Pathological Demand Avoidance

25^th June 2026

Pathological Demand Avoidance (PDA) is a behavioural profile most commonly described within the autism spectrum [1,2]. It is characterised by an extreme avoidance of everyday demands and expectations, often accompanied by high levels of distress and a strong need for autonomy or perceived control.

Individuals described as presenting with a PDA profile may experience significant distress in response to everyday demands, which can impact emotional wellbeing, relationships, education, and daily functioning. Supportive, low-arousal, and flexible approaches are generally recommended to help reduce distress and improve engagement.

Even with appropriate environmental adjustments and behavioural support strategies, some individuals continue to experience significant anxiety, emotional dysregulation, and functional avoidance [3].

In this context, some individuals and families may explore additional supportive approaches, including medical cannabinoid-based treatments, particularly where co-occurring symptoms such as anxiety, sleep disturbance, or emotional dysregulation are present. At present, there is limited evidence specifically relating to PDA, and research into cannabinoids in neurodevelopmental and anxiety-related presentations more broadly remains evolving and mixed. Where medical cannabinoids are considered, they should be used within a specialist-guided, individualised treatment framework, with careful attention to potential benefits, side effects, and interactions with existing therapies.

Common Symptoms and Presentations

Individuals described as presenting with a PDA profile may experience a range of features that can vary in intensity and presentation [4,2]. These may include avoidance of everyday demands, heightened distress in response to expectations, and a strong need for autonomy or predictability. Anxiety is commonly reported in this context and may contribute to how these experiences are expressed, alongside differences in emotional regulation and sensory or environmental sensitivity. Difficulties engaging with routine activities may also be present.

Other commonly reported features include sleep disturbance, emotional dysregulation, intense emotional responses, difficulty recovering from distressing experiences, and reduced participation in everyday or valued activities.

Conventional Treatments

Support typically focuses on reducing distress and increasing predictability through flexible, low-demand strategies. This may include offering choices, using collaborative communication styles, and avoiding approaches that feel overly directive or controlling to the individual.

Psychological support may include adapted cognitive-behavioural therapy (CBT) or acceptance and commitment therapy (ACT), tailored to the individual’s anxiety profile and neurodevelopmental needs.

Family-based support and parent coaching can help caregivers understand distress-driven avoidance and develop supportive, low-arousal interaction strategies.

Autism-informed approaches may also include sensory adjustments, environmental modifications, and structured emotional support.

Sleep difficulties are common and may be supported through sleep hygiene strategies and, in some cases, melatonin under clinical supervision.

Medications such as selective serotonin reuptake inhibitors (SSRIs) or other anxiolytic treatments may be considered in some cases; however, responses are variable and should be carefully monitored, particularly in neurodevelopmental populations.

How Cannabinoids Can Help

Some individuals and families explore medical cannabinoid-based treatments within specialist care for co-occurring symptoms such as anxiety, sleep disturbance, emotional dysregulation, and stress-related functional impairment [5,6,7]. These are commonly reported in autistic individuals and those described as presenting with a PDA profile.

The endocannabinoid system regulates mood, stress response, emotional processing, and sleep-wake cycles. Through these pathways, cannabinoid-based medicines may support symptom management in some individuals, particularly where anxiety, hyperarousal, and sleep disruption affect daily functioning. In clinical practice, some individuals with autism and PDA report improvements in sleep quality, anxiety-related arousal, and emotional regulation with appropriately prescribed and monitored cannabinoid-based treatments, although responses vary by formulation, dosing, and co-existing therapies.

Evidence specific to PDA-related profiles is still developing; however, cannabinoid-based treatments are increasingly considered within broader neurodevelopmental and anxiety-related care where conventional approaches provide incomplete symptom control.

Where used, treatment should be specialist-led and individualised, with ongoing monitoring of response, tolerability, functional outcomes, and potential interactions with other medicines.

Mechanisms of Action

Tetrahydrocannabinol (THC)

THC is one of the primary active compounds found in cannabinoids [8]. It works by interacting with cannabinoid receptors as well as other receptors in the brain and nervous system, which are involved in regulating functions such as mood, perception, and sleep. In some individuals, THC may help promote relaxation and support sleep. Responses to THC can vary from person to person and may depend on the dose used. For this reason, treatment decisions, product selection, and dosing should always be guided by a healthcare professional and reviewed regularly based on individual response.

Cannabidiol (CBD)

CBD is a non-intoxicating compound found in cannabis that does not typically produce a “high.” It interacts with multiple systems in the body involved in mood regulation, stress response, and sleep. Some individuals report benefits such as reduced anxiety-related arousal, improved sense of calm, or better sleep quality; however, responses vary and are not guaranteed.

The mechanisms of CBD are still being researched, and its effects may differ depending on formulation, dose, and co-existing conditions or treatments. CBD should therefore be used under appropriate clinical guidance and monitored for both response and tolerability, particularly when used alongside other medications.

Clinical Evidence of Cannabinoids in PDA Autism

PDA is not a formal medical diagnosis, but it is a profile described in some individuals on the autism spectrum. People described with PDA often experience co-occurring challenges such as anxiety, sleep difficulties, and emotional dysregulation. Because of this overlap, symptom improvements seen in ASD research may sometimes be relevant in a broader sense. However, there are currently no studies looking specifically at cannabinoid-based medicines in PDA as a distinct group.

Anxiety Reduction

Research suggests that cannabinoid-based medicines, particularly cannabidiol (CBD), may help reduce anxiety symptoms in some individuals with Autism Spectrum Disorder (ASD) [9,10]. In an open-label study [6], caregivers reported improvements in anxiety and related behaviours in children using CBD-rich preparations, although responses varied between individuals. Reviews of the evidence [11] also suggest possible benefits for anxiety symptoms, while noting that results are not consistent across all studies.

Emotional Regulation

Early evidence and clinical reports suggest that cannabinoid-based medicines may help some individuals with ASD and PDA with emotional regulation, particularly where emotional responses are linked to anxiety or high levels of stress. Some studies have reported reductions in irritability and improved behavioural stability [6,11], although research is still developing and results are not the same for everyone.

Sleep Quality and Anxiety Reduction

Some evidence suggests that cannabinoid-based medicines may help improve sleep difficulties, which are common in ASD [5,12]. Studies have reported improvements in sleep quality with CBD-containing or combined cannabinoid treatments [6,11], although effects can differ depending on the product, dose, and individual response. The endocannabinoid system is also involved in regulating normal sleep-wake cycles [13,14].

Summary of Benefits of Medical Cannabinoids

Some individuals with Autism Spectrum Disorder (ASD), including those described as presenting with a PDA profile, experience significant co-occurring symptoms such as anxiety, sleep disturbance, emotional dysregulation, and functional impairment. Cannabinoid-based medicines are being explored within specialist care as a potential option to support these symptom domains in some individuals.

• Addresses Anxiety: CBD-based medicines may help reduce anxiety symptoms in some individuals. Research in ASD populations suggests possible improvements in anxiety and related behaviours, although responses vary and are not consistent across all individuals or studies.
• Sleep Support: Sleep difficulties are common in ASD and may be associated with increased daytime anxiety and emotional dysregulation. Some studies suggest that cannabinoid-based medicines (CBD and balanced THC:CBD formulations) may support improvements in sleep quality in certain individuals.
• Emotional Regulation: Early evidence and clinical observations suggest that cannabinoid-based medicines may help some individuals with ASD experience improved emotional regulation, particularly where emotional responses are linked to anxiety or stress-related arousal Without Sedation: CBD reduces anxiety and improves emotional resilience without causing the sedation that can worsen PDA-related passivity.
• Reduced Medication Side Effects: Compared to SSRIs, other or other anti-anxiety medications and mood stabilizing medication, CBD-based therapies have fewer side effects and no dependency risks.
• Supports Engagement with Life Activities: By reducing anxiety, cannabinoids may increase indirectly support day-to-day functioning individuals’ and improve the capacity to engage with school, work, relationships and valued activities.

Side effects of CBD

CBD is generally well tolerated, with most adverse effects being mild to moderate. These may include diarrhoea, nausea, appetite changes, somnolence, and fatigue.

Elevations in liver enzymes may occur, particularly when used with valproate or other medications metabolised by the liver. Serious adverse effects are rare.

Baseline and periodic liver function monitoring is recommended, especially in patients with hepatic impairment or those receiving hepatotoxic medications.

Drug Interactions

CBD may interact with other medications, and some medications may also affect CBD levels in the body [15,16]. These interactions can occur through shared liver enzyme pathways, including CYP3A4 and CYP2C9.

As a result, levels of either CBD or certain medications may increase or decrease, which may affect therapeutic response and the risk of side effects. This may be particularly relevant for certain cardiovascular, psychiatric, and anticonvulsant medications.

The extent of interaction varies depending on the specific medication, cannabinoid formulation, and individual patient metabolism.

Conclusion

For individuals with Autism Spectrum Disorder (ASD) described as presenting with a PDA profile who experience co-occurring symptoms such as anxiety, emotional dysregulation, sleep difficulties, or functional impairment despite anxiety-informed support and accommodations, medical cannabinoids may be considered as an adjunct within specialist-led care focused on symptom management, with ongoing monitoring of response, tolerability, and medication interactions.

Cannabinoid-based formulations in particular may offer potential support for anxiety reduction and sleep quality in some individuals, although responses vary and outcomes are not consistent across all cases. Cannabinoid-based treatment should be integrated with, and never replace, individualised, flexible, low-arousal support strategies that characterise effective PDA-informed care.

With appropriate specialist oversight and coordinated input from families and relevant support systems, cannabinoid-based therapies may form part of a broader, individualised approach aimed at supporting wellbeing, reducing symptom burden, and improving day-to-day functioning and participation.

How to Access AKOS BIO Cannabinoid Therapy

If you are interested in exploring cannabinoid-based treatment as part of your therapeutic plan, discuss this option with your treating healthcare provider. They can help determine whether cannabinoid therapy may be be appropriate for your individual circumstances.

Alternatively, if you would like to explore AKOS BIO’s pharmaceutical-grade cannabinoid products, you can book a consultation with an independent prescribing healthcare practitioner via the AKOS BIO website.

AKOS BIO provides pharmaceutical-grade cannabinoid products and educational resources to support patients and healthcare professionals. Prescribing decisions are made independently by qualified healthcare practitioners.

In South Africa, AKOS BIO doctors will apply for your Section 21 licence (SAHPRA) on your behalf if medical cannabis is appropriate for your condition. The permit is valid for six months and can be renewed if treatment is effective.

For more information or to book a consultation:

Website: www.akos-bio.com

WhatsApp: 066 269 1108

References

[1] Miller, C., & Martin, C. (2026, January 14). Pathological Demand Avoidance (PDA) in Kids. Child Mind Institute. https://childmind.org/article/pathological-demand-avoidance-in-kids/

[2] O’Nions, E., Viding, E., Floyd, C., Quinlan, E., Pidgeon, C., Gould, J., & Happé, F. (2018). Dimensions of difficulty in children reported to have an autism spectrum diagnosis and features of extreme/’pathological’ demand avoidance. Child and Adolescent Mental Health, 23(3), 220–227. https://doi.org/10.1111/camh.12242

[3] Stuart, L., Grahame, V., Honey, E., & Freeston, M. (2020). Intolerance of uncertainty and anxiety as explanatory frameworks for extreme demand avoidance in children and adolescents. Child and Adolescent Mental Health, 25(2), 59-67. https://doi.org/10.1111/camh.12336

[4] 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), 2211-2228. https://doi.org/10.1177/13623613211034382

[5] Shannon, S., Lewis, N., Lee, H., & Hughes, S. (2019). Cannabidiol in anxiety and sleep: A large case series. The Permanente Journal, 23, 18-041. https://doi.org/10.7812/TPP/18-041

[6] Barchel, D., Stolar, O., De-Haan, T., Ziv-Baran, T., Saban, N., Fuchs, D. O., Koren, G., & Berkovitch, M. (2018). Oral Cannabidiol Use in Children With Autism Spectrum Disorder to Treat Related Symptoms and Co-morbidities. Frontiers in Pharmacology, 9, 1521. https://doi.org/10.3389/fphar.2018.01521

[7] David, A., Gal, E., Ben-Sasson, A., Kohn, E., Berkovitch, M., & Stolar, O. (2025). Effects of Medical Cannabis Treatment for Autistic Children on Family Accommodation: An Open-Label Mixed-Methods Study. Children, 12(10), 1373. https://doi.org/10.3390/children12101373

[8] Bilbao, A., & Spanagel, R. (2022). Medical cannabinoids: A pharmacology-based systematic review and meta-analysis for all relevant medical indications. BMC Medicine, 20(1), 259. https://doi.org/10.1186/s12916-022-02459-1

[9] Blessing, E. M., Steenkamp, M. M., Manzanares, J., & Marmar, C. R. (2015). Cannabidiol as a potential treatment for anxiety disorders. Neurotherapeutics, 12(4), 825-836. https://doi.org/10.1007/s13311-015-0387-1

[10] Bergamaschi, M. M., Queiroz, R. H., Chagas, M. H., et al. (2011). Cannabidiol reduces the anxiety induced by simulated public speaking in treatment-naïve social phobia patients. Neuropsychopharmacology, 36(6), 1219-1226. https://doi.org/10.1038/npp.2011.6

[11] Pereira, D. A., Cheidde, L., Megiolaro, M. D. R., Camargo, A. E. F., Weba, E. T. P., Soares, V. G., Pereira Da Silva, A. M., Cheidde, L., Ladeira Júnior, P. P., Amaral, D. C., Triaca, R., Fernandes, M. A. N., & Mimura, P. M. P. (2025). Efficacy and Safety of Cannabinoids for Autism Spectrum Disorder: An Updated Systematic Review. Cureus. https://doi.org/10.7759/cureus.80725

[12] Kuhathasan, N., Dufort, A., MacKillop, J., Gottschalk, R., Minuzzi, L., & Frey, B. N. (2019). The use of cannabinoids for sleep: A critical review on clinical trials. Experimental and Clinical Psychopharmacology, 27(4), 383-401. https://doi.org/10.1037/pha0000285

[13] Chayasirisobhon, S. (2021). Mechanisms of Action and Pharmacokinetics of Cannabis. The Permanente Journal, 25(1), 1–3. https://doi.org/10.7812/TPP/19.200

[14] Hansen, J. S., Boix, F., Hasselstrøm, J. B., Sørensen, L. K., Kjolby, M., Gustavsen, S., Hansen, R. M., Petersen, T., Sellebjerg, F., Kasch, H., Rasmussen, P. V., Finnerup, N. B., Sædder, E. A., & Svendsen, K. B. (2024). Pharmacokinetics and pharmacodynamics of cannabis‐based medicine in a patient population included in a randomized, placebo‐controlled, clinical trial. Clinical and Translational Science, 17(1), e13685. https://doi.org/10.1111/cts.13685

[15] Balachandran, P., Elsohly, M., & Hill, K. P. (2021). Cannabidiol interactions with medications, illicit substances, and alcohol: A comprehensive review. Journal of General Internal Medicine, 36(7), 2074-2084. https://doi.org/10.1007/s11606-020-06504-8

[16] Nachnani, R., Knehans, A., Neighbors, J. D., Kocis, P. T., Lee, T., Tegeler, K., Trite, T., Raup-Konsavage, W. M., & Vrana, K. E. (2024). Systematic review of drug-drug interactions of delta-9-tetrahydrocannabinol, cannabidiol, and Cannabis. Frontiers in Pharmacology, 15, 1282831. https://doi.org/10.3389/fphar.2024.1282831