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When it comes to pediatric neuropsychiatric disorders, two conditions that often fly under the radar – both parents and clinicians – are Pathological Demand Avoidance (PDA) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), including PANDAS.
In my clinical experience, most parents don’t hear about these conditions until they’re deep into Google searches, desperately trying to understand behaviors that just don’t make sense – and haven’t improved with the usual strategies.
What are the differences between PDA and PANS/PANDAS?
While both conditions can look like extreme demand avoidance on the surface, they’re rooted in very different causes. That means they need very different approaches to be treated.
| Pathological Demand Avoidance (PDA) | PANS/PANDAS | |
|---|---|---|
| Definition | A behavioral profile within the autism spectrum characterized by an extreme avoidance of everyday demands and expectations. | A condition characterized by a sudden onset of neuropsychiatric symptoms following infections (PANDAS) or other triggers (PANS). |
| Core Symptoms | Demand avoidance due to anxiety Surface sociability but lack of depth in relationships Lability of mood, impulsivity, and extreme behavior Comfortable in role play and pretending Obsessive behaviors focused on people | Sudden onset of OCD or eating restrictions Severe separation anxiety Motor or vocal tics Anxiety and mood changes Deterioration in academic performance Sensory or urinary issues |
| Etiology | Thought to be related to autism spectrum disorder, but exact cause is unknown. | Triggered by infections or other factors such as stress or environmental triggers. |
| Diagnostic Criteria | No specific diagnostic criteria; usually diagnosed through behavioral assessments and history. | Diagnosed based on clinical criteria including sudden onset of symptoms, association with infections (for PANDAS), and exclusion of other conditions. |
| Assessment Tools | EDA-Q (Extreme Demand Avoidance Questionnaire) Clinical interviews and observations | Clinical evaluations Blood tests to check for infections, toxins or inflammation Neuropsychiatric assessments |
| Common Comorbidities | Autism Spectrum Disorder (ASD) Attention Deficit Hyperactivity Disorder (ADHD) Anxiety Disorders | OCD, ADHD, Anxiety Disorders & Depression |
| Intervention Strategies | Low-demand environments Flexibility in routines Anxiety management techniques Support for social skills and relationships | Antibiotic or antiviral treatments (for infections) Anti-inflammatory treatments Neurofeedback & PEMF Exposure and Response Prevention (ERP) Cognitive-behavioral therapy (CBT) Parent Coaching Supportive therapies (e.g., occupational therapy, speech therapy) |
| Prognosis | Varies widely depending on assets and support symptoms. | Prognosis varies; some children respond well to treatment and recover fully, while others may have persistent or recurrent symptoms |
What is Demand Avoidance and why is it so challenging?
Demand avoidance refers to a pattern of behavior where a child actively resists everyday requests, making tasks like getting dressed or completing homework incredibly difficult.
The families I work with in my BrainBehaviorReset® Program often seek help when they find it hard to engage with their child or teen due to this resistance.
What is Demand Avoidance in PANS/PANDAS?
While both PDA and demand avoidance in PANS/PANDAS can look similar on the outside, they arise from different underlying causes.
For kids with PDA, avoiding demands is kind of their default—it’s tied to deep anxiety and a strong need to stay in control. Even small requests can feel overwhelming, so they dodge them to protect themselves.
In contrast, with PANS or PANDAS, demand avoidance usually shows up alongside sudden changes like OCD behaviors, mood swings, or irritability. These shifts often follow an infection or other trigger, which points to an immune system reaction.
One study by Franklin and colleagues (2023) looked at kids with PANS/PANDAS and found that a lot of them also showed traits similar to PDA. The tricky part? Figuring out whether it’s true PDA or just looks like it because of what the brain and body are going through.
This underscores the need for thorough assessments and individualized care plans that address both the medical and behavioral aspects of each child’s presentation.
Why Does Demand Avoidance Happen 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.
What are the Symptoms of PANS and PANDAS?
- Obsessive-Compulsive Behaviors: obsessions or rituals take over, making it hard for your child to follow through, even with simple tasks.
- Irritability and Emotional Dysregulation: big feelings make little requests feel overwhelming, so your child avoids to cope.
- Sensory Sensitivities: loud sounds, bright lights, or scratchy clothes can overload their system, leading them to avoid it.
- Executive Function Challenges: organizing and planning is hard. Even starting a task can feel impossible.
- Fatigue and Malaise: exhaustion makes everyday tasks feel too hard to even try.
- Disruption of Routine: changes in routine throw them off, making them resist anything that’s not familiar.
- Fear of Failure: worry about messing up can cause them to avoid things that feel too risky.
- Communication Difficulties: expressing is hard. Even simple requests can feel overwhelming.
- Social Anxiety: play dates and family gatherings feel scary for your child, so they avoid anything that puts them on the spot.
- Hyperactivity and Impulsivity: they crave stimulation and struggle with focus. Boring tasks don’t stand a chance.
- Cognitive Rigidity: change feels unsafe, so they resist anything new or unexpected.
- Emotional Distress: when their emotions feel too big to handle, they avoid tasks to feel safe and in control.
How Do We Treat Demand Avoidance Differently?
Treating demand avoidance depends on what’s causing it—PDA and PANS/PANDAS have different triggers, so the strategies need to be tailored.
In our program, we don’t just focus on the child but the whole family, since PANS/PANDAS can be really hard on everyone.
For kids with PDA, we take a more flexible approach. It’s about working with their need for control while gently building up their ability to handle demands. Some of the key strategies are:
- Using indirect language
- Offering choices
- Sticking to predictable routines
In PANS/PANDAS, treatment focuses on the neuropsychiatric side of things. To address underlying issues, we make use of the following:
- Antibiotics for PANDAS
- Immunomodulatory therapy
- Cognitive Behavioral Therapy (CBT)
- Exposure and response prevention (ERP)
Once we understand what's driving the demand avoidance, it's easier to help kids manage it. Recognizing the differences between these conditions is crucial for finding the right approach.
Parent Action Steps
FAQs
What is PDA in children?
PDA (Pathological Demand Avoidance) is a behavior pattern in children marked by intense resistance to everyday demands and requests. Kids with PDA often struggle with following instructions, participating in tasks, and adapting to routines, which can lead to challenges in social situations and daily life.
Is demand avoidance just defiance?
No. While it might look like defiance, demand avoidance is usually not intentional misbehavior. It’s often a coping response to internal stress, anxiety, or neurological dysfunction.
What triggers demand avoidance in PANS/PANDAS?
Triggers can include cognitive fatigue, inflammation, sensory overload, or anxiety. Even small demands may feel impossible when a child’s brain and body are in fight-or-flight mode.
How should parents support a child with PDA?
Parents should approach a child with PDA collaboratively, respecting their need for control while gradually increasing tolerance to demands. Helpful strategies include using indirect language, offering choices, and creating structured routines.
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
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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