While both can manifest with behaviors resembling demand avoidance, they are distinct conditions with different underlying mechanisms and treatment approaches.
So what is demand avoidance and why is it so frustrating for both parent and child?
Demand avoidance refers to a pattern of behavior where an individual actively resists or avoids everyday demands and requests, often leading to difficulties in daily functioning and social interactions. This can include tasks as simple as getting dressed or completing homework. The families I work with in my BrainBehaviorReset® Program often come to me because they just don’t know how to approach their resistant child or teen.
Demand Avoidance vs PANS and PANDAS
Pathological Demand Avoidance is a subtype of Autism Spectrum Disorder (ASD) characterized by an extreme avoidance of everyday demands alongside social communication difficulties and anxiety. Individuals with PDA often display persistent, pervasive, extreme, passive, or personal demand avoidance, among others.
PANS and PANDAS, on the other hand, are conditions characterized by the sudden onset of obsessive-compulsive disorder (OCD) or tics, accompanied by other neuropsychiatric symptoms such as anxiety, irritability, and emotional lability. PANS often occurs in the absence of a known infectious or toxin trigger (could be Lyme Disease, mold, etc.) while PANDAS specifically links symptom onset to a streptococcal infection.
What is Demand Avoidance in PANS/PANDAS?
While both PDA and demand avoidance in PANS/PANDAS share similarities in behavioral presentation, they arise from different underlying causes.
PDA is a core feature of the condition and is believed to stem from an underlying need for control and anxiety. Individuals with PDA often feel overwhelmed by demands, leading to a heightened sense of anxiety and a need to maintain a sense of control over their environment.
In PANS/PANDAS, demand avoidance may occur as a result of neuropsychiatric symptoms such as obsessive-compulsive behaviors or irritability. The sudden onset of symptoms and association with infections suggest an immune-mediated or autoimmune component underlying the disorder.
One study explores the co-occurrence of PDA traits in children and adolescents diagnosed with PANS or PANDAS. Through a case series analysis, the study highlights the prevalence of PDA traits among children with PANS/PANDAS. It discusses the challenges in distinguishing between PDA as a primary presentation versus a symptom of PANS/PANDAS.
The importance of comprehensive assessment and tailored interventions to address both the neuropsychiatric symptoms of PANS/PANDAS and the demand avoidance behaviors is emphasized (Franklin et al., 2023).
Why Demand Avoidance Happens in PANS/PANDAS
Demand avoidance in PANS/PANDAS may be a manifestation of the underlying neuropsychiatric symptoms rather than a primary feature of the disorder.
Obsessive-Compulsive Behaviors: Children with PANS/PANDAS may exhibit demand avoidance as a result of compulsions or obsessions interfering with their ability to comply with requests.
Irritability and Emotional Dysregulation: Emotional lability and irritability common in PANS/PANDAS may lead to resistance or avoidance of demands as a coping mechanism.
Sensory Sensitivities: Children with PANS/PANDAS often experience heightened sensory sensitivities, such as aversions to certain textures, sounds, or lights. These sensitivities can trigger anxiety or discomfort in response to demands that involve sensory stimuli, leading to avoidance behaviors.
Executive Function Challenges: PANS/PANDAS can impair executive functions like planning, organization, and decision-making. As a result, children may struggle to initiate or complete tasks, leading to avoidance of demands that require cognitive effort or organization.
Fatigue and Malaise: PANS/PANDAS can cause physical symptoms such as fatigue, lethargy, and malaise. When feeling unwell, children may lack the energy or motivation to engage with demands, opting to avoid tasks requiring physical or mental effort.
Disruption of Routine: Children with PANS/PANDAS may thrive on routine and predictability. Any disruption to their established routines, whether due to illness, changes in the environment, or stressors, can trigger demand avoidance behaviors as they struggle to adapt to the new circumstances.
Fear of Failure: PANS/PANDAS can heighten anxiety and perfectionism in children. Fear of making mistakes or not meeting expectations may lead to avoidance of demands to avoid the possibility of failure or negative outcomes.
Communication Difficulties: PANS/PANDAS can impact language and communication skills, making it challenging for children to express their needs or understand instructions. Difficulty communicating effectively may result in avoidance of demands that require clear communication or comprehension.
Social Anxiety: Children with PANS/PANDAS may experience social anxiety or discomfort in social situations. Demands that involve social interaction or performance in front of others may trigger avoidance behaviors as they seek to avoid perceived judgment or embarrassment.
Hyperactivity and Impulsivity: Some children with PANS/PANDAS may exhibit hyperactive or impulsive behaviors, making it difficult to regulate their responses to demands. They may avoid tasks requiring sustained attention or self-control, opting for activities that provide immediate gratification or stimulation.
Cognitive Rigidity: PANS/PANDAS can lead to cognitive inflexibility or rigidity, making it challenging for children to adapt to changes in demands or expectations. They may resist or avoid tasks that deviate from their preferred routines or ways of doing things.
Emotional Distress: Children with PANS/PANDAS may experience intense emotional distress, such as anxiety, sadness, or frustration, which can interfere with their ability to engage with demands. Avoiding demands may serve as a coping mechanism to alleviate emotional discomfort or overwhelm.
How Demand Avoidance Needs to Be Treated Differently:
How to support kids and teens with demand avoidance is as unique as these conditions due to the distinct etiologies of demand avoidance in PDA and PANS/PANDAS. In our program, we support the whole family ecosystem because PANDAS and PANS can be so traumatic.
In PDA, interventions often focus on collaborative approaches that respect the individual's need for control while gradually increasing tolerance to demands. Strategies such as using indirect language, offering choices, and providing structured routines can be beneficial.
On the other hand, the treatment of demand avoidance in PANS/PANDAS typically involves addressing the underlying neuropsychiatric symptoms through a combination of antibiotics (in the case of PANDAS), immunomodulatory therapy, and psychosocial interventions such as cognitive-behavioral therapy (CBT) or exposure and response prevention (ERP).
While demand avoidance can be a challenging aspect of both PDA and PANS/PANDAS, understanding the underlying mechanisms is crucial for effective intervention. By recognizing the distinct features and treatment approaches for each condition, parents can better support their children in managing demand avoidance behaviors and improving overall functioning.
If your child's extreme mood, behavior, and personality changes wreak havoc at home and school, then you need the Natural PANS/PANDAS Calm Brain Kit to help guide you to science backed solutions that support dysregulated kids.
What is PDA in children?
In kids, PDA refers to pathological demand avoidance, a behavior pattern characterized by extreme avoidance or resistance to everyday demands and requests. Children with PDA may struggle to follow instructions, engage in tasks, or participate in routines, often resulting in challenges in social interactions and daily functioning.
What is PDA autism?
PDA autism is characterized by an extreme avoidance of everyday demands, alongside social communication difficulties and anxiety. Children with PDA autism often display persistent and pervasive demand avoidance behaviors that significantly impact their daily functioning and social interactions.
What is Pathological Demand Avoidance syndrome in adults?
Pathological Demand Avoidance (PDA) syndrome in adults refers to a behavioral profile characterized by extreme avoidance or resistance to everyday demands and requests, often accompanied by social communication difficulties and anxiety. Adults with PDA may struggle to cope with situations requiring flexibility or adherence to social norms, leading to challenges in employment, relationships, and daily functioning.
What is a PDA child symptom?
A symptom of a child with PDA might include extreme avoidance or resistance to everyday demands and requests. These children may also exhibit difficulties with social communication, such as understanding social cues or maintaining relationships. Additionally, they may display anxiety or emotional dysregulation when faced with demands or changes in routine.
What's demand avoidance in a school setting?
Demand avoidance in a school setting refers to behaviors where a student consistently avoids or resists tasks, instructions, or requests from teachers or peers. This can manifest as refusal to participate in activities, defiance towards authority figures, or procrastination when given assignments. Demand avoidance in school settings can significantly impact academic performance, social interactions, and overall classroom dynamics.
How Should Parents Support a Child with PDA?
Parents can support a child with Pathological Demand Avoidance (PDA) by employing collaborative approaches that respect the child's need for control while gradually increasing tolerance to demands. Strategies such as using indirect language, offering choices, and providing structured routines can be beneficial in managing demand avoidance behaviors.
Citations
Franklin, M. E., Eken, S., & Osterlund, E. (2023). Current Research Updates on PANDAS and PANS. Current Developmental Disorders Reports, 10(4), 264–273. https://doi.org/10.1007/s40474-023-00280-w
Kildahl, A. N., Helverschou, S. B., Rysstad, A. L., Wigaard, E., Hellerud, J. M., Ludvigsen, L. B., & Howlin, P. (2021). Pathological demand avoidance in children and adolescents: A systematic review. Autism, 25(8), 136236132110343. https://doi.org/10.1177/13623613211034382
Dr. Roseann is a mental health expert in PANS and PANDAS who frequently is in the media:
- Healthy Parenting Connector (Video) Why “My Kid is Acting Crazy” Might be PANS/PANDAS
- Living with Lyme (Podcast) Neurofeedback and biofeedback for PANS/PANDA
- Maria Rickert Hong (Audio) PANS/PANDAS
Always remember… “Calm Brain, Happy Family™”
Disclaimer: This article is not intended to give health advice and it is recommended to consult with a physician before beginning any new wellness regime. *The effectiveness of diagnosis and treatment vary by patient and condition. Dr. Roseann Capanna-Hodge, LLC does not guarantee certain results.
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Dr. Roseann is a Children’s Mental Health Expert and Licensed Therapist who has been featured in/on hundreds of media outlets including The Mel Robbins Show, CBS, NBC, PIX11 NYC, Today, FORBES, CNN, The New York Times, The Washington Post, Business Insider, Women’s Day, Healthline, CNET, Parade Magazine and PARENTS. FORBES called her, “A thought leader in children’s mental health.”
She coined the terms, “Re-entry panic syndrome” and “eco-anxiety” and is a frequent contributor to media on mental health.
Dr. Roseann Capanna-Hodge has three decades of experience in working with children, teens and their families with attention-deficit hyperactivity disorder (ADHD), autism, concussion, dyslexia and learning disability, anxiety, Obsessive Compulsive Disorder (OCD), depression and mood disorder, Lyme Disease, and PANS/PANDAS using science-backed natural mental health solutions such as supplements, magnesium, nutrition, QEEG Brain maps, neurofeedback, PEMF, psychotherapy and other non-medication approaches.
She is the author of three bestselling books, It’s Gonna Be OK!: Proven Ways to Improve Your Child's Mental Health, The Teletherapy Toolkit, and Brain Under Attack. Dr. Roseann is known for offering a message of hope through science-endorsed methods that promote a calm brain.
Her trademarked BrainBehaviorResetⓇ Program and It’s Gonna be OK!Ⓡ Podcast has been a cornerstone for thousands of parents facing mental health, behavioral or neurodevelopmental challenges.
She is the founder and director of The Global Institute of Children’s Mental Health, Neurotastic™Brain Formulas and Dr. Roseann Capanna-Hodge, LLC. Dr. Roseann is a Board Certified Neurofeedback (BCN) Practitioner, a Board Member of the Northeast Region Biofeedback Society (NRBS), Certified Integrative Mental Health Professional (CIMHP) and an Amen Clinic Certified Brain Health Coach. She is also a member of The International Lyme Disease and Associated Disease Society (ILADS), The American Psychological Association (APA), Anxiety and Depression Association of America (ADAA) National Association of School Psychologists (NASP), International OCD Foundation (IOCDF).
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